Diagnostic Digital Subtraction Angiography Research Articles

Digital Subtraction Angiogram: Beginners Perspective

Digital Subtraction Angiography (DSA) is a modern technique which integrates digital data collection and computer processing to produce a medical image. X-ray signals are detected electronically rather than on film and then converted to digital form to be processed by a computer before being displayed. DSA is an integral investigation in the management of patients with neurovascular diseases. It is basically used for diagnosis, but in many instances, it may be therapeutic in the same sitting. Indications for diagnostic DSA include both extracranial and intracranial vascular diseases. A sound understanding of the principles of appropriate periprocedural care and anatomy, catheter technique and basic disease pathology are vital to use DSA as a diagnostic as well as therapeutic purposes. Bang. J Neurosurgery 2023; 12(2): 102-113

Evaluation of the contribution of individual arteries to the cerebral blood supply in patients with Moyamoya angiopathy: comparison of vessel-encoded arterial spin labeling and digital subtraction angiography.

Vessel-encoded arterial spin labeling (VE-ASL) is able to provide noninvasive information about the contribution of individual arteries to the cerebral perfusion. The aim of this study was to compare VE-ASL to the diagnostic standard digital subtraction angiography (DSA) with respect to its ability to visualize vascular territories. In total, 20 VE-ASL and DSA data sets of 17 patients with Moyamoya angiopathy with and without revascularization surgery were retrospectively analyzed. Two neuroradiologists independently assessed the agreement between VE-ASL and DSA using a 4-point Likert scale (no- very high agreement). Additionally, grading of the vascular supply of subterritories (A1-A2, M1-M6) on the VE-ASL images and angiograms was performed. The intermodal agreement was calculated for all subterritories in total and for the subdivision into without and after revascularization (direct or indirect bypass). There was a very high agreement between the VE-ASL and the DSA data sets (median = 1, modus = 1) with a substantial inter-rater agreement (kw = 0.762 (95% CI 0.561-0.963)). The inter-modality agreement between VE-ASL and DSA in vascular subterritories was almost perfect for all subterritories (k = 0.899 (0.865-0.945)), in the subgroup of direct revascularized subterritories (k = 0.827 (0.738-0.915)), in the subgroup of indirect revascularized subterritories (k = 0.843 (0.683-1.003)), and in the subgroup of never revascularized subterritories (k = 0.958 (0.899-1.017)). Vessel-encoded ASL seems to be a promising non-invasive method to depict the contributions of individual arteries to the cerebral perfusion before and after revascularization surgery.

Neurovascular considerations in patients with Down syndrome and moyamoya syndrome.

In this article, we describe a rare and complex case of moyamoya syndrome in a 7-year-old boy with Down syndrome and atlantoaxial subluxation. The patient presented with an ischemic stroke in the left hemisphere and cervical cord compression with increased cord edema. Diagnostic digital subtraction angiography revealed unique patterns of vascular involvement, with retrograde flow through the anterior spinal artery, ascending cervical artery, occipital artery, and multiple leptomeningeal arteries compensating for bilateral vertebral artery occlusion.This case underscores the underreported phenomenon of upward retrograde flow through the anterior spinal artery in bilateral vertebral artery occlusion. We address the rare manifestation of posterior circulation involvement in moyamoya syndrome, highlighting the importance of considering atlantoaxial instability as a contributing factor, as the absence of atlantoaxial stability is a risk factor for vertebral artery dissection. This study contributes valuable insights into the intricate relationship of moyamoya syndrome, Down syndrome, and atlantoaxial instability, urging clinicians to consider multifaceted approaches in diagnosis and treatment. It also emphasizes the potential significance of the anterior spinal artery as a compensatory pathway in complex vascular scenarios.

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

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. 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. 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 5cm 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). Diagnostic catheter DSAs have low complication rates.

Jugulotympanic paraganglioma: A cause of sequential cranial nerve fallout and obstructive hydrocephalus

Abstract A 46-year-old male presented with a longstanding history of a sequential cranial nerve fallout. Following extensive imaging which included contrast enhanced computed tomography, computed tomography angiography, and diagnostic digital subtraction angiography, a diagnosis of jugulotympanic paraganglioma was made. The tumour was found to be locally invasive, encapsulating major neurovascular structures and ultimately inaccessible. Furthermore, the clinical presentation was complicated by acute obstructive hydrocephalus secondary to tumour mass effect. Given the rarity of the condition and unusually extensive presentation, neurosurgery alongside a multidisciplinary team collaborated to formulate a management plan aimed at maximizing functional outcome and minimizing intraoperative morbidity. A decision was made to perform palliative surgical debulking procedure followed by multidisciplinary care and rehabilitation. The patient demised in the care of his family prior to any further intervention.

Interleaved x-ray imaging: A method for simultaneous acquisition of quantitative and diagnostic digital subtraction angiography.

Flow altering angiographic procedures suffer from ill-defined, qualitative endpoints. Quantitative digital subtraction angiography (qDSA) is an emerging technology that aims to address this issue by providing intra-procedural blood velocity measurements from time-resolved, 2D angiograms. To date, qDSA has used 30 frame/s DSA imaging, which is associated with high radiation dose rate compared to clinical diagnostic DSA (up to 4 frame/s). The purpose of this study is to demonstrate an interleaved x-ray imaging method which decreases the radiation dose rate associated with high frame rate qDSA while simultaneously providing low frame rate diagnostic DSA images, enabling the acquisition of both datasets in a single image sequence with a single injection of contrast agent. Interleaved x-ray imaging combines low radiation dose image frames acquired at a high rate with high radiation dose image frames acquired at a low rate. The feasibility of this approach was evaluated on an x-ray system equipped with research prototype software for x-ray tube control. qDSA blood velocity quantification was evaluated in a flow phantom study for two lower dose interleaving protocols (LD1: and LD2: ) and one conventional (full dose) protocol ( . Dose was measured at the interventional reference point. Fluid velocities ranging from 24 to 45cm/s were investigated. Gold standard velocities were measured using an ultrasound flow probe. Linear regression and Bland-Altman analysis were used to compare ultrasound and qDSA. The LD1 and LD2 interleaved protocols resulted in dose rate reductions of -67.7% and -85.5%, compared to the full dose qDSA scan. For the full dose protocol, the Bland-Altman limits of agreement (LOA) between qDSA and ultrasound velocities were [0.7, 6.7] cm/s with a mean difference of 3.7cm/s. The LD1 interleaved protocol results were similar (LOA: [0.3, 6.9] cm/s, bias: 3.6cm/s). The LD2 interleaved protocol resulted in slightly larger LOA: [-2.5, 5.5] cm/s with a decrease in the bias: 1.5cm/s. Linear regression analysis showed a strong correlation between ultrasound and qDSA derived velocities using the LD1 protocol, with a of , a slope of and an offset of cm/s. Similar values were also found for the LD2 protocol, with a of , a slope of and an offset of cm/s. The interleaved method enables simultaneous acquisition of low-dose high-rate images for intra-procedural blood velocity quantification (qDSA) and high-dose low-rate images for vessel morphology evaluation (diagnostic DSA).

Endovascular Treatment of Brain Arteriovenous Malformations in Pediatric Patients: A Single Center Experience and Review of the Literature.

Brain arteriovenous malformations (bAVMs) are abnormal vascular connections with direct arteriovenous shunts, generally symptomatic in the adult life. However, a small number of bAVMs may manifest in pediatric patients, with higher bleeding risk and mortality rates when compared to adults. The purpose of this study is to review our experience with endovascular treatment of bAVMs in pediatric patients. This is a retrospective analysis of all bAVMs in pediatric patients (0-18 years) who underwent diagnostic digital subtraction angiography (DSA) at our institution from January 2010 to June 2021. Twenty-six patients met the inclusion criteria, of which 12 underwent endovascular treatment. Treated patients had a mean age of 10.25 years and 58% were females. Complete angiographic exclusion was achieved in five (42%) patients with endovascular treatment. Five patients with residual bAVM after embolization needed adjuvant therapy with surgery (n = 3) or stereotactic radiosurgery (SRS; n = 2). Two patients are still undergoing embolization sessions. Procedure-related complications occurred in two patients (17%) and included small vessel perforation and an occipital ischemic stroke. Two patients showed bAVM recurrence on follow-up (17%) and subsequently underwent SRS (n = 1) or surgery (n = 1), both resulting in complete bAVM exclusion. All patients had a modified Rankin scale (mRS) score of 0 to 2 on follow-up. Our experience supports the effectiveness and safety of endovascular treatment of bAVM in selected pediatric patients. A multidisciplinary approach combining surgery and SRS is warranted to achieve higher complete bAVM obliteration rates. Long-term follow-up is important as these lesions may show recurrence over time, especially in the pediatric population.

Adaptation and Change in Practices in Neuro-Intervention during COVID-19 Pandemic: Experience from Department of Interventional Neurology at Referral Tertiary Care Hospital in Bangladesh

Background: Different adaptation and changes have been practiced during COVID-19 pandemic. Objective: In this paper we investigated the impact of the COVID-19 pandemic on service delivery in the department of interventional neurology and adaptation of the department to the changed environment. Methodology: This was a retrospective analysis of diagnostic digital subtraction angiography (DSA) procedures done from January 2018 to December 2020 and were analyzed to detect significant breaks in time trend. Results: A total of 358, 426 and 251 patients got admitted for DSA in consecutive three years from 2018 to 2020 respectively. There was a sudden drop in the number of DSA procedures from 30 to 50 patients per month in the pre-COVID era before March 2020 to less than 10 patients per month during the COVID period of March to June 2020. However, the situation gradually improved following the introduction of RT-PCR test for SARS CoV-2 in June 2020. A poison regression showed a significant increase in monthly DSA procedures in the year 2019 compared to the year 2018, but a significant decrease in the pandemic year of 2020. Conclusion: By incorporating COVID-19 testing as a pre-requisite test before DSA procedures, the department of interventional neurology recovered from experiencing a significant drop in the number of performed DSA procedures in the initial periods of the pandemic to reaching a level observed in the pre-COVID era. Bangladesh Journal of Infectious Diseases, April 2022;9(Suppl_1): S3-S8

Digital Subtraction Angiography (DSA) Technical and Diagnostic Aspects in the Study of Lower Limb Arteries

Cardiovascular diseases represent one of the most frequent diseases worldwide; among these, lower limb ischemia is a threatening condition, which can lead to permanent disability if not promptly and correctly diagnosed and treated. A patient’s clinical evaluation and diagnostic imaging (e.g., color-Doppler ultrasound, computed tomography angiography (CTA), and magnetic resonance imaging (MRI)) are mandatory to carefully assess arterial lesion extension and severity. Digital subtraction angiography (DSA) is a minimally invasive technique that represents the gold standard for percutaneous revascularization treatment of symptomatic patients who are refractory to medical management. However, when dealing with patients with lower limb terminal ischemia, the correct interpretation of diagnostic DSA findings is mandatory for treatment re-planning and to effectively evaluate post-treatment results and complications. The purpose of this review is to provide interventional radiologists and endovascular practitioners with an up-to-date practical guide to diagnostic angiography of the lower limbs, which is mandatory to address correct treatment decisions and post-treatment evaluation.

The role of ripc in preventing organ damage, inflammation and oxidative stress during lower limb DSA: A randomised controlled trial

Background and Aims : Diagnostic digital subtraction angiography (DSA) and DSA with percutaneous transluminal angioplasty (DSA-PTA) are common procedures for diagnosing and treating symptomatic lower extremity arterial disease (LEAD). However, organ damage following DSA and DSA-PTA is often under-recognised and hence undiagnosed. The aim of the current study was to assess the effect of remote ischemic preconditioning (RIPC) intervention on the organ damage markers profile, oxidative stress and inflammation biomarkers in LEAD patients undergoing DSA and DSA-PTA procedure.

Radiation Dose and Fluoroscopy Time of Diagnostic Angiography in Patients with Spinal Dural Arteriovenous Fistula

PurposeSpinal dural arteriovenous fistulas (SDAVFs) represent the most common indication for a spinal angiography. The diagnostic reference level (DRL) for this specific endovascular procedure is still to be determined. This single-center study provides detailed dosimetrics of diagnostic spinal angiography performed in patients with SDAVFs.MethodsRetrospective analysis of all diagnostic spinal angiographies between December 2011 and January 2021. Only patients with an SDAVF who had baseline magnetic resonance angiography (MRA), diagnostic digital subtraction angiography (DSA), treatment and follow-up at this institution were included. Dose area product (DAP, Gy cm2) and fluoroscopy time were compared between preoperative and postoperative angiographies, according to SDAVF locations (common versus uncommon), MRA results at baseline (positive versus negative) and DSA protocols (low-dose, mixed-dose, normal-dose). The 75th percentile of the DAP distribution was used to define the local DRL.ResultsA total of 62 spinal angiographies were performed in 25 patients with SDAVF. Preoperative angiographies (30/62, 48%) yielded a significantly higher DAP and longer fluoroscopy time when compared to postoperative angiographies (32/62, 53%) (p < 0.01). The local DRL was 329.41 Gy cm2 for a nonspecific (n = 62), 395.59 Gy cm2 for a preoperative and 138.6 Gy cm2 for a postoperative spinal angiography. Preoperative angiography of uncommonly located SDAVFs yielded a significantly longer fluoroscopy time (p = 0.02). The MRA-based fistula detection had no significant impact on dosimetrics (p > 0.05). A low-dose protocol yielded a 61% reduction of DAP.ConclusionThe results of the present study suggest novel DRLs for spinal angiography in patients with SDAVF. Dedicated low-dose protocols enable radiation dose optimization in these procedures.

The Role of RIPC in Preventing Organ Damage, Inflammation, and Oxidative Stress during Lower Limb DSA: A Randomised Controlled Trial.

Objective Diagnostic digital subtraction angiography (DSA) and DSA with percutaneous transluminal angioplasty (DSA-PTA) are common procedures for diagnosing and treating symptomatic lower extremity arterial disease (LEAD). However, organ damage following DSA and DSA-PTA is often underrecognised and hence undiagnosed. To reduce the risk induced by invasive procedures in symptomatic LEAD patients, the method of remote ischemic preconditioning (RIPC) has been suggested. The aim of the current study was to assess the effect of RIPC intervention on the organ damage markers profile, oxidative stress, and inflammation biomarkers in LEAD patients undergoing DSA and DSA-PTA procedure. Methods The RIPC intervention was performed by inflating a standard blood pressure cuff on the patient's upper arm to 200 mmHg for 5 minutes four times with 5-minute perfusion between each cycle. The sham intervention was performed similarly, but the cuff was inflated to 20 mmHg. Changes in the cardiac and renal damage biomarkers' profile, oxidative stress, and inflammation biomarkers were recorded before and 24 hours after DSA or DSA-PTA. Results A total of 111 (RIPC 54, sham 57) patients with symptomatic LEAD scheduled for endovascular procedure were randomised, and 102 patients (RIPC 47, sham 55) completed the study protocol. RIPC significantly limited the increase of adiponectine levels after DSA and DSA-PTA, compared to sham intervention (p = 0.020), but CK-MB levels were markedly lower in the sham group (p = 0.047) after procedure. There was no significant difference between the RIPC and the sham group in mean changes in hs-troponin-T (p = 0.25), NT-proBNP (p = 0.24), creatinine (p = 0.76), eGFR (p = 0.61), urea (p = 0.95), beta-2-microglobuline (p = 0.34), or cystatine C (p = 0.24) levels. Conclusion In this controlled clinical study, RIPC failed to improve the profile of renal and cardiac biomarkers in patients with LEAD periprocedurally. RIPC significantly limits the rise in adiponectin levels and may influence the decrease of CK-MB levels 24 hours after endovascular procedure.

Contrast-induced encephalopathy mimicking stroke after a second cerebral DSA: an unusual case report

BackgroundContrast-induced encephalopathy (CIE) is a rare complication of the angiography process. CIE may mimic stroke symptoms clinically and subarachnoid hemorrhage radiologically. Previous CIE cases occurred after the initial digital subtraction angiography (DSA) scan. Here, we encountered an unusual case of CIE mimicking a stroke with an internal carotid artery (ICA) aneurysm and ipsilateral ICA stenosis that occurred after a second DSA procedure.Case presentationA 77-year-old female with a history of hypertension and coronary heart disease underwent two cerebral DSA procedures over 1 week. She was given the same nonionic and iso-osmolar Visipaque agent (smaller than 200 ml) for both procedures. However, neurological complications only occurred after the second DSA procedure. On the first diagnostic cerebral DSA, she was diagnosed with an intracranial aneurysm of the left ICA with moderate stenosis (approximately 50%) in the initial part of the ipsilateral ICA. However, after the second aneurysm embolization procedure by DSA, she developed right hemiplegia, aphasia, and epilepsy, mimicking left middle cerebral artery occlusion. An emergency CT showed a diffuse hyperdensity in the left subarachnoid space, mimicking SAH. MRI demonstrated that the lesion was hyperintense on T2WI, FLAIR imaging, and DWI but was normal on ADC mapping. On postoperative Day 6, her neurologic deficits had completely resolved after initial fluid restriction, corticosteroid treatment, and rehydration.ConclusionThis case indicates that clinicians should consider the occurrence of CIE following any angiography procedure, even if the initial cerebral DSA procedure is successful and without complications.

Length of hospital stay in aneurysmal subarachnoid hemorrhage patients without vasospasm on angiography: potential for a fast-track discharge cohort

BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) frequently suffer from vasospasm. We analyzed the association between absence of early angiographic vasospasm and early discharge.MethodsAll aSAH patients treated from August 1, 2007,...

Overestimation of carotid stenosis on CTA – Real world experience

BackgroundSymptomatic carotid stenosis is responsible for 10% of all strokes. Currently, CT angiography (CTA) is the main diagnostic tool for carotid stenosis. It is frequently the only diagnostic test preceding recommendations for carotid angioplasty and stenting (CAS) or carotid endarterectomy (CEA). However, the specificity of CTA, especially in patients with 50–70% stenosis, was previously reported to be relatively low. Most studies testing the diagnostic accuracy of CTA were published more than a decade ago. Therefore, we aimed to test the diagnostic accuracy of CTA, performed with current available technology, compared with digital subtraction angiography (DSA) in patients with carotid stenosis. This study aims to characterize patients who were candidates for CAS/CEA based on CTA, but may not require it based on DSA. MethodsConsecutive candidates for carotid interventions (CAS or CEA) following CTA were identified from prospectively maintained stroke center registries at two large academic centers. As part of our institutional practice all patients had a routine pre-procedural diagnostic DSA. In each patient, degree of carotid stenosis was compared between CTA and DSA. Patients with concordant degree of stenosis on DSA and CTA (true positive group) were compared to patients with a discordant degree of stenosis with less than 50% on DSA (false positive group). ResultsOut of 90 patients with significant stenosis on CTA, only 70 (78%) were found to have a significant stenosis on DSA. Severe plaque calcification was significantly more common in the false-positive group. In those patients whose CTA reported stenosis of ≥90%, we found a strong agreement between CTA and DSA (positive predictive value [PPV] – 0.9) for a significant stenosis (≥50%). Conversely, the correlation between CTA and DSA in patients with CTA reported 50–70% stenosis was poor (PPV – 0.29) (p < 0.001). ConclusionsOur results suggest that despite ongoing radiological progress, the specificity of CTA in accurately assessing carotid stenosis remains relatively low in patients with both moderate stenosis and heavily calcified plaques. Consequently, patients could possibly be referred for unnecessary CEA surgery and may become exposed to associated potential complications.

A technique for determining pump injector settings for an on-table CT or 3D DSA in interventional radiology

IntroductionOn-Table computed tomography (CT) or 3D digital subtraction angiography (DSA) in interventional radiology (IR) has become a valuable diagnostic tool. MethodsA review of the literature found a poor evidential base supporting the technical parameters for iodinated contrast delivery during these acquisition sequences. Results and conclusionThis technical note presents an easy method of estimating the parameters needed to reliably obtain diagnostic on-table CT or 3D DSA images, whilst attempting minimising contrast dose. Implications for practiceA systematic approach to estimating contrast delivery regimes during on-table CT and 3D DSA can help ensure diagnostic quality images are obtained. Further clinical studies are now required to rigorously evaluate this protocol.

Abstract No. 698 ■ FEATURED ABSTRACT Role of Time-resolved angiography With Interleaved Stochastic Trajectories (TWIST) magnetic resonance angiography for treatment planning in Nonspecific aorto-arteritis: a prospective study

Nonspecific aorto-arteritis (NSAA) is a rare, chronic granulomatous panarteritis affecting primarily aorta and its branches. DSA is gold standard for the assessment of vascular involvement in these patients. Recent advances in MR Angiography such as Time-resolved angiography With Interleaved Stochastic Trajectories (TWIST) sequence can noninvasively assess the vascular involvement. We conducted a prospective study to evaluate the role of TWIST MR angiography for treatment planning in NSAA patients. Over the period between 2017 and 2019, 17 patients with NSAA were included in the study. Contrast-enhanced MRA using TWIST and diagnostic digital subtraction angiography (DSA) was performed in all the 17 patients. The average age of our patient cohort was 27.13 years and majority were females (11 were females and 6 patients were males). 17 patients underwent both MRA using TWIST sequence and DSA. Data from both MRA and DSA findings were compared, considering DSA is gold standard for the evaluation of arterial system. Common vessel involved are right renal artery (82.35%) followed by abdominal aorta (70.6%) followed by left renal artery (64.7%). Left subclavian artery was involved in 10 (58.8%) patients and right subclavian artery in 6 (35.3%) patients. In all the patients, the involved vessels were correctly identified in both TWIST angiography images and DSA. The sensitivity and specificity of TWIST MRA is 100% as compared to DSA in the detection of lesions involving Aorta, arch, arch vessels, celiac artery, SMA. However, the sensitivity and specificity of TWIST MR angiography in the assessment of renal arteries are 100% and 71.4% respectively. However, the sensitivity and specificity of VA lesion evaluation in 85.7% and 33.3%, respectively. TWIST MRA can be effective for the evaluation of vascular involvement in treatment planning in NSAA patients. TWIST MRA will be useful in those patients where breath holding is an issue or in uncooperative patients. It provides dynamic assessment of vascular system noninvasively. To the best of our knowledge, there is no study in the literature, which used TWIST MRA in the vascular evaluation in the patients of NSAA.

Treatment of cavernous sinus dural arteriovenous fistula using different surgical approaches: Analysis of 32 consecutive cases

ObjectiveTransarterial and transvenous embolization methods are considered effective and safe approaches for the treatment of cavernous sinus dural arteriovenous fistula (CSDAVF). Here., we report the angioarchitectural features and clinical outcomes of CSDAVF in patients treated with either the inferior arterial approach (IAA) or the inferior petrosal sinus approach (IPSA). MethodsThe clinical data of 32 patients with CSDAVF treated at our institution from May 2008 to May 2014 were retrospectively analyzed. All patients underwent routine diagnostic digital subtraction angiography (DSA) before surgery. Embolization was performed using the IPSA through the internal jugular vein or IAA, based on angioarchitectural features. ResultsOf the 32 patients with CSDAVF, 24 underwent embolization treatment through the internal jugular vein-IPSA and 8 patients underwent treatment through IAA. Nineteen patients in the IPSA group experienced mild headache, which improved after specific treatment. The immediate postembolization angiographic results revealed complete occlusion in 26 cases (18 IPSA and 8 IAA) and almost complete occlusion in 6 cases (IPSA). Complications that occurred during the procedure included abducens nerve palsy (n = 1, IPSA) and prosopoplegia (n = 1, IAA). One patient developed tinnitus, which was diagnosed as anterior cranial fossa new-onset dural arteriovenous fistula on DSA, whereas the symptoms of other patients all improved with no recurrence. ConclusionsOn the basis of the angioarchitectural features of CSDAVF, IAA can be considered the primary treatment when the blood-supplying artery and fistula are relatively singular, and when the microcatheter can easily reach the fistula through the artery. The venous approach should be selected as the primary approach when the fistula is indistinguishable and blood is supplied by multiple arteries through small plexiform vessels. Choosing the optimal surgical approach may increase the success rate of intravascular CSDAVF surgery and may help avoid complications.

Advantages of Coil Embolization Performed Immediately After Diagnostic Cerebral Digital Subtraction Angiography in Unruptured Intracranial Aneurysms: Patients' Perspective

We are inevitably faced with the need to perform coil embolization immediately after diagnostic cerebral digital subtraction angiography (DSA) for economic reasons, patient convenience, fear of rupture, and other reasons. Here we report the advantages of coil embolization performed immediately after diagnostic cerebral DSA for unruptured intracranial aneurysms (UIAs) from the patients' perspective. Between January 2017 and October 2018, 145 patients were treated for UIAs with endovascular coil embolization at the Yeungnam University Medical Center. There were 87 patients in the group in which coil embolization was to be performed at least 1 week after diagnostic cerebral DSA (regular [R] group) and 58 patients in the group in which coil embolization was to be performed immediately after diagnostic cerebral DSA (immediate [I] group). There were no statistically significant between group differences in any factor analyzed expect for medical expenses (out-of-pocket costs), 2,218,416 KRW (1963 USD) for the R group and 1,128,906 KRW (999 USD) for the I group (P < 0.001). There were no statistically significant differences in the rate of complications between the 2 groups, with 4 minor complications and 1 death in the R group and 3 minor complications and 1 death in the I group. Our findings indicate that coil embolization performed immediately after diagnostic cerebral DSA can be a relatively safe alternative approach to treating patients with UIAs.

Transient Cortical Blindness: a Rare Complication After Cerebral Digital Subtraction Angiography

Transient cortical blindness (TCB) is a rare complication after cerebral or coronary angiography. In this article, we elaborate the condition and present a case which occurred in our hospital. With increasing numbers of diagnostic angiographies and endovascular interventions, we want to raise awareness of TCB and its clinical course. We report about a 57-year-old woman with TCB after a diagnostic digital subtraction angiography (DSA) and endovascular treatment of a ruptured aneurysm of the basilar tip. Symptoms disappeared spontaneously after 36 h with no residual deficits. Multimodal imaging including non-contrast enhanced cerebral CT-scan (NECT), cerebral magnetic resonance imaging (cMRI), and cerebral DSA are presented. Despite the seemingly grave event, the prognosis of this condition can be considered as excellent. The exact pathophysiology remains speculative, but might be related to contrast agent neurotoxicity with transient disruption of blood brain barrier integrity. Immediate computed tomographic angiogram (CTA) and CT-scan or magnetic resonance angiography (MRA) and cMRI should be performed after an occurrence of a suspected TCB to rule out embolic occlusions or hemorrhage. The administration of steroids can be considered.