Cerebral thromboembolic complications during cerebral angiography and their risk factors in different subgroups: Analysis of 2,457 procedures

PURPOSE

Diagnostic cerebral digital subtraction angiography (DSA) is an invasive examination that involves catheterization of the major supra-aortic arterial trunks and evaluation of intracranial vessels for diagnostic purposes. Although considered the gold standard method for investigating cerebrovascular diseases, DSA carries measurable and potentially serious complication rates. This report describes the frequency of neurological and non-neurological complications of DSA performed in five hospitals in the state of São Paulo, Brazil, and analyzes them in different disease subgroups. It has a special focus on thromboembolic cerebral complications.

METHODS

We retrospectively reviewed clinical records of all adult patients who underwent DSAs between January 2019 and December 2022. Demographic variables, DSA reports, CT/MRI reports, and clinical follow-up notes were reviewed.

RESULTS

Twenty-four patients experienced some type of complication among 2,457 diagnostic DSAs (0.97%). Thromboembolic complications were recorded in 9 patients (0.36%), and access site hematomas larger than 5 cm were registered in six patients (0.24%). There was a statistical trend for thromboembolic complications in patients with cervical and/or intracranial atherosclerosis (p = 0.07), but age was not associated with them (p = 0.93). Patients who received heparin had lower rates of embolic complications than those who did not receive it, but there was no statistically significant difference (p = 0.17). Intravenous administration of heparin showed a trend toward significance with groin hematoma (p = 0.10).

CONCLUSION

Diagnostic catheter DSAs have low complication rates.

Usefulness of Different Imaging Methods in the Diagnosis of Cerebral Vasculopathy

Assessment of cerebral vasculopathies is challenging and requires understanding the utility of different imaging methods. Various techniques are available to image the vessel lumen, each with unique advantages and disadvantages. Bolus-based CT and MR angiography requires careful timing of a contrast bolus to provide optimal luminal enhancement. Non-contrast MRA techniques do not require a contrast agent and can provide images with little venous contamination. Digital subtraction angiography remains the gold standard but is invasive, while VW-MRI provides a non-invasive way of assessing vessel wall pathology. Conventional brain MRI has high sensitivity in the diagnosis of vasculitis but findings are nonspecific.

Primary central nervous system vasculitis and headache: Ten themes

PURPOSE OF REVIEW

The primary central nervous system (CNS) vasculitides refers to clinicopathologic disorders that share the histopathology of inflammation of cerebral or spinal blood vessels. Unrecognized and therefore untreated, vasculitis of the CNS results in irreversible injury and disability making these disorders of paramount importance to clinicians.

RECENT FINDINGS

Headache is an important clue to vasculitic involvement of CNS vessels. CNS vasculitis can be primary, in which only intracranial or spinal vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. The suspicion of vasculitis based on the history, clinical examination, and laboratory studies warrants prompt evaluation and treatment to prevent cerebral ischemia or infarction.

SUMMARY

Primary CNS vasculitides can be diagnosed with certainty after intensive evaluation that includes tissue confirmation whenever possible. As in its systemic counterparts, clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, tempered by anticipated medication adverse effects.

Adult and childhood vasculitis

Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.

The advantages of radial trajectories for vessel-selective dynamic angiography with arterial spin labeling

OBJECTIVES

To demonstrate the advantages of radial k-space trajectories over conventional Cartesian approaches for accelerating the acquisition of vessel-selective arterial spin labeling (ASL) dynamic angiograms, which are conventionally time consuming to acquire.

MATERIALS AND METHODS

Vessel-encoded pseudocontinuous ASL was combined with time-resolved balanced steady-state free precession (bSSFP) and spoiled gradient echo (SPGR) readouts to obtain dynamic vessel-selective angiograms arising from the four main brain-feeding arteries. Dynamic 2D protocols with acquisition times of one minute or less were achieved through radial undersampling or a Cartesian parallel imaging approach. For whole-brain dynamic 3D imaging, magnetic field inhomogeneity and the high acceleration factors required rule out the use of bSSFP and Cartesian trajectories, so the feasibility of acquiring 3D radial SPGR angiograms was tested.

RESULTS

The improved SNR efficiency of bSSFP over SPGR was confirmed for 2D dynamic imaging. Radial trajectories had considerable advantages over a Cartesian approach, including a factor of two improvements in the measured SNR (p < 0.00001, N = 6), improved distal vessel delineation and the lack of a need for calibration data. The 3D radial approach produced good quality angiograms with negligible artifacts despite the high acceleration factor (R = 13).

CONCLUSION

Radial trajectories outperform conventional Cartesian techniques for accelerated vessel-selective ASL dynamic angiography.

Imaging the Vasculitides

"Neuroimaging plays a vital role in the diagnosis of primary and secondary vasculitic disorders. There multiple neuroimaging options available to accurately describe the underlying clinical deficits of involved cases. Noninvasive neuroimaging modalities provide less risk and when interdigitated, form the basis for a more conclusive understanding of the disease process. There are instances in which invasive cerebral angiography may be needed to image the intricate and at times, small involved vessels. Neuroradiologists should be included in the multidisciplinary team of physicians caring for patients with vasculitides and in research to provide more sensitive and safe modalities for accurate diagnosis."

Cerebral catheter angiography and its complications

Catheter-based angiography is an important but invasive procedure in vascular neurology. It is used mainly for diagnosis and for planning treatment in patients with a suspected underlying vascular abnormality. It is often performed as a semiurgent, planned investigation or linked to an interventional procedure. Cerebral angiography provides high-resolution, three-dimensional, pathoanatomical data about the cerebral vasculature and also allows real-time analysis of blood flow. Contrast injections can be repeated to identify subtleties. A physical intervention may also follow angiography. For these reasons, angiography remains the gold standard for delineating vascular lesions of the brain (and spine). Permanent neurological complications are rare, approximately 1%, but become increasingly common in patients aged over 55 years. The main complications are embolic stroke, groin haematoma and contrast-induced nephropathy. In the new era of thrombectomy, it may transpire that other specialists including neurologists may learn to perform the procedure and to manage its complications.

Use of the 2.8 French Progreat microcatheter in diagnostic cerebral angiography

BACKGROUND

Tortuous vascular anatomy poses a significant challenge to performing diagnostic cerebral angiography.

OBJECTIVE

To report a new cerebral angiography technique for overcoming tortuous aortic and supra-aortic anatomy using a 2.8 French (F) Progreat microcatheter (0.028 inch (internal diameter) (Terumo; Somerset, New Jersey, USA) to obtain a diagnostic cerebral angiogram.

MATERIALS AND METHODS

A retrospective analysis of consecutive cases undergoing diagnostic cerebral angiography at our institution between 1 January 2013 and 30 November 2015 in which a 2.8F Progreat microcatheter was used. Clinical and operative notes were reviewed and correlated with imaging. Radiologic imaging, including CT, MRI, and digital subtraction angiography, was reviewed. Neurologic, systemic, and local complications were recorded on the basis of clinical follow-up results after each angiographic examination. Events that occurred within 24 h of the angiography were considered to be complications of the procedure.

RESULTS

Initial attempts at catheterization of the target vessel with various 4F and 5F catheters were unsuccessful owing to tortuosity, atherosclerotic disease, or occlusion of the catheter in the target vessel. Microcatheterization of the target vessel was successful in 59/62 (95%) target vessels. A diagnostic cerebral angiogram with a power injection was obtained in 59 (100%) of the successfully catheterized vessels. In one case, angiography proceeded to aneurysm coiling after over-the-wire exchange. In two cases, angiography proceeded to mechanical thrombectomy after over-the-wire exchange. No procedural complications were seen.

CONCLUSIONS

The 2.8F Progreat microcatheter can be used to obtain a diagnostic cerebral angiogram in patients with anatomic challenges limiting catheterization by standard techniques.

Contrast-enhanced time-resolved MRA for follow-up of intracranial aneurysms treated with the pipeline embolization device

BACKGROUND AND PURPOSE

Endovascular reconstruction and flow diversion by using the Pipeline Embolization Device is an effective treatment for complex cerebral aneurysms. Accurate noninvasive alternatives to DSA for follow-up after Pipeline Embolization Device treatment are desirable. This study evaluated the accuracy of contrast-enhanced time-resolved MRA for this purpose, hypothesizing that contrast-enhanced time-resolved MRA will be comparable with DSA and superior to 3D-TOF MRA.

MATERIALS AND METHODS

During a 24-month period, 37 Pipeline Embolization Device-treated intracranial aneurysms in 26 patients underwent initial follow-up by using 3D-TOF MRA, contrast-enhanced time-resolved MRA, and DSA. MRA was performed on a 1.5T unit by using 3D-TOF and time-resolved imaging of contrast kinetics. All patients underwent DSA a median of 0 days (range, 0-68) after MRA. Studies were evaluated for aneurysm occlusion, quality of visualization of the reconstructed artery, and measurable luminal diameter of the Pipeline Embolization Device, with DSA used as the reference standard.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of contrast-enhanced time-resolved MRA relative to DSA for posttreatment aneurysm occlusion were 96%, 85%, 92%, and 92%. Contrast-enhanced time-resolved MRA demonstrated superior quality of visualization (P = .0001) and a higher measurable luminal diameter (P = .0001) of the reconstructed artery compared with 3D-TOF MRA but no significant difference compared with DSA. Contrast-enhanced time-resolved MRA underestimated the luminal diameter of the reconstructed artery by 0.965 ± 0.497 mm (27% ± 13%) relative to DSA.

CONCLUSIONS

Contrast-enhanced time-resolved MRA is a reliable noninvasive method for monitoring intracranial aneurysms following flow diversion and vessel reconstruction by using the Pipeline Embolization Device.

Anesthesia for interventional radiology

Pediatric patients in the neurointerventional radiology setting pose the dual challenges of caring for relatively sick patients in the outfield environment. For safe and successful practice, the anesthesiologist must not only understand the nuances of pediatric anesthesia and the physiologic demands of the cerebral lesions. They must also help maintain a team-based approach to safe, compassionate care of the child in this challenging setting. In this review article, we summarize key aspects of success for several of these topics.

3D Rotational Angiography in Follow-Up of Clipped Intracranial Aneurysms

Introduction. 3D Rotational Angiography (RA) is indispensable for evaluation of intracranial aneurysms, providing infinite viewing angles and defining the aneurysm morphology. Its role in follow-up of clipped aneurysms remains unclear. We aimed to compare the aneurysm residue/recurrence detection rate of 3D RA with 2D digital subtraction angiography (DSA). Methods. 47 patients harboring 54 clipped aneurysms underwent both 2D DSA and 3D RA. The residual/recurrent aneurysms were classified into five grades and the images of both modalities were compared. Results. The residual/recurrent aneurysm detection rate was 53.70% (29/54 aneurysms) with 2D DSA and 66.67% (36/54 aneurysms) with 3D RA (P = 0.05). In 12 aneurysms, 3D RA upgraded the residue/recurrence among which nine had been completely not detected on 2D DSA and were found to have grade one or two residual necks on the 3D RA, and, in three cases, a small neck on 2D DSA turned out to be aneurysm sac on 3D RA. In a total of 5 aneurysms, the classification was downgraded by 3D RA. Conclusion. 3D RA picks up more aneurysm residue/recurrence; hence, both 2D DSA and 3D RA should be performed in follow-up evaluation of clipped aneurysms.

Challenges in pediatric neuroanesthesia: awake craniotomy, intraoperative magnetic resonance imaging, and interventional neuroradiology

This article gives a review of 3 challenges in caring for children undergoing neurosurgical and neurointerventional procedures. Anesthesiologists may have experience with certain aspects of these situations but may not have extensive experience with each clinical setting. This review addresses issues with awake craniotomy, intraoperative magnetic resonance imaging, and neurointerventional procedures in children with neurologic disease. Familiarization with these complex clinical scenarios and their unique considerations allows the anesthesiologist to deliver optimal care and helps facilitate the best possible outcome for these patients.

Cost-effectiveness of CTA, MRA and DSA in patients with non-traumatic subarachnoid haemorrhage

Objectives

Intra-arterial digital subtraction angiography (DSA), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) are imaging modalities used for diagnostic work-up of non-traumatic subarachnoid haemorrhage. The aim of our study was to compare the cost-effectiveness of MRA, DSA and CTA in the first year after the bleed.

Methods

A decision model was used to calculate costs and benefits (in quality-adjusted life-years [QALYs]) that accrued to cohorts of 1,000 patients. Costs and characteristics of diagnostic tests, therapy, patients’ quality of life and associated costs were respected. The diagnostic strategy with highest QALYs and lowest costs was considered most cost-effective.

Results

DSA was the most effective diagnostic option, yielding on average 0.6039 QALYs (95 % CI, 0.5761–0.6327) per patient, followed by CTA 0.5983 QALYs (95 % CI, 0.5704–0.6278) and MRA 0.5947 QALYs (95 % CI, 0.5674–0.6237). Cost was lowest for DSA (39,808 €; 95 % CI, 37,182–42,663), followed by CTA (40,748 €; 95 % CI, 37,937–43,831) and MRA (41,814 €; 95 % CI, 38,730–45,146). A strategy of CTA followed by DSA if CTA was negative or coiling deemed not feasible, was as effective as DSA alone at average costs of 39,767€ (95 % CI, 36,903–42,402).

Conclusion

A combined strategy of CTA and DSA was found to be the most cost-effective diagnostic approach.

Main Messages

• We defined a standard model for cost-effectiveness analysis in diagnostic imaging.

• Comparing total 1-year health costs and benefits, CTA is superior to MRA.

• A strategy of combining CTA and DSA was found to be the most cost-effective diagnostic approach.

The role of imaging in the diagnosis of central nervous system vasculitis

Cerebral vasculitis is diagnosed with difficulty. Its presentation with heterogeneous symptoms and signs often delays diagnosis. In this context, imaging plays an important role in advancing the diagnosis. Digital subtraction cerebral angiography, MRI, and MRA, the most useful examinations for vasculitis, provide supportive, but not pathognomonic, evidence of cerebral vasculitis. On MRI, multiple infarcts in different vascular territories and of different ages are suggestive of vasculitis. On digital subtraction cerebral angiography, areas of stenosis, dilatation, and occlusion are suggestive of vasculitis. Small vessel vasculitis is currently best demonstrated by changes seen in brain parenchyma on MRI, but high field strength (7 T) magnetic resonance angiography offers the possibility of directly evaluating small vessel vasculitis. Ultrasound and high-resolution contrast MRI are excellent modalities for evaluating the superficial extracranial circulation.

State of the art head and neck imaging for the endovascular specialist

Recent technologic advances including multidetector CT, dynamic CT angiography, high-field MR imaging, four-dimensional MR angiography, and physiologic studies, such as perfusion imaging, have revolutionized the imaging work-up of head, neck, and skull base lesions. These techniques not only provide accurate diagnostic information, but also help plan endovascular therapy. The future holds great promise for interventional neuroradiologists because excellent imaging tools are becoming available that are capable of providing morphologic, hemodynamic, and physiologic information. Furthermore, availability of faster, real-time guidance systems and hybrid systems improves the ability to perform procedures not only in a rapid and safe manner but also with great precision.