Four-vessel Cerebral Angiography Research Articles

Brain Failure and Brain Death

Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation. This review contains 2 figures, 3 tables, and 69 references. Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation

Brain Failure and Brain Death

Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation. This review contains 2 figures, 3 tables, and 69 references. Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation

Brain Failure and Brain Death

Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation. This review contains 2 figures, 3 tables, and 69 references. Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation

Brain Failure and Brain Death

Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation. This review contains 2 figures, 3 tables, and 69 references. Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation

De Novo Aneurysm of the Anterior Communicating Artery Presenting with Subarachnoid Hemorrhage 7 Years After Initial Cryptogenic Subarachnoid Hemorrhage: A Case Report and Review of the Literature

Spontaneous subarachnoid hemorrhage (SAH) is usually caused by a ruptured cerebral aneurysm. Despite the use of initial four-vessel cerebral digital subtraction angiography (DSA), 15 % of all cases remain idiopathic. According to the initial computed tomographic scan, the spontaneous SAH can be divided into a perimesencephalic group associated with a benign nature and a nonperimesencephalic group with a similar clinical course as aneurysmal SAH. We present a case of a 49-year-old man with a de novo aneurysm formation of the anterior communicating artery with SAH 7 years after initial cryptogenic nonperimesencephalic SAH. This observation suggests that in some cases, long-term angiographic studies might be justified.

Beware of “Old” Horner Syndrome

Chronic Horner syndrome is a rare clinical condition, the etiology of which often remains undiscovered. A patient is presented with an 8-year history of Horner syndrome who was diagnosed with multiple cervical artery dissections. A 42-year-old woman presented to our emergency department with a severe occipital headache that woke her up from sleep 3 days earlier. She had a history of headaches and recalled one in particular dating back to 2003. At that time, she sought medical attention at general practitioner's office because of the terrible headache and a noticeable disparity of her pupils. She was told that she had miosis of the right pupil. The examination conducted in 2011 revealed Horner syndrome with right miosis and ptosis. A four-vessel cerebral angiography revealed an occlusion of the right internal carotid artery. The morphology of stenosis and pseudoaneurysm of C1 segment of left internal carotid artery, as well as a pseudoaneurysm of V3/V4 junction of left vertebral artery indicated a probable dissective etiology. This case illustrates that Horner syndrome with a chronic presentation can be as potentially dangerous as its acute counterpart and should be judiciously investigated.

Subarachnoid haemorrhage associated with an intrathecal catheter

Although 15 to 20 percent of patients with subarachnoid haemorrhage (SAH) do not have a vascular lesion on four-vessel cerebral angiography, venous injury is a potential cause. This case describes an intracranial catheter associated with nonaneurysmal SAH. It suggests that intrathecal catheters can cause vascular injury, and that nonaneurysmal perimesencephalic SAH may be due to injury of small blood vessels.

Complications after angiogram-negative subarachnoid haemorrhage: Comparative study of pretruncal and nonpretruncal hemorrhage patients

Subarachnoid haemorrhages (SAH) of unknown aetiology usually have a mild clinical presentation, favourable outcome and low complication rate. The aim of this study was to analyse the complications in two forms of angiogram-negative spontaneous SAH: pretruncal (PNSAH) and nonpretruncal (NPNSAH). The study group involved 18 patients with PNSAH and 16 patients with NPNSAH. CT scan was done within 72 hours from bleeding. All patients underwent four-vessel cerebral angiography. Repeat angiography was performed in five PNSAH and all NPNSAH patients. Twenty-nine patients were in grade I or II of the Hunt-Hess Scale (17 PNSAH and 12 NPNSAH). There was one case of rebleeding (NPNSAH patient), 10 cases of transient acute hydrocephalus (4 PNSAH and 6 NPNSAH). Cerebral vasospasm visualized by angiographies in two NPNSAH patients was local and mild, but was not found in PNSAH patients. Acute electrocardiography changes were found in 19 patients (significantly more frequently in NPNSAH than in PNSAH, 12 and 7 patients, respectively; p = 0.037). Cardiac problems following these types of SAH are more frequent than expected, and therefore cardiac monitoring is necessary.

Non-aneurysmal subarachnoid hemorrhage as presentation of moyamoya disease in an adult

Background:The presentation of moyamoya disease (MMD) as an aneurysmal subarachnoid hemorrhage (SAH) is relatively frequent and in the absence of aneurysms is extremely rare.Case Description:A 53-year-old male patient suddenly developed severe headache associated with dysarthria and an altered state of consciousness. At the time of admission, he was found drowsy with global aphasia, stiff neck, right hemiparesis and right Babinski's sign. A non-contrast brain computed tomography was performed and a small bleeding in the subarachnoid space over the left frontal and parietal cortex was observed. Four-vessel cerebral angiography showed bilateral stenosis of the internal carotid arteries, with multiple tortuous vessels branching from the anterior and middle cerebral arteries. These abnormal vessels were anastomosing with branches from the posterior cerebral and middle meningeal arteries. With this information, a diagnosis of MMD was made. A three-dimensional reconstruction from digital angiography ruled out aneurysms or vascular malformations. After 4 weeks, another angiography was performed and remained the same as previous one.Conclusion:Clinical and radiological characteristics of this case are consistent with previous reports, supporting the theory that non-aneurysmal SAH in MMD is caused by rupture of fragile moyamoya vessels.

脳底動脈解離後に生じた高度感音難聴例

A 55-year-old woman suddenly noticed right hearing loss and tinnitus. Several days later, she lost consciousness, and was referred to Ehime Prefectural Central Hospital. Computed tomography (CT) showed subarachnoidal hemorrhage at the right cerebellopontine angle. However, subsequent CT-angiography and four-vessel cerebral angiography could not detect the exact cause of hemorrhage, such as aneurysm and arterial dissection. When she regained consciousness a few days later, she noticed worsening of right hearing loss and dizziness. Pure-tone audiogram showed complete deafness in the right ear. Distortion product otoacoustic emission and auditory brainstem response were not elicited in the right ear. Caloric test demonstrated canal paresis of the right ear with normal response in visual suppression. There were no neurological deficits other than right VIIIth nerve damage. Cerebral infarction and vasospasm were negative in magnetic resonance imaging (MRI) and MR-angiography performed on the 5th day. One month after onset, four-vessel angiogram demonstrated stenosis of the basilar artery near the branching site of AICA. These findings suggested that her deafness and disequilibrium were due to inner ear ischemia caused by dissection of the basilar artery, which also caused subarachnoidal hemorrhage.

Delayed rupture of pre-existing cerebral aneurysm in a young patient with minor head trauma

An intracranial saccular aneurysm is not commonly diagnosed in a patient with head injury. We present a patient with a history of minor head trauma and a CT scan of the brain revealing minimal subarachnoid hemorrhage 17 days prior to admission, complaining of severe headache, dysarthria and focal right limb seizures 3 hours prior to admission. A traumatic aneurysm was suspected based on clinical history and radiological findings including hematoma in the falx region on a CT scan of the brain and an aneurysm of the pericallosal artery on magnetic resonance angiography and four-vessel cerebral angiography. However, at craniotomy, an intracranial non-traumatic saccular aneurysm at the bifurcation of the pericallosal artery was found. The patient recovered fully after successful clipping the aneurysm.

Moyamoya Syndrome in a Child With Trisomy 12p Syndrome

A female, 2 years and 7 months of age, was admitted to the hospital with stupor and nystagmus following projectile vomiting. She had been prenatally diagnosed with trisomy 12p with a familial pericentric inversion of chromosome 12 originating from her mother. She manifested developmental delay and some dysmorphic features of the face and limbs compatible with the clinical features of trisomy 12p. Four-vessel cerebral angiography revealed severe stenosis and occlusion of the supraclinoid portion of the right and left internal carotid arteries with numerous collateral vessels in the vicinity of the occlusion. These features are consistent with moyamoya syndrome. This report presents the first case of moyamoya syndrome with trisomy 12p with a familial pericentric inversion of chromosome 12.

Sixteen-Slice Multi-Detector Computed Tomographic Angiography Improves the Accuracy of Screening for Blunt Cerebrovascular Injury

Blunt cerebrovascular injuries (BCVI) are rare but potentially devastating injuries, particularly if the diagnosis is delayed. Only four-vessel cerebral angiography (FVCA) has been shown to be adequately sensitive and specific as a screening tool for BCVI but is resource-intensive and invasive. Computed tomography (CT) angiography has emerged as a possible alternative, but its accuracy has been poor, particularly for low-grade injuries. Recent advances in CT technology, particularly the use of a multi-detector array for image acquisition should improve the accuracy of this technique. This study is the first reported experience of the role of the 16-slice multi- detector CT scanner in screening for BCVI. From January 2, 2003 to October 31, 2004, all patients who met predefined screening criteria were screened for blunt injury to the carotid (BCI) and vertebral (BVI) arteries with a 16-slice multi-detector CT scanner with angiographic reconstruction (CTA). If CTA was positive or equivocal for BCVI, FVCA was performed as a confirmatory test. If CTA was negative, no further diagnostic studies were performed. There were 435 patients who met criteria and were screened with CTA. Of these, 25 injuries were identified in 24 patients for an incidence of BCVI of 1.2% (24/2023) among all blunt admissions (BTA) and 5.5% (24/435) among screened patients (SP). This was increased compared with the four-slice era (0.38% BTA, 2.4% SP, p<0.01). No patient with a negative CTA was subsequently identified as having, or developed neurologic symptoms attributable to a missed BCVI. Sixteen-slice multi-detector CT angiography is an excellent tool to screen for BCVI and detects all clinically significant injuries. The detected incidence of BCVI increased more than threefold with the 16-slice scanner when compared with the four-slice scanner. This demonstrates a clear technological improvement in our ability to screen for these injuries.

Fusiform aneurysm of a persistent trigeminal artery

Fusiform aneurysms of the persistent trigeminal artery are rare and endovascular treatment of these aneurysms has not been attempted previously. We describe a case of persistent trigeminal artery with a fusiform aneurysm in its middle third, managed using Guglielmi detachable coils (GDC). A 50-year-old, diabetic and hypertensive patient presented with sudden onset headache and neck stiffness. On examination, she was conscious but disoriented, without cranial nerve or sensorimotor deficits. Four-vessel cerebral digital subtraction angiography revealed a fusiform aneurysm of the middle third of a persistent trigeminal artery on the left side with adult type posterior cerebral arteries. Guglielmi detachable coils were used for occlusion of the persistent trigeminal artery. The procedure was well tolerated but delayed ischemic neurological deficits developed due to vasospasm. (1) In spite of angiographically documented independence of the anterior and posterior cerebral circulation, occlusion of a persistent trigeminal artery using endovascular techniques may result in posterior circulation stroke due to a number of factors, including occlusion of brainstem perforators taking origin from the persistent trigeminal artery or vasospasm. (2) The timing for endovascular intervention following aneurysmal rupture remains poorly defined.

Clipping the Eagle’s wings: Treatment of an unusual cause of transient cerebral ischemia

Transient monocular blindness (TMB) associated with hemispheric TIA is indicative of internal carotid artery (ICA) occlusive disease and an increased risk for stroke.1 However, not all cases of TMB or TIAs reflect intraluminal ICA pathology. We present a patient who had recurrent, stereotypical TMB and hemispheric TIAs from an elongated styloid process compressing the extracranial portion of the ICA, leading to intermittently decreased cerebral blood flow. A previously healthy 38-year-old right-handed woman was examined for a 14-month history of recurrent spells, consisting of sudden left eye “graying out,” followed by right arm, then right leg heaviness and “shaking,” dysarthria, and a feeling of fainting. Symptoms occurred once or twice every 2 to 3 months initially, increasing to three per month. Episodes lasted up to 1 minute and resolved in reverse order. Left head rotation while reaching with her arms was identified as a trigger. Four-vessel cerebral angiography …

Rare cause of subarachnoid hemorrhage: spinal meningeal carcinomatosis

Subarachnoid hemorrhage (SAH) of spinal origin is a rare entity accounting for approximately 1% of all cases of SAH. Its most frequent causes are trauma and vascular malformations. Although primary spinal tumors, especially ependymomas, are also relatively common causes, SAH secondary to a metastatic spinal tumor arising from outside the central nervous system is an extremely rare condition; only one case has been reported in the literature. The authors present a case of spinal meningeal carcinomatosis secondary to cutaneous malignant melanoma in which the patient presented with only symptoms of SAH. Although very rare, this case underscores several factors. 1) Spinal SAH due to spinal metastases should be considered in the differential diagnosis of patients with previously known malignancy. 2) Spinal SAH may manifest without paraparesis or sensory deficit. 3) Magnetic resonance imaging of the spinal cord may be important to determine the source of SAH in patients in whom four-vessel cerebral angiography demonstrates no abnormal findings.

Helical CT-Angiography: A Sensitive Tool for Blunt Cerebrovascular Injury

Patients at risk for blunt cerebrovascular injury (BCVI) to the carotid or vertebral arteries must be screened. Earlier studies demonstrated that four-vessel cerebral angiography (4-VCA), a difficult and time-consuming procedure, has superior diagnostic accuracy to helical computed tomographic angiography (hCT-A; JWEM Dec 30 2002). These authors obtained hCT-A in 486 patients who experienced high-speed acceleration/deceleration or direct blunt force to the cervical …

Aneurysm at the posterior inferior cerebellar artery of extradural origin for preoperative evaluation of safe clipping: case report and review of the literature

Background As far as we know, 6 cases of extracranial (including craniocervical junction) intradural aneurysms of the posterior inferior cerebellar artery have been previously reported. However, preoperative detailed evaluation of the origin site and a course of the posterior inferior cerebellar artery by means of angiography were not reported in previous papers. Case description We report a rare case of aneurysm of the posterior inferior cerebellar artery, which originated extradurally from the right vertebral artery. A 69-year-old woman experienced a sudden headache 16 years ago and a computed tomography scan showed a subarachnoid hemorrhage around the midbrain. Four-vessel cerebral angiography, however, failed to disclose a source of the hemorrhage. Magnetic resonance angiography incidentally revealed an aneurysm at the craniocervical junction 16 years after the subarachnoid hemorrhage. The aneurysm was exposed and clipped via a suboccipital route. At surgery, it was of no use to apply a temporary clip on the intradural segment of the vertebral artery, because the posterior inferior cerebellar artery was found to enter the intradural space separately from the vertebral artery. The blood flow to such an aneurysm cannot be stopped with this procedure. Conclusion Careful neuroimaging study is essential for the accurate diagnosis and successful treatment of such a rare aneurysm.

Recurrence of intracranial aneurysms in autosomal-dominant polycystic kidney disease

The natural history of intracranial aneurysms (ICAs) in individuals with autosomal-dominant polycystic kidney disease (ADPKD) is poorly defined. We followed twenty ADPKD subjects, eleven with ruptured and nine with intact ICA, for 15.2 +/- 8.1 years (range, 6.0 to 33.2 years). Initial diagnosis was by four-vessel cerebral angiography in eighteen subjects. Follow-up examinations were four-vessel cerebral angiography in fourteen and magnetic resonance angiography (MRA) in six subjects. We examined the occurrence of new ICAs, an increase in size of existing ICAs, recurrent rupture or surgical intervention, and death. Age at initial diagnosis of ICA was 37.7 +/- 10.4 years (range, 20.2 to 53.1 years). Seventeen subjects (85%) had an anterior and three (15%) had a posterior ICA at initial diagnosis. On restudy, five subjects (25%) had a significant change, consisting of new ICAs in a different location in all five and an increase in size of an existing ICA in two of the five. All subjects with ruptured ICA and one subject with intact ICA had undergone surgery at the time of initial diagnosis. Ten subjects (50%) underwent further surgery 8.1 +/- 6.1 years later (1.3 to 17 years). No subject died during follow-up and one subject experienced a recurrent RICA (RICA). We were unable to identify risk factors associated with development of a new ICA or increase in size of an existing ICA. Individuals with ADPKD and ICA appear to be at moderate risk for new ICAs and increase in size of existing ICAs; mortality and risk of recurrent rupture, however, appear to be low.

Three-dimensional computed tomographic angiography with low loads of contrast agent in acute subarachnoid hemorrhage

In the pre-operative evaluation of aneurysmal subarachnoid hemorrhage (SAH), three-dimensional computed tomographic angiography (3D-CTA) is very helpful. However, it is usually difficult to perform 3D-CTA following four-vessel cerebral angiography in the setting of acute SAH because of high loads of contrast agent. The present report is designed to enable 3D-CTA following catheter angiography for surgical planning. Fourteen consecutive patients with acute SAH underwent four-vessel cerebral angiography. After identification of the aneurysm, all patients were moved to the CT room next to the angiography room under catheterization. Contrast agent (10 ml) was diluted with 40 ml of heparinized saline. This diluted contrast agent was then injected through intra-arterial catheter for 3D-CTA. 3D-CTA with diluted contrast agent which was injected through intra-arterial catheter revealed sufficiently clear images. In addition, this method could provide anatomical information that was not readily available from catheter angiography. 3D-CTA with additional low dose of contrast agent can immediately follow four-vessel cerebral angiography in the setting of acute SAH. No complications were noted throughout the procedures. It has been our experience that the imaging modality in combination with not only catheter angiography but also 3D-CTA is advantageous in case of acute SAH and provides better detail for surgical planning. [Neurol Res 2002; 24: 233-236]