Intraoperative Cerebral Angiography Research Articles

The M2-M1 middle cerebral artery reimplantation bypass with protective superficial temporal artery to middle cerebral artery bypass for giant partially thrombosed middle cerebral artery aneurysm in the hybrid operating suite.

Giant middle cerebral artery (MCA) aneurysms are complex and challenging. Revascularization is frequently required in addition to trapping or clip reconstruction, and the MCA reimplantation bypass is ultimately needed when aneurysm excision is planned. The operation was conducted in the hybrid operating suite, where an intraoperative cerebral angiography revealed a compromised MCA after multiple attempts of clip reconstruction. Therefore, we decided to perform an M2-M1 reimplantation bypass in conjunction with trapping and aneurysmectomy. Reimplantation bypass can be a rescue procedure for revascularization in complex aneurysms. The angioarchitecture varies among individuals; therefore, the optimal bypass technique should be tailored.

Transradial Versus Transfemoral Intraoperative Cerebral Angiography for Open Cerebrovascular Surgery: Effectiveness, Safety, and Learning Curve.

Intraoperative cerebral angiography (IOA) is a valuable adjunct in open and hybrid cerebrovascular surgery. Commonly, transfemoral access (TFA) is used. Lately, transradial access (TRA) has gained popularity for neurointervention. However, the TRA has not yet been compared with the TFA for IOA. To compare the effectiveness and safety of the TRA and TFA for IOA. In addition, the learning curve for implementing the TRA for IOA was evaluated. Between July 2020 and 2022, 92/1787 diagnostic cerebral angiographies met inclusion criteria for IOA. Sheath run time to primary target vessel run time (STT), amount of contrast dye (CD), fluoroscopy time (FT), and dose-area products (DAPs) were compared between TRA and TFA, different aortic arch types, and both study years. One case required transitioning from TRA to TFA (1/26, 3.8%) because of a minute proximal radial vasculature. The STT, CD, FT, and DAP were similar for the TRA (n = 25) and the TFA groups (n = 67) (p = ns). One groin hematoma (1.5%) was observed in the TFA group. No other complications or any change in modified Rankin Scale were observed. Aortic arch type II/III was associated with longer STT ( P = .032) but not CD, FT, or DAP. There was a nonsignificant decline of STTs among the TRA cases ( P = .104) but stable STTs among TFA cases ( P = .775). The TRA and TFA represent equally effective and safe routes for IOA. In addition, expertise with the TRA can rapidly be gained and facilitates tailoring the access for IOA to patient's individual anatomy and surgeon's needs.

Role of hybrid operating room in management of low-velocity penetrating brain injury

Penetrating brain injuries (PBIs) are a severe subtype of traumatic brain injuries (TBIs), where an object pierces the cranium and meninges. Based on the speed of penetration, it can be classified into high and low-velocity penetration. Low-velocity penetrating injury (LVPBI) cause lacerations to the scalp, depressed skull fractures as well as localized brain tissue and blood vessel damage along the object's path of travel. There have been many case reports and small case series published describing these events. However, there is no standardized guideline for general management to improve patient outcomes. In this report we discuss our experience of using the hybrid theatre to manage such cases. We present the clinical management of a 10-year-old boy who was shot in the head with a harpoon. Computed Tomography Angiography (CTA) demonstrated that the harpoon punctured through the jugular foramen and had a high probability of internal jugular vein (IJV) and internal carotid artery (ICA) involvement. The surgery was performed seven days after injury in a hybrid operating room (OR). We used intraoperative digital subtraction angiogram (DSA) to guide our decision to permanently occluded the IJV and ICA. The patient had a good postoperative recovery and was sent home after three weeks of observation in the hospital. Despite the high cost, intraoperative cerebral angiography in hybrid theatre for selected patients with penetrating brain injury where major blood vessel damage is anticipated might benefit overall patient outcome.

Examination of the Risk of Normal Perfusion Pressure Breakthrough and Occlusive Hyperemia after Cerebral Arteriovenous Malformation (AVM) Resection Using Intraoperative Cerebral Angiography

Examination of the Risk of Normal Perfusion Pressure Breakthrough and Occlusive Hyperemia after Cerebral Arteriovenous Malformation (AVM) Resection Using Intraoperative Cerebral Angiography

Combined frameless stereotactical biopsy and intraoperative cerebral angiography by 3D-rotational fluoroscopy with intravenous contrast administration: a feasibility study

BackgroundMobile 3-dimensional fluoroscopes are an integral part of modern neurosurgical operating theatres and can also be used in combination with free available image post processing to depict cerebral vessels. In preparation of stereotactic surgery, preoperative Computed Tomography (CT) may be required for image fusion. Contrast CT may be of further advantage for image fusion as it regards the vessel anatomy in trajectory planning. Time-consuming in-hospital transports are necessary for this purpose. Mobile 3D-fluoroscopes may be used to generate a CT equal preoperative data set without an in-hospital transport. This study was performed to determine the feasibility and image quality of intraoperative 3-dimensional fluoroscopy with intravenous contrast administration in combination with stereotactical procedures.Methods6 patients were included in this feasibility study. After fixation in a radiolucent Mayfield clamp a rotational fluoroscopy scan was performed with 50 mL iodine contrast agent. The image data sets were merged with the existing MRI images at a planning station and visually evaluated by two observer. The operation times were compared between the frame-based and frameless systems (“skin-to-skin” and “OR entry to exit”).ResultsThe procedure proves to be safe. The entire procedure from fluoroscope positioning to the transfer to the planning station took 5–6 min with an image acquisition time of 24 s. In 5 of 6 cases, the fused imaging was able to reproduce the vascular anatomy accurately and in good quality. Both time end-points were significantly shorter compared to frame-based interventions.ConclusionThe images could easily be transferred to the planning and navigation system and were successfully merged with the MRI data set. The procedure can be completely integrated into the surgical workflow. Preoperative CT imaging or transport under anaesthesia may even be replaced by this technique in the future. Furthermore, hemorrhages can be successfully visualized intraoperatively and might prevent time delays in emergencies.

Intraoperative cerebral angiography by intravenous contrast administration with 3-dimensional rotational fluoroscopy in patients with intracranial aneurysms: a feasibility study.

Intraoperative imaging of cerebral aneurysms may be desirable in emergency situations with large space-occupying hematomas or to visualize vessels after clip placement. Mobile 3-dimensional fluoroscopes are available in a number of neurosurgical departments and may be useful in combination with simple image postprocessing to depict cerebral vessels. To assess whether intracranial aneurysms are detectable with appropriate image quality with intraoperative 3-dimensional fluoroscopy with intravenous contrast administration. Eight patients were included in the study. The patients' heads were fixed in a radiolucent Mayfield clamp. First, a rotational fluoroscopy scan was performed without contrast agent. Then, a second scan with 50 mL iodine contrast agent was performed. The DICOM (digital imaging and communications in medicine) data of both scans were transferred to an Apple PowerMac workstation, subtracted, and reconstructed with OsiriX imaging software. The images were compared with preoperative angiograms. No adverse effects were observed during contrast administration. The entire procedure from fluoroscope positioning to the production of usable 3-dimensional images took 5 to 6 minutes with an image acquisition time of 2 × 24 seconds. The configuration of the aneurysm and the vessel anatomy were assessable. Previous coiling limited image quality in 1 patient. This technique quickly provides images of adequate quality to assess the configuration of intracranial aneurysms, which may be helpful when immediate intraoperative information about intracranial vessel pathologies is required. The positioning of the fluoroscope, image acquisition, and processing can be completely integrated into the surgical workflow.

Comparing routine versus selective use of intraoperative cerebral angiography in aneurysm surgery: a prospective study

IntroductionWhile the use of intraoperative angiography (IA) has been shown to be a useful adjunct in aneurysm surgery, its routine use remains controversial.ObjectiveWe wished to determine if IA is required...

Intraoperative cerebral angiography in arteriovenous malformation resection in children: a single institutional experience

The use of cerebral intraoperative angiography has been described in resection of arteriovenous malformations (AVMs) in adults. More recently, studies have described experiences with intraoperative angiography in a small number of children. However, data on the safety and clinical utility of intraoperative angiography in the pediatric population remains limited in comparison with available data in adults. The aim of the study was to evaluate the use of cerebral intraoperative angiography in children undergoing AVM resection. The clinical utility of intraoperative angiography and procedure-related complications were evaluated. A retrospective review was performed for all patients undergoing cerebral AVM resection with intraoperative angiography at The Children's Hospital of Philadelphia between 2008 and 2012. Patient imaging and operative and medical notes were reviewed to evaluate for end points of the study. A total of 17 patients (8 males, 9 females) were identified, with a median age of 12.1 years (range 1.2-17.9 years) and median weight of 45.5 kg (range 12.1-78.9 kg). A total of 21 intraoperative angiography procedures were performed for 18 AVM resections in 17 patients. The technical success rate was 94%. In 2 cases (11%), intraoperative angiography demonstrated a residual AVM, and repeat resections were performed. In both cases, no recurrent disease was noted on postoperative follow-up. One procedure-related complication (4.8%) occurred in 1 patient who was positioned prone. Recurrence to date was noted in 2 (14%) of the 14 cases with available postoperative follow-up at 3.5 and 4.7 months following resection with intraoperative angiography. The median follow-up time from intraoperative angiography to the most recent postoperative angiography was 1.1 years (range 4.3 months to 3.8 years). Intraoperative angiography is an effective and safe adjunct for surgical management of cerebral AVMs in the pediatric population.

Abstract No. 48: Intraoperative cerebral angiography in the pediatric population

Abstract No. 48: Intraoperative cerebral angiography in the pediatric population

Intraoperative angiography during microsurgical removal of arteriovenous malformations in children

Confirming the successful management of pediatric arteriovenous malformations (AVMs) requires high-quality postoperative digital subtraction angiography. Although the role of intraoperative angiography during the microsurgical removal of AVMs is well established in adults, the technique has several limitations including poor image quality, uniplanar image acquisition, and absent full heparin protection. Here, the authors report on their experience with high-quality intraoperative angiography during the surgical management of pediatric AVMs in their image-guided therapy (IGT) facility. The authors retrospectively reviewed the demographic, clinical, and radiological characteristics of 22 patients who underwent the surgical management of AVMs at the Hospital for Sick Children in Toronto, with the aid of high-quality intraoperative or immediate postresection cerebral angiography via a transfemoral approach. Between January 2000 and August 2009, 18 children (mean age 13.05 ± 4.04 years, range 4-21 years) underwent both surgical management of an AVM and intraoperative cerebral angiography at an IGT facility. An additional 4 children underwent angiography immediately after surgery in the regular operating room while under the same anesthesia. The mean AVM size was 2.55 ± 1.43 cm (range 1-6 cm) with a mean Spetzler-Martin grade of 2.27 (range 1-4). Intraoperative angiography in 4 of the 18 patients demonstrated residual AVM requiring additional resection. One patient demonstrated residual AVM on immediate postoperative angiography and underwent immediate reoperation. Successful excision of the residual AVM was confirmed on angiography the following day in that case. Procedural complications occurred in connection with 1 (3.3%) of 30 angiograms, including asymptomatic transient nonfilling of an ophthalmic artery, which was resolved on follow-up angiography. Negative intraoperative angiograms were confirmed with follow-up angiograms in 15 (93.75%) of 16 patients at a mean of 9.93 ± 5.70 months. One patient with a negative intraoperative angiogram demonstrated a tiny residual AVM on follow-up angiography at 8 months (false-negative rate 6.25%), but had a negative preoperative angiogram 1 year later in the IGT facility. No patient with a negative intraoperative angiogram required further AVM-directed treatment. Intraoperative angiography is a safe and effective adjunct to the surgical management of AVMs in children. This novel approach allows the pre-, intra-, and postoperative acquisition of high-quality images, which can help guide the resection of AVMs, especially those that are small, diffuse, or of a complex angioarchitecture.

Minimal invasive method for intraoperative angiography using the superficial temporal artery with preservation of its trunk

Background Intraoperative angiography is useful in evaluating the vascular lesion before clipping/excision, presence of any residual lesion, and excluding unintended occlusion/stenosis of the arterial branch/parent artery. The previously reported techniques using the superficial temporal artery involved either retrograde cannulation of the aortic arch or its permanent obliteration at the end of the procedure. The present report describes a simple method that enables cannulation of the artery using standard Sildenger's technique and ensures its patency at the end of the procedure for possible use in present or future procedures. Methods The method was applied during craniotomies performed for various intracranial vascular lesions. One division of the superficial temporal artery was subjected to catheterization. At the end of the procedure, the division of the superficial temporal artery that was punctured was hemostased, leaving the main trunk patent. Results Intraoperative cerebral angiography was performed by the author via catheterization of one division of the superficial temporal artery in 56 craniotomies. Intraoperative cerebral angiography showed adequate high-quality subtraction images. Conclusion The present report describes a simple method that enables cannulation of one division of the superficial temporal artery and preserves the main trunk at the end of the procedure.

Intraoperative angiography through the occipital artery and muscular branch of the vertebral artery: technical note

Background Intraoperative cerebral angiography has been known as a useful tool for diagnosing neurovascular diseases. There are few reports of intraoperative angiography in the prone position. Intraoperative angiograms through the occipital artery and muscular branch of the vertebral artery have not also previously been described. Methods The occipital artery or muscular branch of the vertebral artery was used for the intraoperative cerebral angiography. With retrograde catheterization of these arteries, the contrast medium (5 to 10 mL) was manually injected by a surgeon. Results Adequate angiograms were obtained with this method. No complications occurred with this procedure. Conclusions Intraoperative angiography through these arteries is useful, with good efficacy and safety, for a patient in the prone position.

MANAGEMENT OF DISTAL ANTERIOR CEREBRAL ARTERY ANEURYSMS

Our goal was to assess the clinical and angiographic outcomes among patients undergoing treatment for distal anterior cerebral artery aneurysms at the Jefferson Hospital for Neuroscience (1997-2005). Forty-one patients (1.5% of all aneurysms treated) with distal anterior cerebral artery aneurysms had undergone treatment. The clinical and angiographic outcomes of these patients were studied retrospectively using chart reviews, operative reports, and angiographic reports. The mean clinical and angiographic follow-up periods were 16 months (range, 3-74 mo) and 16.5 months (range, 6-81 mo), respectively. Twenty-eight (68%) patients had undergone endovascular embolization (22 women, six men; mean age, 58.2 yr), whereas 13 (32%) had undergone microsurgery for clip ligation (six men, seven women; mean age, 47.4 yr). Within the coiled group, 50% of the patients belonged in the Hunt and Hess (HH) III and IV groups, whereas 46.2% of the patients in the clipped group were elective patients (HH Grade 0). The mean aneurysmal sizes among the clipped and coiled groups were 4.9 and 5.5 mm, respectively. Among the clipped patient population, 100% of the patients had successful clip ligation as evidenced by intraoperative cerebral angiography, there was a 0% recurrence rate among the two patients who have had long-term follow-up, 0% recurrent subarachnoid hemorrhage, and 92% patients achieved a modified Glasgow Outcome Scale score of I to II. Among the coiled patient population, there was an 89% rate of successful embolization, 18% recurrence rate, 0% recurrent subarachnoid hemorrhage, and 64% achieved a modified Glasgow Outcome Scale score of I to II. None of the patients had clinically symptomatic vasospasm. A strong correlation existed between having a ventriculostomy and requiring a shunt in patients with HH Grade IV compared with patients in HH Grades I through III. In our analysis, clinical outcomes were better in the clipped group; however, the differences are not statistically significant (P = 0.3675) and are explained by the selection bias. Statistically significant predictors of outcomes were age (<60 yr), size of the aneurysm (>5 mm), absence of ventriculostomy, and presenting HH grade.

Intraoperative cerebral angiography: superficial temporal artery method and results.

To report the method for and results of intraoperative cerebral angiography performed via the superficial temporal artery, for assessment of cerebral aneurysm surgery. All patients undergoing craniotomies for treatment of intracranial aneurysms were prospectively entered into a database. A policy of performing angiography via the superficial temporal artery in appropriate cases was instituted. This procedure was performed with retrograde catheterization of the superficial temporal artery, as it coursed over the zygomatic arch, with an 18-gauge, 1.88-inch, intravenous catheter and hand injection of contrast material, with intraoperative digital subtraction fluoroscopic guidance. Thirty-six patients who underwent 38 craniotomies for clipping of 43 aneurysms underwent intraoperative angiography via the superficial temporal artery. There were six unexpected findings (14%), including four unexpected arterial occlusions and two unexpected residual aneurysms. One aneurysm was observed to be patent when it was punctured, after intraoperative angiography had indicated no filling of the aneurysm. Additional clips were placed. Three patients (8%) developed multiple arterial infarctions in the territory of the injected carotid artery, for which multiple causes were possible. Adequate angiographic images could usually be obtained with this method. Intraoperative angiography via the superficial temporal artery is simple and is not associated with substantial complications. It is a reasonable alternative to transfemoral angiography for detection of adverse consequences of intracranial aneurysm clipping.

Surgical management of giant arteriovenous malformations

The surgical management of giant arteriovenous malformations (AVMs) remains a significant treatment challenge. Perhaps the most important factor in surgical outcome for giant AVMs is patient selection. We treat most giant AVMs conservatively. Exceptions include patients with progressive neurological deficits from AVM hemorrhage. We prefer staged transfemoral glue embolization followed by craniotomy for microsurgical resection, often using frameless stereotactic guidance as a surgical adjunct. Somatosensory evoked potentials and electroencephalographic monitoring with barbiturate burst suppression are used to insure neural protection. Intraoperative cerebral angiography minimizes the possibility of residual AVM and postoperative hemorrhage. Strict postoperative control of blood pressure and staged embolization can prevent normal perfusion pressure breakthrough. A team approach with a neurosurgeon, endovascular neurosurgeon, and neuroanesthesiologist optimizes the outcomes associated with these challenging lesions.

Modified, multipurpose, radiolucent sugita head frame for intraoperative cerebral angiography.

Although several radiolucent head-fixation devices have been developed to allow intraoperative cerebral angiography, no device provides satisfactory freedom to obtain the most suitable head position. We recently designed a multipurpose radiolucent Sugita head frame (modified radiolucent Sugita frame) with satisfactory degrees of freedom and rigidity for intraoperative head positioning and head holding, respectively. A short arm and a ring joint, made of engineering plastic, were added to the prototype radiolucent Sugita frame, to permit side-tilting movements of the frame. The shape of all handles at the joints was also changed and the size was enlarged, to facilitate adjustment of the head position. We used this modified radiolucent Sugita frame in 20 cases involving aneurysms or arteriovenous malformations. The frame performed satisfactorily in all cases, in terms of firm head fixation and unrestrained freedom of head positioning at the surgeon's request. The modified radiolucent Sugita frame was evaluated with respect to its resistance to physical forces. The physical strength of the modified radiolucent Sugita frame is almost equivalent to that of the metallic Sugita frame and is considered sufficient for clinical usage. With its rigidity, satisfactory degrees of freedom, and ease of handling, the clinical applicability of the dramatically improved radiolucent head frame enables us to obtain satisfactory intraoperative angiograms.

The use of intraoperative angiography in the management of neurovascular disorders

Objective: To review our experience of intraoperative angiography in dealing with neurovascular disorders and to substantiate the usefulness of this investigation.Method: From April 1999 to November 2000, 32 cases of intraoperative angiogram were studied.Results: Two out of 30 intraoperative angiograms were unsuccessful. The angiographic machine broke down during one of the attempts. In one patient, intimal dissection of the femoral artery was noted during the procedure and the study was abandoned; the patient recovered uneventfully. Among the 30 completed angiograms, 19 were for cerebral aneurysm, 10 for arteriovenous malformation (AVM) and one for extracranial–intracranial (EC‐IC) bypass. There was no procedure‐related complication. Among the 19 angiograms performed for cerebral aneurysms, total occlusion was confirmed in 14 patients (74%), residual aneurysms were detected in two patients (10%) and branch occlusions were detected in three patients (16%). Of the 10 angiograms performed for AVM, total removal was confirmed in nine (90%), whereas residual AVM was detected in one patient (10%). One intraoperative angiogram for EC‐IC bypass confirmed the patency of the graft.Conclusions: The study showed that cerebral intraoperative angiography is safe and frequently reveals unclipped aneurysm necks, unexpected major vessel occlusion and residual AVM. Intraoperative cerebral angiography should be recommended as a standard practice for treating neurovascular disorders. Chinese Abstract imageimage

P-1-30 - Intraoperative cerebral angiography. Its effectiveness and homework in the future

P-1-30 - Intraoperative cerebral angiography. Its effectiveness and homework in the future

Radiopaque markers facilitate intraoperative angiography: Technical note

Lead markers taped to patients' heads prior to surgery can facilitate positioning during intraoperative cerebral angiography. More rapid positioning reduces the duration of interruption of surgery required for angiography.