Angiographic Appearance Research Articles

The arrow-tipped loop is a marker of radiculomedullary vein thrombosis linked to the anti-reflux mechanism—angiographic anatomy and clinical implications

This article proposes that the "arrow-tipped" loop or anastomosis classically described as an anatomic variant represents in fact a pathological phenomenon resulting from the partial thrombosis of a radiculomedullary vein (RMV) with a duplicated origin (double-rooted RMVs). The arrow-tip loop concept proposed in this report is illustrated with angiographic observations of patients with underlying pathologies of the spinal venous system, three cases of spinal arteriovenous fistulas, and one case of spinal venous insufficiency. In each clinical case, the presence of arrow-tip loops was associated with diffuse alteration of the perimedullary venous system, including the lack of detectable RMVs. The angiographic appearance of the arrow-tip loops suggested partially thrombosed double-rooted RMVs, with rootlets originating either from the anterior or posterior spinal veins, or from both. While a thrombosed single-rooted RMV typically becomes anatomically and angiographically undetectable, double-rooted MRVs keep a flowing proximal segment made of their two rootlets of origin. This residual proximal segment takes the appearance of an arrow-tip loop, which therefore be seen as an indicator of spinal venous thrombosis.

Interventional treatment of arterio-venous malformations

BackgroundDue to their hemodynamic effects and tendency to progress, the majority of congenital arterio-venous malformations (AVM) require treatment. AVM are classified according to clinical severity (Schobinger classification, stages I–V) and angiographic appearance (types I–IV).TreatmentEndovascular embolization is the treatment of choice. However, because complications such as necrosis and neuropathy occur in up to 15% of cases, treatment is challenging and is dependent on the angiographic appearance. Critical for treatment success is elimination of the so-called nidus, which is the location of the short circuit connection between the artery and the often extended aneurysm-like drainage vein. Embolization of only the feeding artery without the actual nidus or the incomplete elimination of drainage veins should be avoided. Absolute 96 % alcohol in addition to coiling of the nidus has been established as the most effective technique.ConclusionUnlike other embolic agents, alcohol leads to a definitive destruction of the vessel wall. Recanalization and recurrence are excluded due to adequate elimination of the nidus.

E-003 Aneurysm Re-treatments Following Recurrences After Initial Use of the Pipeline Embolization Device

IntroductionAlthough the Pipeline Embolization Device (PED, eV3 Neurovascular, Irvine, California) has provided the field of neuro-interventional surgery with a significant leap forward in the treatment of cerebral aneurysms, treatment failures...

Moya Moya disease presenting as Chorea: A case report

Moya moya disease is a rare disease characterized by multiple occlusions of the cerebral circulation with an unusual net like system of collaterals. In Japanese moya moya means HAZY. The disease derives its peculiar name from the angiographic appearance of cerebral vessels in the disease that resembles a `PUFF OF SMOKE`. Ischemic insult is more common in children. Chorea is rarely noted with this disease. When a child presents with chorea, clinicians may attribute this symptom to a number of diseases. Any child with involuntary movements, moya moya disease can be a possibility.

Segmental arterial mediolysis, a vasculitis mimic: Case report and review of literature

Segmental Arterial Mediolysis (SAM) is a non-inflammatory vascular condition that most commonly affects the medium sized vessels in the abdomen including splanchanic and renal arteries. Its angiographic appearance closely mimics other conditions affecting these blood vessels, such as polyarteritis nodosa (PAN), infections such as syphilis and fibromuscular dysplasia. SAM is under-recognized, however it is important to distinguish it from PAN because the management of the two conditions differs significantly. Here we report a case of a woman presenting with intra-abdominal bleeding, with imaging evidence for large retroperitoneal hematoma. Arteriography revealed diffuse, segmental dilation and aneurysms of the arterial supply to the entire colon. Discussion includes review of current understanding of physiopathology, clinical features, imaging, and differential diagnosis of this rare disease. Recent highlights on the disease course are also discussed.

ACUTE CORONARY SYNDROME DUE TO LEFT MAIN PLAQUE RUPTURE, WITH NEGATIVE FFR AND MILD ANGIOGRAPHIC STENOSIS: TO REVASCULARIZE OR NOT?

Deferring revascularization of a hemodynamically insignificant, intermediate left main (LM) lesion in the setting of stable coronary artery disease is well established. However, in a patient with acute coronary syndrome (ACS) due a left main plaque rupture that has mild angiographic appearance and

“Nipple” and “hawk's beak” appearances on contrast left ventricular angiography in Takotsubo syndrome: What's in a sign?

Appearances at left ventricular (LV) contrast angiography of patients presenting with Takotsubo syndrome (TTS) vary depending on the cardiac region that is impacted by the affliction. Desmet et al. recently reported [1] on their series of 119 patients with TTS, who had LV contrast angiography at cardiac catheterization, 92 of whom had the apical variety of TTS, characterized by systolic ballooning of the LV apex with preservation of LV basal contractility; out of these 92 patients, 28 (30.4%) had a “very small zone with preserved contractility in the most apical portion of the LV”, for which the authors coined the term “apical nipple sign”, which by contrast was not present in any of 405 patients “who had been treated for anterior ST-elevation myocardial infarction (STEMI) by emergency percutaneous intervention on the left anterior descending artery”. Thus the “apical nipple sign” may aid in the differential diagnosis of apical TTS from anterior STEMI. Roncalli et al. [2] recently reported the case of a 76-year-old womanwith the midventricular variant of TTS, characterized by LV midventricular systolic ballooning with preservation of LV apical contractility, which gave the appearance of a “hawk's beak” to the LV apex, prompting the authors to proposing the “hawk's beak” as an angiographic diagnostic sigh of the midventricular variant of TTS. Since TTS is characterized by a large variation in LV wall motion abnormalities (LVWMAs) of individual afflicted patients, more such signs are expected to be observed at contrast LV angiography. In addition there have been descriptions of patents with TTS with repeat presentations featuring different patterns of LVWMAs, or involvement of LV and/or right ventricle, during the same, or temporally different, admissions for TTS [3–14]. Furthermore territorial “migration” of LVWMAs has been noted in some patients in serial imaging studies, with akinesis involving different LV regions and recovery of previously involved regions [15]. The remarks by Desmet et al. [1] about their patients with LV apical TTS with the “apical nipple sign” as clinical TTS phenotypes representing presentation of “a very extensive form of the mid-ventricular variant of apical TTS, just nearly missing evolvement to truly complete apical akinesis”, or that the “apical nipple sign” may represent the “earliest stage of mechanical recovery of a true apical ballooning” are relevant of a need for serial heart imaging for patients admitted with suspected, or subsequent proven, TTS. Certainly such repeated imaging cannot be implemented with contrast LV angiography, or computed axial tomography angiography, or magnetic resonance angiography, but with echocardiography. The later modality, which may be argued that may lack sensitivity for such a role, particularly in interrogation of LV apex, should be vigorously evaluated in its classic application, and the currently enhanced format of two-dimensional speckle tracking [16]. The hypotheses of Desmet et al. about the mechanism of the “apical nipple sign” being due to very extensive form of the mid-ventricular variant of apical TTS [1] and Roncalli et al. about the “hawk's beak” as a sign of a midventricular variant of TTS [2], notwithstanding these 2 LV contrast angiographic appearances, may not be substantially different phenotypes of TTS. We should all be on the look-out for more LV and right ventricular angiographic “signs”, and naturally for more names, as more cases of TTS are being detected.

Superior rectal artery origin from the median sacral artery—angiographic appearance, developmental anatomy, and clinical implications

Two angiographic observations of significant rectal vascularization by branches originating from the median sacral artery (MSA) are reported. In the first case, the MSA provided a complete superior rectal trunk, with left and right branches, while in the second, the MSA only contributed superior rectal branches to the right side of the rectum, the left side being supplied by left internal iliac branches. The angiographic appearance, developmental anatomy, and clinical significance of these variants are discussed.

Contrast Layering

Patients with angiographically normal coronary arteries sometimes exhibit delayed clearance of contrast medium. This contrast layering (CL) was tested with intravascular ultrasound (IVUS) and markers of endothelial dysfunction and oxidative stress. The study group (n = 26) consisted of patients with CL and the control group (n = 32) comprised patients with normal coronary arteries despite angina symptoms. The CL was observed in 36 coronary arteries of 26 patients in the study group. Total antioxidant status and nitric oxide levels were significantly lower; total oxidant status, malondialdehyde plasma levels, and oxidative stress index were significantly higher in patients with CL than in controls. The IVUS studies revealed that atherosclerotic plaque burden, fibrous tissue, dense calcific tissue, and necrotic core ratios were significantly higher in the coronary segments with CL compared with adjacent normal segments. These results support the concept of CL as a new angiographic appearance of early atherosclerosis.

Abstract 18568: Normal Angiographic Appearance of the Coronary Arteries is Common in Antiphosopholipid Syndrome Patients Presenting With Acute Coronary Syndrome

Background: Antiphospholipid syndrome (APLS) is known to be associated with Acute Coronary Syndrome (ACS) due to coronary artery thrombosis or embolism. Because individual cases of ACS with normal angiographic appearance of the coronary arteries have been reported in this population, we aimed to determine the prevalence of this presentation amongst patients with known APLS at our institution. Methods: Our institutional database was queried for all patients testing positive for antiphospholipid antibodies (n=575) between 2000 and 2012. From this sample, we identified 46 patients having cardiac catheterization. ACS (n=32) was defined as the presence of angina chest pain, ECG with ST segment or T-wave abnormalities and troponin-I > 0.1 mg/dL. Results: Normal appearing coronary arteries, without evidence of atherosclerosis or embolism, were found in 8 patients (52±7 years, 5 female) with APLS (lupus anticoagulant n=5; anti-cardiolipin n=5; anti-B2-GP1 n=3) presenting with ACS. All 8 patients had history of prior arterial (stroke n=5) or venous thrombosis (n=3). Median troponin-I was 0.30 mg/dL [range 0.15, 0.50]. One subject was found to have diffuse coronary artery spasm, which reversed following administration of intra-coronary nitroglycerine. One patient had a regional wall motion abnormality in a single territory and another patient had global ventricular dysfunction. Median left ventricular ejection fraction was 60% [range 30, 60]. Conclusions: A high proportion of patients with APLS presenting with ACS did not have evidence of either coronary thrombosis or embolism on angiography. This clinical presentation is suspicious for either coronary artery spasm or myopericarditis.

Angiographic Perfusion Imaging: Real‐Time Assessment of Endovascular Treatment for Cerebral Vasospasm

Cerebral perfusion analysis is useful in the diagnosis and treatment of cerebral vasospasm. A new modality of real-time cerebral perfusion imaging and analysis has been developed using standard 2-dimensional angiography. We report our initial experience with this technique to assess response to therapy during endovascular vasospasm procedures. Colorized angiographic perfusion maps were obtained immediately before and after endovascular vasospasm treatment. Semiquantitative perfusion parameters (cerebral blood flow, cerebral blood volume, mean transit time, and time to peak) were calculated from time-density curves obtained from intraarterial contrast injection. The effects of intraarterial vasospasm therapy were assessed. Eight vascular territories in 4 patients with vasospasm underwent interventional angiography and angiographic perfusion analysis. Pretreatment perfusion maps demonstrated variable perfusion deficits in specific vascular territories. After endovascular treatment in 6 vessels, improvement was seen to varying degrees in both angiographic appearance and perfusion parameters. Clinical improvement and reduction in transcranial Doppler velocity was also observed. Real-time angiographic perfusion imaging is feasible during endovascular procedures for vasospasm. Perfusion analysis may aid in assessment of efficacy of the intervention. Comparison with traditional perfusion imaging is needed to validate this technique.

Catastrophic Reversible Cerebral Vasoconstriction Syndrome Associated With Serotonin Syndrome

To report fulminant cases of reversible cerebral vasoconstriction syndrome (RCVS) in the setting of serotonin syndrome. RCVS is characterized by acute onset of severe headaches, with or without neurologic deficit, with evidence of reversible cerebral vasoconstriction. It is often benign, and prognosis is generally considered favorable. In the largest prospective study on RCVS, only 4% of patients were disabled from strokes and there were no fatalities. We report a case series. We report 2 women with history of depression on selective serotonin re-uptake inhibitors who presented with thunderclap headache and dizziness, respectively. Through the course of hospitalization, both patients developed rigidity, diaphoresis, fever, tachycardia with labile blood pressures and clonus on examination. Since there was a recent addition/increase in a known serotonergic agent, they met criteria for serotonin syndrome. Cerebrovascular imaging in both patients revealed severe multi-focal vessel narrowing. The first patient developed large bi-hemispheric ischemic infarcts and increased intra-cranial pressure that was refractory to management, and she eventually expired. The second patient developed bilateral parieto-occipital strokes and decerebrate posturing. Her course slowly stabilized, and she was eventually discharged with residual left-sided hemiparesis. Repeat cerebrovascular imaging 1 month later showed normal vessels. In both patients, intra-arterial nicardipine infusion improved angiographic appearance of stenoses, consistent with RCVS. Both cases satisfied the Sternbach criteria for serotonin syndrome. Fatality in case 1 prevents demonstration of reversal of cerebral vasoconstriction, but improvement of arterial diameters with intra-arterial calcium channel blockers in both cases suggests that both had RCVS. Serotonergic agents are known triggers of RCVS, but the concurrent presence of serotonin syndrome likely precipitated the malignant course in our patients. Severe clinical and angiographic manifestations should be considered as part of the spectrum of RCVS.

Phenotype/genotype correlation in a case series of Stargardt’s patients identifies novel mutations in the ABCA4 gene

To investigate phenotypic variability in terms of best-corrected visual acuity (BCVA) in patients with Stargardt disease (STGD) and confirmed ABCA4 mutations. Entire coding region analysis of the ABCA4 gene by direct sequencing of seven patients with clinical findings of STGD seen in the Retina Clinics of Southampton Eye Unit between 2002 and 2011.Phenotypic variables recorded were BCVA, fluorescein angiographic appearance, electrophysiology, and visual fields. All patients had heterozygous amino acid-changing variants (missense mutations) in the ABCA4 gene. A splice sequence change was found in a 30-year-old patient with severly affected vision. Two novel sequence changes were identified: a missense mutation in a mildly affected 44-year-old patient and a frameshift mutation in a severly affected 34-year-old patient. The identified ABCA4 mutations were compatible with the resulting phenotypes in terms of BCVA. Higher BCVAs were recorded in patients with missense mutations. Sequence changes, predicted to have more deleterious effect on protein function, resulted in a more severe phenotype. This case series of STGD patients demonstrates novel genotype/phenotype correlations, which may be useful to counselling of patients. This information may prove useful in selection of candidates for clinical trials in ABCA4 disease.

GW24-e2526 Clinical characteristics, coronary angiographic and intravascular ultrasound appearances in the patients with ectopic right coronary artery originating from left coronary sinus

ObjectivesTo study clinical characteristics, coronary angiography appearance and the effect of drug-eluting stent implantation in the patients with ectopic right coronary artery (RCA) originating from left sinus and passing between...

Human placenta as an ex vivo vascular model for neurointerventional research

BackgroundHuman placenta is a convenient resource for biomedical research, and has not yet been used for neurointerventional surgery research.ObjectiveOur objective was to explore the feasibility of using human placenta to...

Differences in the Angiographic Evaluation of Coiled Cerebral Aneurysms between a Core Laboratory Reader and Operators: Results of the Cerecyte Coil Trial

Independent evaluation of angiographic images is becoming widely applied in the assessment of treatment outcomes of cerebral aneurysms. In the current study, we assessed the agreement between an independent core laboratory and the operators regarding angiographic appearance in a recent randomized, controlled trial. Data were derived from the Cerecyte Coil Trial. Angiographic images of each coiled aneurysm, taken immediately after embolization and at 5- to 7-month follow-up, were evaluated by the operator at the treating center and by an independent neuroradiologist at the core laboratory. For the purpose of this study, images were interpreted on a 3-point scale to provide uniformity for analysis; grade 1: complete occlusion, grade 2: neck remnant; and grade 3: sac filling. "Unfavorable angiographic appearance" was defined as grade 3 at follow-up or interval worsening of grade between the 2 time points. The study included 434 aneurysms. Immediately after embolization, grade 3 was reported by operators in 39 (9%) compared with 52 (12%) by the core laboratory (P = .159). On follow-up, grade 3 was reported by operators in 44 (10%) compared with 81 (19%) by the core laboratory (P < .0001). Overall, operators noted unfavorable angiographic appearance in 78 (18%) compared with 134 (31%) by the core laboratory (P < .0001). At every time point, agreement between the core laboratory and the operators was slight. Unfavorable angiographic appearance was noted almost twice as frequently by an independent core laboratory as compared with the operators. Planning of trials and interpretation of published studies should be done with careful attention to the mode of angiographic appearance interpretation.

Amyloidosis and spontaneous hepatic bleeding, transcatheter therapy for hepatic parenchymal bleeding with massive intraperitoneal hemorrhage: a case report and review of the literature

Hepatic hemorrhage can be devastating, especially in patients with underlying hepatic pathology. This is a case report of a 50-year-old man who presented to the emergency room with Stage 3 shock as evidenced by a systolic blood pressure of 90 mmHg, a heart rate of 125 beats per minute, respiration of 32, with delayed capillary refill and agitation. At this time, he was found to have a massive spontaneous intra-abdominal hemorrhage with an advanced stage of amyloidosis with multiple organ malfunctions. The initial diagnosis was based on an abdominal computed tomography scan and the patient was taken expeditiously to a hybrid angiography suite for a celiac angiogram. An intraoperative diagnosis of extravasation from amyloid related vasculopathy was made based on the angiographic appearance of hepatic circulation. Coil embolization of the feeding branch of the bleeder was achieved using the interlock coil system and a completion angiogram was done showing complete cessation of active bleeding. The postoperative phase was uneventful and the patient was discharged home on postoperative day three. His postoperative visit at five months later was unremarkable.

Fibromuscular dysplasia and childhood stroke

Arteriopathies are the leading cause of childhood stroke but mechanisms are poorly understood. Fibromuscular dysplasias are non-inflammatory arteriopathies classically described in adults with a cerebral-renal distribution and distinct 'string-of-beads' angiographic appearance. Diagnostic characteristics of paediatric fibromuscular dysplasia are uncharacterized. We aimed to compare pathologically proven versus clinically suspected paediatric fibromuscular dysplasia stroke cases to elucidate diagnostic features. Children in the Canadian Paediatric Ischaemic Stroke Registry, Calgary Paediatric Stroke Program, and published literature were screened for stroke associated with fibromuscular dysplasias or renal arteriopathy. Comparison variables included pathological classification, presentations, stroke types, imaging/angiography, treatments, and outcomes. We report 81 cases (15 new, 66 from the literature). For pathologically proven fibromuscular dysplasia (n = 27), intimal fibroplasia predominated (89%) and none had typical adult medial fibroplasia. Ischaemic strokes predominated (37% haemorrhagic) and were often multifocal (40%). Children often presented early (33% <12 months). Angiography demonstrated focal, stenotic arteriopathy (78%) rather than 'string-of-beads'. Renal arteriopathy (63%) with hypertension (92%) was common, with systemic arteriopathy in 72%, and moyamoya in 35%. Anti-inflammatory (29%) and anti-thrombotic (27%) therapies were inconsistently applied. Outcomes (mean 43 months) were poor in 63%, with stroke recurrence in 36%. Clinically suspected fibromuscular dysplasias (n = 31) were usually older, normotensive with string-of-beads angiography and good outcome. We conclude that fibromuscular dysplasia causes childhood stroke with distinctive clinic-radiological features including hypertension and systemic arteriopathy. Intimal fibroplasia predominates while 'string of beads' angiography is rare. Accurate clinical diagnosis is currently challenging.

1:38 PM Abstract No. 151 - Angiographic appearance and treatment of arterial injuries secondary to partial nephrectomy. A single center retrospective review

Purpose The authors wish to report their experience with the angiographic appearance and management (selective transcatheter embolization) of arterial lesions following partial nephrectomy. Materials and Methods Between February 2007 and January of 2011, 947 patients underwent a partial nephrectomy at our institution. Of these, 22 patients ages 28-83 (19 men, 3 women), were referred for selective angiography to treat hemorrhage or a suspected arterial lesion. Retrospective chart review was performed for the 22 patients. Angiographic technique and therapy for each patient was at the discretion of the individual operator. Follow-up consisted of clinical evaluation for the cessation of hematuria and cross-sectional imaging as part of the patient’s routine oncologic management. Results 20/22 patients presented with symptomatic postprocedure bleeding occurring within 10 +/- 4 days of partial nephrectomy. Two incidentally-noted and asymptomatic pseudoaneurysms were found in 2 patients on routine follow-up CT exams 120 +/- 2 days postprocedure. The most common bleeding complication for all patients was a solitary pseudoaneurysm formation, documented in 12 of the 22 patients (69%). The second most common complication was AV fistula in addition to pseudoaneurysm formation, documented in 6 of the 22 patients (27%). Solitary AV fistula was documented in only 2 of the 22 patients (9%). 19/22 patients were treated with coil embolization only. 4 of 22 patients were treated with a combination of coil and either alcohol, Gelfoam, PVA-particles or Ivalon-assisted embolization. All patients experienced short-term technical success except for one patient who presented with recurrent bleeding secondary to extravasation from an untreated vessel, which was observed to be partially thrombosed on initial angiographic evaluation. Conclusion Arterial injury secondary to partial nephrectomy presents with variable and recognizable angiographic appearances and often affects more than one segmental or interlobar artery. Angiographic coil embolization with or without particle assistance is an effective treatment strategy allowing for selective branch occlusion.

Nonalcoholic fatty liver in nondiabetic patients with acute coronary syndromes

Growing evidence was collected that non-alcoholic liver fatty disease (NAFLD) is a risk factor for coronary atherosclerosis in terms of angiographic appearance, but its involvement in acute coronary syndromes is still debated. We investigated the prevalence and severity of NAFLD in non-diabetic patients admitted for ST-segment elevation myocardial infarction (STEMI) and its association with multi-vessel coronary artery disease (CAD). Ninety-five consecutive non-diabetic patients admitted to cardiac ICU for STEMI were studied by ultrasound within 72 h from admission. NAFLD was graded according to a semi-quantitative severity score as mild (score < 3) or moderate-severe (> 3 score). Prevalence of cardiovascular (CV) risk factors, atherosclerotic burden markers and metabolic syndrome (MS) was investigated. The overall prevalence of NAFLD was 87%. Forty-eight patients showed moderate-severe NAFLD (SFLD). Thirty-five patients showed mild NAFLD (MLFD group) and 12 patients had no NAFLD. Patients with SFLD were younger and showed higher prevalence of multi-vessel CAD (i.e. > 2) than patients with mild MFLD (P < 0·01). Total cholesterol, triglycerides, body mass index and waist circumference were higher and HDL lower in SFLD than MFLD patients. About 50% of all NAFLD patients did not have MS. MS prevalence was higher in SFLD than MLFD patients (P < 0·05) and among MS components, waist circumference and triglyceride levels showed the strongest association with SFLD (P < 0·05). At logistic regression analysis, SFLD was independently associated with a three-fold risk of multi-vessel CAD. In non-diabetic patients admitted for STEMI NAFLD prevalence was very high. Severe NAFLD independently increased the risk for multi-vessel CAD associated to CV events.