Angiographic Appearance Research Articles

POS-751 AN UNUSUAL PRESENTATION OF ARTERI-VENOUS FISTULA AFTER RENAL BIOPSY: CASE REPORT

Renal biopsy is an important diagnostic procedure but is associated with a number of significant complications even when performed by a skilled operator. While most of these complications present with haemodynamic disturbance, pain or macroscopic haematuria, some – such as the development of a post-biopsy arteriovenous fistula may be occult. We present an unusual presentation of a post-biopsy arteriovenous fistula which was diagnosed after the patient reported an audible bruit. A 39-year-old woman with end stage renal disease of unknown etiology received her first kidney transplant in February 2020. The right kidney from a deceased after cardiac death donor was transplanted into her right iliac fossa. Before transplantation, she had been on hemodialysis via an arteriovenous fistula (AVF) for a year. There was delayed graft function and the patient was dialysed through her AVF on the 2nd day of transplantation. Graft function was slow to improve and a kidney biopsy was performed on the 6th day post-transplantation. The biopsy was performed under ultrasound (US)control with two passes of a 16 G needle. Post-procedure observations were unremarkable and the patient went home after 6 hours of bed rest.The biopsy showed borderline rejection and the patient was prescribedthree doses of intravenous methylprednisolone. On the second day post-biopsy, graft function remained poor and routine bloods showed a drop in haemoglobin from 107 to 78 g/L. Abdominal US did not show any abnormality. Patient received blood transfusion and was observed overnight. The patient was discharged home next day. On the 5th day post-biopsy, the patient presented with reports of hearing “buzzing” sounds. ENT review was unremarkable. Graft function was poor and the patient remained on dialysis. Abdominal US and Doppler studies showed a large AVF within the transplanted kidney at the site of the earlier biopsy (fig 1). Figure 1: Doppler ultrasound of renal transplant showing post biopsy AVF The fistula was large and, with evidence of recent bleeding, thus underwent coil embolisation in the interventional radiology department (fig 2). Figure 2: Coil embolisation of AVF. Left panel shows initial angiographic appearance; right panel shows appearance following coil embolisation At present, the patient is nine months post-transplantation and remains dialysis independent with stable graft function and an eGFR 25-30 mL/min/1.73m2. Most biopsy-associated AVFs close spontaneously, are asymptomatic, and do not require intervention. The indication for intervention is usually an increase in the size of fistula over time, the development of signs of heart failure, deterioration in kidney function, or a rise in blood pressure. Embolisation of biopsy-associated AVFs has been reported to result in good outcomes with minimal changes in serum creatinine and estimated glomerular filtration rate. The risks include proximal dissemination of the embolisation material and the resultant focal occlusion of the arterial system causing renal, gut and pulmonary ischaemia. Surgical procedures are reserved for large AVFs with high velocity flows. Complications of kidney biopsy can be asymptomatic, and missed because of late and atypical presentation. A possibility of kidney biopsy related complication should always be considered when a patient presents within few weeks of the kidney biopsy.

Early Venous Filling Following Thrombectomy: Association With Hemorrhagic Transformation and Functional Outcome.

Background and Purpose: Previous studies have noted the angiographic appearance of early venous filling (EVF) following recanalisation in acute ischemic stroke. However, the prognostic implications of EVF as a novel imaging biomarker remain unclear. We aimed to evaluate the correlation between EVF with (i) the risk of subsequent reperfusion hemorrhage (RPH) and (ii) the association of EVF on both the NIHSS score at 24 h and functional outcome as assessed with the Modified Rankin Scale (mRS) score at 90 days.Methods: We conducted a retrospective cohort study of patients presenting with an acute ischemic stroke due to a proximal large-vessel occlusion of the anterior circulation treated by thrombectomy. Post-reperfusion digital subtraction angiography was reviewed to look for EVF as evidenced by the contrast opacification of any cerebral vein before the late arterial phase.Results: EVF occurred in 22.4% of the 147 cases included. The presence of EVF significantly increased the risk of RPH (p = 0.0048), including the risk of symptomatic hemorrhage (p = 0.0052). The presence of EVF (p = 0.0016) and the absence of RPH (p = 0.0021) were independently associated with a better outcome as defined by the NIHSS difference at 24 h, most significantly in the EVF+RPH− group. No significant relationship was however found between either EVF or RPH and a mRS score ≤ 2 at 90 days.Conclusion: Early venous filling on angiographic imaging is a potential predictor of reperfusion hemorrhage. The absence of subsequent RPH in this sub-group is associated with better outcomes at 24 h post-thrombectomy than in those with RPH.

Spontaneous Coronary Artery Dissection in Patients With Fibromuscular Dysplasia.

Clinicians must be mindful of angiographic appearances in patients with spontaneous coronary artery dissection (SCAD) in the setting of fibromuscular dysplasia (FMD) for the timely management of these high-risk patients. The objective is to highlight the clinical diagnostic and treatment modalities in rare case presentations of patients presenting with concurrent SCAD and FMD presentation. A qualitative review of scholarly materials. Twenty-seven patients who presented with a combination of SCAD and FMD from January 1, 2009, to August 2019 were identified. Various demographics such as age, gender, FMD location, acute-phase treatment (i.e., percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) vs. conservative), treatment outcomes, and then grouped into two tables. The mean age >46 years and standard deviation (SD) were used to calculate the normal distribution and percentile used to calculate others for treatment. SCAD and FMD cases were collected from three search engines ranging between 2009 and 2019. 22% of the patients had coronary artery disease (CAD). Additionally, 44.4% representing 12 patients with ST-segment elevation acute myocardial infarction (STEMI), four patients 14.8% presented with a non-ST-segment elevation myocardial infarction (NSTEMI), and nine patients 33.33% offered with unstable angina. Besides, 13 patients were diagnosed with optical coherence tomography (OCT), while intravascular ultrasound (IVUS) diagnosed six patients. SCAD is still very rare compared to other causes of myocardial infarction. Data has shown that up to 25% of acute coronary syndrome (ACS) cases of women between 40 and 65 years are SCAD.

Ischemic Tolerance Evaluated by Computed Tomography Perfusion During Balloon Test Occlusion

Abstract Objectives: Balloon test occlusion (BTO) is performed to evaluate ischemic tolerance for large and giant cerebral aneurysms and head and neck tumors that may require parent artery occlusion. However, ischemic tolerance for the temporary test occlusion does not always guarantee a tolerance for permanent occlusion. In this study, we evaluated the utility of computed tomography (CT) perfusion during BTO to quantify ischemic tolerance for detecting delayed ischemic stroke. Materials and Methods: Forty-one patients who underwent BTO for the internal carotid artery were included. The correlations between the parameters of CT perfusion and collateral angiographic appearance or stump pressure during BTO were evaluated. The cerebral blood flow (CBF), cerebral blood volume, mean transit time (MTT), and time to peak (TTP) were obtained through CT perfusion, and the asymmetry ratios were determined. Collateral angiographic appearances were categorized into 5 grades (0-4). Results: The collateral angiographic appearance showed moderate correlations with CBF, MTT, and TTP that was significant. Of these, the absolute value of the correlation coefficient was the highest for MTT. MTT also showed a moderate correlation with stump pressure. CBF and MTT were significantly different between the poor collateral group (grades 2 and 3) and the good collateral group (grade 4). Based on the MTT, the good collateral group was identified with high sensitivity (75.0%) and specificity (81.2%). Conclusions: In BTO, the MTT obtained through CT perfusion showed a correlation with collateral angiographic appearance and stump pressure. Thus, the MTT might be useful to quantify ischemic tolerance for detecting delayed ischemic stroke.

Abstract 14631: Assessment and Resolution of Complex Coronary Configurations by the Multi-artery Fractional Flow Reserve Method

Introduction: Statistical studies have shown that an FFR method is superior to the traditional coronary assessment method based on angiographic appearance. The current FFR-oriented methods (resting P d / P a , wave-free iFR and hyperemic FFR) however, share a common downside: They do not consider inter arterial interactions and therefore cannot resolve multi-artery configurations, a vital capability provided by the novel multi-artery FFR method. Methods: An independent stand-alone stenotic coronary artery is characterized by its intrinsic FFR (denoted FFR true ). In a multi-artery configuration however, it is influenced by interconnected arteries and the treatment decision criteria apply to the actual FFR (denoted FFR real ) that reflects the arterial current condition. Seeking an optimal resolution of a stenotic configuration, outcomes (FFR true and FFR real ) of optional revascularizations are predicted and evaluated by the multi-artery FFR method. Results: In this work the multi-artery FFR method is applied to the stenotic unprotected configuration LMCA-LCx-LAD-M 2 (second obtuse marginal). The initial characteristics of the configuration are: FFR true (LMCA)=0.87 FFR true (LCx)=0.76 FFR true (LAD)=0.92 FFR true (M 2 )=0.93 FFR real (LMCA)=0.75 FFR real (LCx)=0.67 FFR real (LAD)=0.82 FFR real (M 2 )=0.63 After optimal resolution (by hyperemic FFR criteria), the final characteristics are: FFR true (LMCA)=0.87 FFR true (LCx)=1.00 FFR true (LAD)=1.00 FFR true (M 2 )=0.93 FFR real (LMCA)=0.87 FFR real (LCx)=0.87 FFR real (LAD)=0.87 FFR real (M 2 )=0.80 Conclusions: This work shows that a prerequisite for a successful resolution of a stenotic coronary configuration is a prior numerical simulation of the whole process in which the multi-artery FFR method is applied to the measured intracoronary pressures. This holds for each FFR-oriented method, preserving its specific experimental technique and treatment decision criteria. In conclusion, the multi-artery FFR method has the potential to introduce the PCI practice into an all new era in which the practitioner can devise a resolution strategy and test it by predicting outcomes (in terms of FFR true and FFR real of the arteries) of potential revascularizations, prior to actual implementation.

Abstract 16206: An Atypical Presentation of Spontaneous Coronary Artery Dissection in a Young Male Patient

Background: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women but rare in young healthy males. We report a case of a young male who presented with left hand tingling/numbness and was ultimately diagnosed with SCAD. Case Presentation: A 24-year-old male with history of asthma developed left hand tingling/numbness while playing basketball. This progressed to cold left upper extremity, prompting him to go to emergency room. Doppler ultrasound showed acute left brachial thrombus and emergent embolectomy of left brachial artery was done. Transesophageal echocardiogram, performed to investigate possible cardiac source of thrombus, showed normal ejection fraction, dyskinetic apex and biventricular thrombus (Figure 1A). Cardiac MRI revealed a large transmural MI in distribution of a wraparound left anterior descending artery (LAD) with associated regional akinesis of the left ventricular apex and an infarct in the right ventricular apex. Subsequent angiography revealed normal coronary arteries (Figure 1B) except a heterogenous linear filling defect in the apical LAD consistent with Type 1 SCAD (Figure 1C). No intervention was performed and the patient was treated conservatively. It was postulated that patient sustained an apical MI after SCAD of LAD, leading to formation of ventricular thrombi which then embolized to cause acute brachial artery thrombosis. Discussion: SCAD in young males is rare and can be a diagnostic challenge. Type 1 “pathognomic” angiographic finding in SCAD, is the classic appearance of multiple radiolucent lumens or arterial wall contrast staining. In case of inconclusive angiography, intravascular ultrasound or optical computed tomography can confirm diagnosis. Interventionalists should be familiar with angiographic appearance of SCAD as advanced imaging might not be available and in many cases, conservative management is preferred to percutaneous coronary intervention.

Time for a new paradigm shift from STE/non-STEMI to ACO/non-ACOMI?

Abstract Introduction Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and cause a substantial amount of false catheterization laboratory activations. Purpose We sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy. Methods A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 hours and angiographic appearance. Results In non-STEMI group, 282 patients were re-classified as having ACO. This subgroup had a higher ACO frequency and myocardial damage compared to NSTEMI group. More importantly, in-hospital and long-term mortality rates was similar to STEMI patients. The ECG reviewers prospectively classified 35.6% of ECGs as STEMI and 35.5% of ECGs as ACOMI; 25.6% being shared in the both definitions. Both unweighted and weighted diagnostic accuracy of STEMI/non-STEMI and ACOMI/non-ACOMI approaches for ACO and long-term mortality were presented in Table 1. The diagnostic accuracy of the ACOMI/non-ACOMI approach was superior to the STEMI/non-STEMI approach in three out of four comparisons. We also sought to compare ECG subtypes according to early (ECG-to-PCI time<120 min) and late (ECG-to-PCI time over 120 min) coronary intervention (Figure 1). Conclusions We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. Figure 1 Funding Acknowledgement Type of funding source: None

Spontaneous coronary artery dissection (SCAD) in men: an observational study

Abstract Background/Introduction SCAD is a rare cause of acute coronary syndrome. Approximately 90% of SCAD patients are women, and factors such as the hormonal changes of the menstrual cycle are thought to be relevant. It is therefore interesting to consider why patients without such hormonal exposure may be affected. SCAD in men remains poorly understood. Purpose To study the clinical features and natural history of SCAD in men and to see how it differs from SCAD in women. Methods Patients with SCAD were recruited by self-referral and clinician referral from across the UK. Angiograms are reviewed by two experienced cardiologists and other data is obtained from patient questionnaires and from medical records. Results 53 male SCAD patients were identified from the registry. Mean age at SCAD was 47±5.4 (SD). 1 presented with cardiac arrest, 2 as chronic dissections without a clear acute event, 15 as STEMI and 32 as NSTEMI; admission ECGs were not available for 3 patients. The vessel affected was the circumflex in 15 patients, RCA in 4, LAD in 27 and multi vessel in 7. SCAD type was 1 in seven patients, 2a in 21, 2b in 16, 3 in 7 and 4 in 2. LV function post SCAD was normal in 37 out of 50 patients with data available and mean EF was 52.4%. Of 37 with cardiac MRI data, 11 had no visible late gadolinium enhancement. 23 patients had been screened for fibromuscular dysplasia and only 1/23 had this diagnosis. 2 other patients had a non-FMD aortopathy (dilated ascending aorta) and 1 had a very small cerebral aneurysm that was not thought to represent FMD. Mean follow up from the first SCAD event was 3 years (SD 2 years); over this time period 10/51 patients had recurrent SCAD (2 patients presented as chronic dissections on elective angiography and it was not possible to date the index event). Conclusions This is the largest study so far reported of SCAD in men. The mean age was similar to that seen in women, though with a narrower age range, and the proportions of STEMI and NSTEMI are also similar. The most frequently affected vessel was the LAD. Type 2 SCAD was by far the commonest angiographic appearance. The majority of patients had preserved LV systolic function and a significant proportion had no measurable scar. These findings suggest that the presenting features of SCAD in men are very similar to those in women. The incidence of FMD appears to be far lower than in women, however; studies in female SCAD patients suggest that FMD is present in 11–86% (depending on methods used for screening). Finally, rate of recurrent SCAD in men appears significant. The largest series so far reported in SCAD (327 patients, 90.5% women, followed prospectively) showed a recurrence rate of 10.4% over 3 years. We saw a recurrence rate of 19.6%. This may simply represent the play of chance in a small population, or recruitment bias as our study is primarily retrospective, however it is an intriguing observation worthy of further investigation. Funding Acknowledgement Type of funding source: Other. Main funding source(s): BeatSCAD

Moyamoya: An Update and Review.

This article is a clinical review of Moyamoya disease (MMD) and Moyamoya syndrome (MMS). We review the incidence, epidemiology, pathology, historical context, clinical and radiographic findings, diagnostic imaging modalities, radiographic grading systems, the effectiveness of medical, interventional, and surgical treatment, and some of the nuances of surgical treatment options. This article will help pediatricians, neurologists, neurosurgeons, and other clinical practitioners who are involved in caring for patients with this rare clinical entity.MMD is an intrinsic primary disease process that causes bilateral progressive stenosis of the anterior intracranial circulation with the involvement of the proximal portions of the intracranial internal carotid artery (ICA) extending to involve the proximal portions of the anterior cerebral artery (ACA) and middle cerebral artery (MCA); posterior circulation involvement is very rare. This causes a compensatory response where large numbers of smaller vessels such as the lenticulostriate arteries begin to enlarge and proliferate, which gives the angiographic appearance of a "Puff of Smoke", which is translated into Japanese as "Moyamoya”. MMS is a secondary process that occurs in response to another underlying pathological process that causes stenosis of intracranial blood vessels, such as radiation. For example, an external source of radiation causes stenosis of the ICA with a compensatory response of smaller blood vessels, which then enlarge and proliferate in response and has the same "Puff of Smoke" appearance on the diagnostic cerebral angiogram (DCA).Histological findings include an irregular internal elastic lamina with luminal narrowing, hyperplasia of the tunica media, and intimal thickening with vacuolar degeneration in smooth muscle cells in the tunica media. Compensation for diminishing blood supply occurs through angiogenesis, which causes the proliferation and enlargement of smaller collateral blood vessels to increase blood supply to under-perfused areas of the brain.MMD is rare in the United States, with just 0.086 newly diagnosed cases per 100,000 individuals per year, which is approximately one per million new cases annually. Risk factors for MMD include Eastern Asian ancestry and predisposing conditions such as neurofibromatosis and Down's syndrome.Clinically, patients often present with stroke signs and symptoms from cerebral ischemia. The proliferation of collateral blood vessels within the basal ganglia can produce movement disorders. Catheter-based DCA is the current gold standard for obtaining a diagnosis. CT perfusion allows preoperative identification of ischemic vascular territories, which may be amenable to surgical intervention. MRI enables rapid detection of acute ischemic stroke using diffusion-weighted Imaging (DWI) and apparent diffusion coefficient (ADC) sequences to assess for any diffusion restriction. Non-contrast CT of the head is used to rule out acute hemorrhage in the presentation of a progressive neurological deficit.The treatment option for Moyamoya is generally surgical; medical treatment has failed to halt disease progression and neuro-interventional techniques such as attempted stenting of stenosed vessels have failed. Surgical options include direct and indirect cerebrovascular bypass.

Coronary Artery Vasospasm: A Under-recognized Phenomenon in Orthotopic Heart Transplant

Introduction Cardiac allograft vasculopathy (CAV) is known as the primary cause of death in the first year after orthotopic heart transplant (OHT). Coronary artery spasm (CAS) in OHT is a rare and under-recognized phenomenon in patients undergoing surveillance. The mechanism of coronary vasospasm in OHT remain largely unknown. The presentation can vary from an incidental finding to severe episodes of symptomatic ventricular arrhythmias, high-degree atrioventricular block, syncope, cardiac arrest, or even myocardial infarction in cases of prolonged ischemia. Case Presentation 65 yo female with history of chronic kidney disease, diabetes mellitus type 2, hypertension, hyperlipidemia, and orthotopic heart transplantation with CMV mismatch in 2016 secondary to apical hypertrophic cardiomyopathy. Prior coronary angiography (CA) done at our institution had shown no evidence of vasculopathy. During one of her follow-up visits in the Clinic, she complained of increasing dyspnea on exertion, prompting urgent referral for CA, as per our surveillance protocols. Prior to the procedure, echocardiography was performed which revealed normal graft function and no valvular abnormalities. She underwent CA which showed a proximal significant diffuse luminal narrowing of the right coronary artery (RCA) (Image 1) and normal left coronary artery anatomy (Image 2). We proceed to repeat CA with intracoronary administration of nitroglycerin (ICN) and measurement of fractional flow reserve (FFR) of RCA (Image 3, 4). Angiography revealed near resolution of the RCA lesion, ultimately suggesting that transient vasospasm had been responsible for the previous angiographic appearance (Image 1). Summary CAS can present in patients with or without vasculopathy. It can produce luminal narrowing and can be difficult to distinguish angiographically from CAV. Misdiagnosis of this entity has led to the incorrect diagnosis of CAV and subsequent unnecessary stenting. ICN use can improve angiographic visualization, and prevent the adverse effects of coronary spasm. In conclusion, CAS is a rare and potential complication post OHT. It is a difficult entity to prognosticate due to scarcity of clinical evidence, as prevalence ranges from 4.9% to 12.1%. Some authors hypothesize that CAS in OHT carries a poor prognosis as it is often an early manifestation of CAV. However, this remains largely hypothetical and further studies are needed to better understand this disease.

Incidental Diagnosis of an Arachnoid Granulation on Ga-68 DOTATATE PET/MRI.

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The long-term effects of anti-vascular endothelial growth factor therapy on the optical coherence tomography angiographic appearance of neovascularization in age-related macular degeneration

BackgroundThe short-term effects of anti-vascular endothelial growth factor (anti-VEGF) treatment on macular neovascularization (MNV) morphology is well described, but long-term studies on morphologic changes and correlation of such changes to the type of MNV have not been conducted. This study aims to determine if different types of MNVs in neovascular AMD (nAMD) behave differently with anti-VEGF treatment as visualized on optical coherence tomography angiography (OCTA).MethodsTreatment-naïve nAMD patients were retrospectively screened for baseline and follow-up OCTA imaging 10 or more months after initial treatment. Images were graded for MNV type, area, activity, mature versus immature vessels, vessel density, presence of atrophy, atrophy location and area. Growth rate was calculated as the percent change in lesion area from baseline over the years of follow-up. In addition, the occurrence of complete regression and the percent of lesions that grew, remained stable, and shrunk per type was also evaluated.ResultsForty-three eyes from 43 patients with a mean follow-up of 2 years were evaluated. On structural OCT, 26 lesions were classified as pure type 1 MNVs, 12 MNVs had a type 2 component, and 5 MNVs had a type 3 component. Of these cases, 2 mixed-type MNVs were considered to have completely regressed. There was no significant differences in MNV area and growth rate between type 1 and type 2 lesions, but all cases of type 3 lesions shrunk in the follow-up period. There was no correlation between the number of injections per year and growth rate, endpoint MNV area or endpoint activity status for any MNV type. There was no significant association between the development of atrophy and the number of injections, baseline MNV area, baseline vessel density, or lesion growth rate.ConclusionsIn nAMD, complete regression of an MNV network exposed to anti-VEGF is rare. This work emphasizes the role of anti-VEGF as anti-leakage rather than vascular regression agents in nAMD.

Defining the Cause of Postpartum Myocardial Infarction - Another Use for Optical Coherence Tomography.

SCAD is a rare entity and considered the most common cause of STEMI in the postpartum state.OCT is an intracoronary imaging modality utilizing light waves for image acquisition with high resolution, assisting in clinical decision-making regarding the pathophysiological mechanism of an acute coronary syndrome (ACS).In suspected cases of SCAD, coronary angiography remains the first diagnostic line and OCT can be crucial in confirming an ambiguous angiographic appearance.

DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study).

BackgroundAlthough ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy.MethodsA total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database.ResultsIn non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality.ConclusionsWe believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.)

Vascular Trauma in the Head and Neck and Endovascular Neurointerventional Management.

Traumatic vascular injuries of the head and neck can pose life-threatening emergencies, and therefore, the detection and accurate characterization of these injuries by the radiologist is essential. Computed tomographic angiography (CTA) is commonly performed as part of the initial imaging work-up of patients who have sustained blunt or penetrating craniocervical injuries and are suspected to have or are at risk for vascular injuries. This pictorial essay reviews the CTA and conventional angiographic imaging appearance of various vascular injuries that can occur from trauma in the head and neck and also explores the neurointerventional management of these types of injuries.

Dural Venous Channels: Hidden in Plain Sight-Reassessment of an Under-Recognized Entity.

Tentorial sinus venous channels within the tentorium cerebelli connecting various cerebellar and supratentorial veins, as well as the basal vein, to adjacent venous sinuses are a well-recognized entity. Also well-known are "dural lakes" at the vertex. However, the presence of similar channels in the supratentorial dura, serving as recipients of the Labbe, superficial temporal, and lateral and medial parieto-occipital veins, among others, appears to be underappreciated. Also under-recognized is the possible role of these channels in the angioarchitecture of certain high-grade dural fistulas. A retrospective review of 100 consecutive angiographic studies was performed following identification of index cases to gather data on the angiographic and cross-sectional appearance, location, length, and other features. A review of 100 consecutive dural fistulas was also performed to identify those not directly involving a venous sinus. Supratentorial dural venous channels were found in 26% of angiograms. They have the same appearance as those in the tentorium cerebelli, a flattened, ovalized morphology owing to their course between 2 layers of the dura, in contradistinction to a rounded cross-section of cortical and bridging veins. They are best appreciated on angiography and volumetric postcontrast T1-weighted images. Ten dural fistulas not directly involving a venous sinus were identified, 6 tentorium cerebelli and 4 supratentorial. Supratentorial dural venous channels are an under-recognized entity. They may play a role in the angioarchitecture of dural arteriovenous fistulas that appear to drain directly into a cortical vein. We propose "dural venous channel" as a unifying name for these structures.

Ischemic Tolerance Evaluated by Computed Tomography Perfusion during Balloon Test Occlusion

Objectives: Balloon test occlusion (BTO) is performed to evaluate ischemic tolerance for large and giant cerebral aneurysms and head and neck tumors that may require parent artery occlusion. However, ischemic tolerance for the temporary test occlusion does not always guarantee a tolerance for permanent occlusion. In this study, we evaluated the utility of computed tomography (CT) perfusion during BTO to quantify ischemic tolerance for detecting delayed ischemic stroke. Materials and Methods: Forty-one patients who underwent BTO for the internal carotid artery were included. The correlations between the parameters of CT perfusion and collateral angiographic appearance or stump pressure during BTO were evaluated. The cerebral blood flow (CBF), cerebral blood volume, mean transit time (MTT), and time to peak (TTP) were obtained through CT perfusion, and the asymmetry ratios were determined. Collateral angiographic appearances were categorized into 5 grades (0-4). Results: The collateral angiographic appearance showed moderate correlations with CBF, MTT, and TTP that was significant. Of these, the absolute value of the correlation coefficient was the highest for MTT. MTT also showed a moderate correlation with stump pressure. CBF and MTT were significantly different between the poor collateral group (grades 2 and 3) and the good collateral group (grade 4). Based on the MTT, the good collateral group was identified with high sensitivity (75.0%) and specificity (81.2%). Conclusions: In BTO, the MTT obtained through CT perfusion showed a correlation with collateral angiographic appearance and stump pressure. Thus, the MTT might be useful to quantify ischemic tolerance for detecting delayed ischemic stroke.

Unstable Angina Caused by Honeycomb-Like Coronary Lesion Identified with Use of Optical Coherence Tomography

A 67-year-old man had angina and dyspnea for several weeks during exercise and rest, and he came to our hospital for coronary angiography. He had mild ST-segment variability, without necrosis markers. Cardiac ultrasonograms revealed moderate mitral regurgitation, preserved ejection fraction, and a posterior-wall infarction scar despite no history of infarction.Coronary angiograms, which revealed no obvious culprit lesion, showed mild focal stenosis in the proximal right coronary artery, distal chronic occlusion of a small left circumflex coronary artery, and mild stenosis and haziness in the mid left anterior descending coronary artery (LAD) (Fig. 1). Suspecting thrombus in the mid LAD, we performed optical coherence tomography (OCT) (Fig. 2A). The OCT showed irregular honeycomb-like channels connecting the proximal and distal lumina, smooth appearance of the channels' inner surface and the separating septa, no visible fresh thrombus, and only a small plaque burden at the lesion site (Fig. 2B–E). We thought that the guidewire might have passed into a false lumen of a spontaneous dissection, so we advanced another guidewire, parallel to the first, to ensure entry into the distal true lumen.Given the patient's clinical instability, we performed angioplasty and implanted a bare-metal stent. Afterwards, OCT confirmed good distal flow without residual stenosis and showed a well-apposed stent, mild intima prolapse through the struts (Fig. 3A), and almost complete collapse of the parallel channels (Fig. 3B). Two years later, the patient was asymptomatic and well.Lesions of this type were previously associated with recanalized thrombus.1,2 They were compared with Swiss cheese,1 or, when channels were spread over a larger area, with a honeycomb—a term coined by Toutouzas and colleagues.2In our patient, the small plaque burden at the lesion site seen on coronary angiography suggested an organized coronary embolus, but OCT revealed a recanalized thrombus. This rare case highlights the need to recognize the limits of angiography and to use complementary imaging methods, especially when angiographic appearance is discordant with clinical status.

P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection

Abstract Introduction Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness. Case report We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN< 15.6) and CK 874U/l (ULN <168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic. Discussion and conclusion The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option. Abstract P715 Figure. angio-CT

Changes in the OCT angiographic appearance of type 1 and type 2 CNV in exudative AMD during anti-VEGF treatment

ObjectiveOptical coherence tomography angiography (OCT-A) enables detailed visualisation of the vascular structure of choroidal neovascularisation (CNV). The aim of this study was to determine whether mathematically ascertained OCT-A vascular parameters...