Selective External Carotid Angiography Research Articles

Iatrogenic arteriovenous fistula presenting as a recurrent subdural hematoma

An unusual case of an iatrogenic dural arteriovenous fistula is reported. The patient presented with a history of progressive generalized headache over a period of 3 to 4 weeks. Computerized tomography demonstrated a chronic subdural hematoma that was successfully evacuated by burr-hole drainage. The patient's postoperative course was complicated by recurrent acute subdural hematomas at the drainage site. Coagulation studies were unremarkable. Selective external carotid angiography demonstrated a small dural arteriovenous fistula adjacent to the burr hole used for the initial operative procedure. Extension of the bone flap and coagulation of the fistula resulted in a good outcome. In the patient with recurrent acute subdural hematoma, the possibility of a vascular malformation must be considered. Selective internal and external carotid angiography is key to the correct diagnosis.

Proatlantal Intersegmental Artery associated with Hypertensive Intracerebral Hemorrhage

A 57-year-old male was hospitalized with stroke on the day of onset. An initial computed tomography revealed a hemorrhage in the left caudate nucleus. Common carotid angiography demonstrated a carotid-vertebral anastomosis. Complete selective external carotid angiography disclosed the proatlantal intersegmental and occipital arteries arising from the external carotid artery at the level of the atlas. The proatlantal intersegmental artery, which is one type of persistent primitive carotid-vertebrobasilar anastomosis, is rarely associated with hypertensive intracerebral hemorrhage, according to the literature.

Gliomas with dural invasion: Computed tomography and angiography

This report is a review of the findings of computed tomography and angiography of eight supratentorial gliomas with dural invasion. Computed tomography revealed localized increases in the thickness of ring enhancements at the sites of dural invasion in four cases, which was attributed to increased blood supplies by the meningeal vessels. Angiographically, feeders from the meningeal vessels entered the tumors mostly through relatively broad areas of tumor-dura attachment. A sunburst type of neovascularity from a meningeal artery was seen in only one case. In most such cases the differential diagnosis from meningioma was possible by the computed tomographic and angiographic findings. Selective external carotid angiography was the most important examination for diagnosing dural invasion by gliomas.

Superficial Temporal Artery Aneurysm associated with Pathological Changes mimicking Cystic Medial Necrosis

A case of spontaneous true aneurysm of the left superficial temporal artery (STA) is reported. The patient, a 15-year-old male, had no known history of trauma but had noticed a small, pulsating mass in the left preauricular region 1 month before admission. Physical examination revealed no abnormality other than the 15×10 mm pulsatile mass. Laboratory tests and other routine studies were within normal limits. Left selective external carotid angiography demonstrated a saccular aneurysm of the main trunk of the STA. The aneurysm was resected, and microscopic examination revealed it to be a true aneurysm. Its wall was composed of thickened, uniform tissue with proliferative myointimal cells and pooled acid mucopolysaccharides in the intracellular spaces. Mucoid pools within the residual media separated the cellular elements. In addition, the elastic laminae were disrupted. These findings are quite similar to the characteristic vascular changes of cystic medial necrosis, which often lead to the development of dissecting or saccular aneurysms in large vessels. Aneurysms of the STA are rare and usually post-traumatic. A survey of 165 reported cases of STA aneurysms yielded only 11 cases of spontaneous aneurysms. These aneurysms are assumed to have been congenital or arteriosclerotic. The STA aneurysm described here appears unique, as it was associated with pathological changes resembling those of cystic medial necrosis.

Arteriographic assessment of patency of the inferior alveolar artery and its relevance to alveolar atrophy

Patency of the inferior alveolar artery was investigated on 84 patients who had undergone selective external carotid angiography with digital subtraction. Patency of the artery was lost earlier in males than females, but the presence or absence of teeth did not appear to affect the outcome. The artery was visualized less well on patients with medical conditions that may predispose to early or excessive atherosclerotic disease.

Malignant Fibrous Histiocytoma of the Temporal Bone with Multiple Metastases

Malignant fibrous histiocytoma (MFH) is well known as a soft tissue tumor of the extremities. MFH of the skull is relatively rare, especially with multiple metastases. A 59-year-old female was admitted with complaint of a painless tumor in the left temporal region in March, 1983. Skull plain film showed an osteolytic and osteosclerotic lesion, with a “moth-eaten” appearance, of the temporal bone. Computed tomography (CT) scans revealed a high density mass lesion invading intraand extracranially. Selective external carotid angiography revealed abnormal tumor vessels like a corkscrew and a marked tumor stain. The tumor was extirpated. The histological diagnosis was MFH. The patient received chemotherapy with mitomycin C intraoperatively, and was discharged without any neurological deficits. She was readmitted with complaint of general fatigue 7 months later. Plain chest X-ray films showed a tumor in the mediastinum and depressed fracture of the third thoracic vertebra. CT scans revealed the invasion of the mediastinal tumor to the spinal canal and the hydrothorax. She died in July, 1984. The autopsy showed multiple metastases of MFH to the mediastinum, the third thoracic vertebra, and the right lung, and an associated meningioma in the left cerebellopontine angle. There was no local recurrence.

Aneurysmal bone cyst of the skull

A case of a 48-year-old woman with aneurysmal bone cyst of the skull is reported. By using estrogen, which is one of the chemical embolizing agents, the abnormal vascular shadow disappeared and clinical symptoms were improved. The significance of selective external carotid angiography in the diagnosis of this lesion is discussed and the benefit of this therapeutic method is argued.

Selective External Carotid Angiography and its Clinical Applications

Selective external carotid angiography using Seldinger's technique was employed in 20 cases (9 tumors, 9 spontaneous carotid-cavernous fistulas [CCF], 2 others), and its clinical applications are discussed. Diagrams of normal external carotid angiogram were drawn on the basis of analysis of the films obtained from these 20 cases. Various clinical situations were then investigated as follows: 1) A case with a right temporal bone tumor, where the ophthalmic artery originated solely from the middle meningeal artery of the same side and fed the tumor. 2) Nine cases of spontaneous CCF. One case was an internal CCF, and eight were dural CCF. A case of dural CCF with feeders arising from the accessory meningeal artery, the artery of the foramen rotundum, vidian artery of the external carotid artery, as well as the C4 part of the internal carotid artery, is presented. 3) A case of left sphenoid ridge meningioma with extracranial extension via the base of the cranium. The proximal part of the external carotid artery was ligated. By vertebral and deep cervical angiographies, the external carotid artery was opacificated via the enlarged anastomoses between the occipital, vertebral, and deep cervical arteries. 4) A case of giant neurinoma in the right middle fossa with a feeder arising from the middle meningeal artery of the same side. Other lesions in the cranium, the face, and the scalp are also presented. Selective external carotid angiography proved valuable in the diagnosis of the extra and intracranial lesions.

A stereoangiographic study of the arterial variations in the external carotid system.

Selective external carotid angiography was performed on a series of 80 cadavers and the arteriograms were studied from stereoradiographs taken with a Zonarc® radiographic apparatus. The order of ramification of the lingual, facial and occipital arteries varied: the most proximal branch was most often the lingual (53.8%), whereas the most distal branch was either the facial (40%) or the occipital (36.3%). The facial and lingual arteries had a common origin in 17.5% of the cases. The course of the maxillary artery was superficial in 58.2% and deep in 41.8% of this series. In the superficial variant the inferior alveolar artery most commonly arose after the middle meningeal, and the origins of the middle deep temporal and inferior alveolar arteries were always independent. In contrast in the deep variant, the inferior alveolar artery rarely arose after the middle meningeal, and, in most cases, it showed a common origin with the middle deep temporal artery.

Lung Metastasis of Intraosseous Meningioma prior to Craniotomy

A 38-year-old female was admitted, because of a dull headache and a slowly growing, hard, fixed mass in the vertex area. Severe papilledema was noted. Plain roentgenograms of the skull showed thickening of the outer table and diploe at the vertex. Selective external carotid angiography demonstrated enlarging branches of both the superficial temporal artery and middle meningeal artery entering the region of the thickened skull and forming a homogeneous tumor stain. The superior sagittal sinus was obscured beneath the thickened skull. Computerized tomography revealed no intracranial mass lesion. Chest X-ray film showed multiple coin lesions in both the lung fields. During the operation, an intraosseous meningioma was found as well as isolated small intradural tumors. The superior sagittal sinus was grossly collapsed without any tumor masses. These tumors were totally removed (grade 1 removal after Simpson). The postoperative course was uneventful. An open biopsy of one of the lung tumors was performed. The skull, falx and lung tumors were identical in histological appearance and showed typical features of meningotheliomatous meningioma. Without histologically malignant features, meningioma rarely metastasizes. Only 10 cases of metastatic meningioma without craniotomy were reported in the literature from 1941 to 1983. In the present case the lung metastasis seems most likely hematogenous. The route by which the small falx tumors were seeded is not clear.

Blood supply of acoustic neurinomas.

The arterial blood supply of acoustic neurinomas is reviewed on the basis of normal and pathological anatomical findings as well as neuroradiological and intra-operative observations. Available data suggest that, as a rule, the tumour primarily receives blood from the external carotid by way of dural vessels, with the occipital artery playing a prominent role. The cerebellar vessels, including the anterior inferior cerebellar artery, are apparently no more than secondary contributors. In the light of these observations, selective external carotid angiography on the diseased side is recommended in acoustic neurinomas. In hypervascularized neurinomas preoperative embolization of afferent external carotid branches is discussed as a potential supplementary procedure.

The Diagnostic and Therapeutic Role of Angiography in Lingual Arterial Bleeding

Selective external carotid angiography proved effective in the diagnosis of lingual arterial bleeding in seven patients. The cause of the hemorrhage was carcinoma of the tongue in six patients and stab wounds in one. Therapeutic Gelfoam embolization controlled hemorrhaging in four patients.

Extravasation and arteriovenous shunting after epidural bleeding -- a radiological study.

Eighteen patients with epidural bleeding had preoperative angiography with visualization of the meningeal arteries. Thirteen of these had extravasation of contrast medium from meningeal arteries and eleven also had shunting of contrast medium from meningeal arteries to meningeal or diploic veins. For easier demonstration of these findings, selective external carotid angiography and the use of larger amounts of contrast medium are recommended. Our results support the theory that the arteriovenous shunting has important implications on the pathophysiology of epidural bleeding. Failure to demonstrate extravasation and arteriovenous shunting may be explained in three ways: (1) inadequate angiographic technique; (2) arterial bleeding has stopped; (3) epidural bleeding is not arterial.

Selective external carotid angiography in diagnosis of head and neck tumors.

Using a double needle and X-ray television monitoring, selective angiography of the external carotid artery was performed in 25 patients with head or neck tumors. Good correlation was obtained between the surgical and radiographic findings. Location and invasion of the tumor, and in some cases the nature of the tumor, were determined by this technique, based on the dislocation, disappearance of hypervascularization of the artery. In combination with another radiographic method, selective external carotid angiography seems to be a promising technique for diagnosis of head and neck tumors.

Angiography of the external carotid to internal carotid anastomosis.

The EC/IC bypass is being performed more and more, and angiography is essential as part of the postoperative evaluation. This review of 41 patients points out the need for selective external carotid angiography in those cases where intracranial vessels fill spontaneously at the same time as the shunt. However, 8 of 11 cases showed the superficial temporal artery to be larger on the selective external carotid angiogram than in the common carotid study done during the same session. In two cases undergoing staged occlusive procedures as treatment for giant aneurysm, the external carotid artery leading to an EC/IC was occluded as an angiographic complication without neurologic sequelae.

Blutversorgung der Orbita �ber die A. maxillaris: normale und pathologische Aspekte

Both normal and pathological orbital vascularization appears to be partially dependent on three deep maxillary artery branches. The authors use selective angiograms and microradiographs of injected specimens to describe the orbital branches of the middle meningeal, anterior deep temporal and infraorbital arteries. Variable embryological developments determine the orbital contributions of the middle meningeal artery via the recurrent meningeal and meningolacrimal branches. The anterior deep temporal artery supplies constant branches to the inferior and lateral lacrimal territories. The infraorbital artery sends branches to the inferomedial portion of the orbit and the inferior lacrimal territory. Selective external carotid angiography may opacify the whole ophthalmic arterial system and faintly opacifies the ophthalmic veins.

Importance of angiography in identifying false aneurysm of the middle meningeal artery as a cause of extradural hematoma. Case report.

Received for publication May 14, 1968. parieto-occipital region. Internal carotid angiograms revealed an extracerebral hematoma (Fig. 1). First Operation. A burr hole over the suspected area disclosed a large extradural hematoma. I t was evacuated, apparently completely. No definite source of bleeding was found. First Postoperative Course. The patient regained consciousness the following morning; the paresis and dysphasia were little improved. To investigate the cause of the incomplete recovery, selective external carotid angiography was done on the 8th postoperative day; it revealed a false aneurysm of the posterior branch of the middle meningeal artery (Fig. 2) . Second Operation. A small bone flap centered over the site of the false sac was raised. Evacuat ion of the underlying residual clot exposed the bleeding artery; the hemor-

Some observations on the angiography of supratentorial meningiomas

The angiographic findings in 71 histologically proven cases of supratentorial meningiomas were reviewed. The following conclusions are made:— 1. While the overall sex incidence of the meningiomas is approximately 2 females to 1 male, there is almost equal distribution between the two sexes in parasagittal and convexity meningiomas. Meningiomas situated in the skull base are commoner in females. 2. Meningeal supply and tumour circulation were more frequently demonstrated in parasagittal and convexity meningiomas and infrequently in basal meningiomas. This success or failure has no relation to the size of the tumour. 3. In tumours situated near the midline, angiography should not be limited to the side of the tumour, since its meningeal supply may be partially or totally derived from the contralateral side. 4. Although selective external carotid angiography provides a more illustrative demonstration of the meningeal supply of the tumour, it has almost no value in subfrontal, subtemporal and suprasellar meningiomas. The majority of these tumours derive their blood supply from the meningeal vessels of the internal carotid artery. 5. Tumour circulation was demonstrated in 34 cases (less than 50%). In 8 additional cases there was an enlarged middle meningeal artery with no angiographic evidence of intraneoplastic vessels. In one case only we observed tumour circulation but the feeding meningeal artery was not seen. In 29 cases (approximately 40%) neither ameningeal supply nor tumour circulation was demonstrated.

A catheter for selective internal or external carotid angiography.

Internal carotid angiography using a metal canula and a short Seldinger guide wire was reported by Sheldon (1964) as being a safer method than using the traditional carotid angiography needle. External carotid angiography, to supplement internal carotid angiography, by the method of Ruggiero and Jay (1958) was often a very tedious investigation and was not always successful with the Sheldon (1964) instrument. Over the last two years a teflon catheter has been used for carrying out the double investigation without any complications and with a high rate of successful external carotid examinations.

Superficial temporal artery aneurysms.

Traumatic aneurysms of the extracranial segment of the external carotid artery are rare. With the exception of four cases involving the facial artery (1–4) and one involving the retroparotid segment of the external carotid artery (6), the site of aneurysm is always the superficial temporal artery. Winslow and Edwards (5) in 1935 reviewed the world literature and were able to find fewer than 100 cases of post-traumatic aneurysms of the superficial temporal artery. Occasional case reports have appeared in the literature since that time. Because of the rarity of these aneurysms, we are reporting two cases demonstrated by selective external carotid angiography. Case Reports Case I: C. M., a 62-year-old white woman with a past history of a cerebrovascular accident, fell at home, striking her head. She was examined in the Emergency Department of the Boston City Hospital. Small contusions over the right orbit and in the right temporal area were noted. The patient was discharged and remained asymptomatic for three days until she was found semistuporous in bed. On examination she was drowsy but responded to verbal stimuli. Under the resolving contusion in the right temporal area were two 5 mm pulsatile masses, the pulses synchronous with the radial pulse. Compression of the superficial temporal artery obliterated the pulses. Skull roentgenograms showed no evidence of fracture. A right internal carotid angiogram was normal. Right external carotid angiography, performed to permit study of the pulsatile mass over the scalp, disclosed 2 saccular aneurysms of the superficial temporal artery (Figs. 1 and 2). After the coma cleared, both aneurysms were excised. They proved to be false aneurysms of the superficial temporal artery, that is, the lining of the aneurysms was fibrous connective tissue rather than intima. Case II: C. H., a 28-year-old Negro male, was struck in the left temple with a bottle and a 2 cm laceration was produced. The patient controlled the bleeding by compression; he was not seen by a physician, and the laceration was not sutured. Approximately one week later the patient noted a pulsatile mass at the laceration site, but because it was painless, he did not seek medical attention. Bifrontal headaches developed shortly thereafter, and by three months they had become persistent and incapacitating. Examination showed a 1 em pulsatile mass in the left temporal area. The mass could be reduced and the pulse obliterated by compressing the ipsilateral superficial temporal artery. Skull radiographs were normal. Left external carotid angiography showed a saccular aneurysm (Figs, 3 and 4) with a well delineated neck. Because of the regression of the headache and lack of further expansion, it was elected to follow the patient clinically rather than to excise the lesion. Discussion A false aneurysm is an organized hematoma which retains its communication with the arterial lumen.