Use Of Digital Subtraction Angiography Research Articles

Vascular imaging for Stereoelectroencephalography: A safety and planning study

BackgroundStereoelectroencephalography (SEEG) is a procedure used to localize the epileptogenic zone in patients with medically refractory epilepsy, involving the stereotactic implantation of electrodes into brain parenchyma. Magnetic Resonance Imaging (MRI), Digital Subtraction Angiography, and Computed Tomography have been used preoperatively to prevent Intracranial Hemorrhage (ICH) by identifying electrode-vessel conflicts (EVC’s) on planned electrode trajectories. There is variation in the use of Digital Subtraction Angiography and non-invasive sequences for vascular planning. Digital Subtraction Angiography provides high spatial resolution, but carries risks of arterial dissection, groin and retroperitoneal hematoma, and a 0.5–1.9% risk of stroke. Our group has incorporated Intravenous Cone Beam Computed Tomography (CBCT A/V) Brain into our SEEG workflow, given its effective implementation in other neurosurgical domains. Primary aims include validating the safety of our CBCT A/V sequence for SEEG planning and determining if CBCT A/V is comparable to other modalities in detecting EVC’s. Secondary aims include elucidating the relationship of conflicting vessel calibre with ICH incidence in SEEG using CBCT A/V imaging. MethodsA single-center retrospective study was conducted of 20 patients who underwent preoperative CBCT A/V Brain and MRI Brain with gadolinium enhancement, encompassing 273 electrode implantations from August 2020 − July 2023. The incidence and grade of post-implant, post-explant symptomatic ICH and asymptomatic ICH was noted. The total number of EVC’s identifiable on MRI and CBCT A/V was recorded, along with average diameter of conflicting vessels. ResultsAcross 20 patients and 273 implanted electrodes, there were four ICH events, where two were symptomatic and two were asymptomatic. The mean diameter of EVC’s across all patients was 1.4 mm (±0.5). A significant difference (P < 0.0001) was observed between the number of EVC’s that CBCT A/V could identify (20) compared to MRI (6). Two EVC’s were identified in the region of two symptomatic ICH’s, with the mean diameter of these conflicted vessels being 1.5 mm (±0.4). The two symptomatic ICH-associated EVC’s were observed on CBCT A/V but not MRI. ConclusionsIn our series, CBCT A/V demonstrates an acceptable safety profile for SEEG planning compared to other imaging modalities. CBCT A/V identified significantly more EVC’s compared to MRI, including those contributing to transient symptomatic intracranial hemorrhage. A conflicting vessel calibre of less than 1.2 mm on CBCT A/V did not contribute to ICH in our SEEG series. Unstructured abstract:For patients with medically refractory epilepsy, stereoelectroencephalography (SEEG) is a procedure utilized to localize the epileptogenic zone by the stereotactic implantation of electrodes into brain parenchyma. Digital Subtraction Angiography and non-invasive neuroimaging sequences have been used preoperatively to identify potential electrode-vessel conflicts (EVC’s) on planned electrode trajectories and prevent ICH. Intravenous Cone Beam Computed Tomography (CBCT A/V) is a sequence that we adopted for SEEG planning at our institution. It provides clear vascular segmentation of both cerebral arteries and veins, potentially reducing ICH risk, without some of the traditional risks associated with Digital Subtraction Angiography. The primary aims included determining if CBCT A/V is comparable to other modalities in detecting EVC’s and validating the safety of our CBCT A/V sequence for SEEG planning. Secondary aims included elucidating the relationship of conflicting vessel calibre with ICH incidence for SEEG. In our SEEG series, we identified two asymptomatic ICH’s, and two symptomatic ICH events, which were transient in nature and recovering within 24 h of onset. CBCT A/V demonstrates an acceptable safety profile, produces a sharp image for visualising vessel contours during SEEG planning, and identifies more clinically significant EVC’s compared to MRI. Conflicting vessels of less than 1.2 mm on CBCT A/V did not contribute to ICH in our SEEG series.

Our Experience with Sinonasal Glomangiopericytoma in North India: A Case Series.

Glomangiopericytoma (GPC) is a rare benign sinonasal tumor originating from Zimmerman's Pericytes surrounding capillaries and accounting for less than 0.05% of all sinonasal tumors. Glomangiopericytoma has low malignant potential (5-10%) and is mostly diagnosed in the 6th or 7th decade of age with slight female preponderance. We presented here a case series of 5 patients with sinonasal GPC. This research was conducted at a tertiary healthcare centre in North India. In our case series, all the patients were evaluated and underwent endoscopic surgical resection. All patients underwent digital subtraction angiography (DSA) and preoperative embolization. The coblation technique used for haemostasis proved very effective and time-saving. All patients exhibited cytoplasmic SMA positivity (a marker of GPC) and CD34 negativity, while one patient exhibited a high Ki-67 index (> 10%), which is a predictor of aggressive tumor behavior. None of the patients showed any recurrence in follow-up. We recommend performing complete endoscopic surgical excision to prevent recurrence. The use of DSA, preoperative embolization, and intraoperative use of the coblation technique provides a cleaner surgical field and reduced operating time.

Fluoroscopically guided vascular and cardiac transcatheter procedures: a comparison of occupational and patient dose by anatomical region

X-ray guided procedures are being performed by an increasing variety of medical specialties. Due to improvements in vascular transcatheter therapies, there is an increasing overlap of imaged anatomy between medical specialties. There is concern that non-radiology fluoroscopic operators may not have sufficient training to be well informed of the potential implications of radiation exposure and mitigation strategies to reduce dose. This was a prospective, observational, single center study to compare occupational and patient dose levels when imaging different anatomical regions during fluoroscopically guided cardiac and endovascular procedures. Occupational radiation dose was measured at the level of the temple of 24 cardiologists and 3 vascular surgeons (n = 1369), 32 scrub nurses (n = 1307) and 35 circulating nurses (n = 885). The patient dose was recorded for procedures (n = 1792) performed in three angiography suites. Abdominal imaging during endovascular aneurysm repair (EVAR) procedures was associated with a comparatively high average patient, operator and scrub nurse dose despite additional table-mounted lead shields. Air kerma was relatively high for procedures performed in the chest, and chest + pelvis. Higher dose area product and staff eye dose were recorded during procedures of the chest + pelvis due to the use of digital subtraction angiography to evaluate access route prior to/during transaortic valve implantation. Scrub nurses were exposed to higher average radiation levels than the operator during some procedures. Staff should be cognizant of the potentially higher radiation burden to patients and exposed personnel during EVAR procedures and cardiac procedures using digital subtraction angiography.

A comparison of patient dose and occupational eye dose to the operator and nursing staff during transcatheter cardiac and endovascular procedures

The number and complexity of transcatheter procedures continue to increase, raising concerns regarding radiation exposure to patients and staff. Procedures such as transaortic valve implantations (TAVI) have led to cardiologists adopting higher dose techniques, such as digital subtraction angiography (DSA). This study compared the estimated patient and occupational eye dose during coronary angiography (CA), percutaneous coronary intervention (PCI), TAVI workups (TWU), TAVI, endovascular aneurysm repairs (EVAR), and other peripheral diagnostic (VD) and interventional (VI) vascular procedures. A quantitative analysis was performed on patient dose during 299 endovascular and 1498 cardiac procedures. Occupational dose was measured for the cardiologists (n = 24), vascular surgeons (n = 3), scrub (n = 32) and circulator nurses (n = 35). TAVI and EVAR were associated with the highest average dose for all staff, and significantly higher patient dose area product, probably attributable to the use of DSA. Scrub nurses were exposed to higher average doses than the operator and scout nurse during CA, VD and VI. Circulating nurses had the highest average levels of exposure during TAVI. This study has demonstrated that EVAR and TAVI have similar levels of occupational and patient dose, with a notable increase in circulator dose during TAVI. The use of DSA during cardiac procedures is associated with an increase in patient and staff dose, and cardiologists should evaluate whether DSA is necessary. Scrub nurses may be exposed to higher levels of occupational dose than the operator.

Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis.

Digital subtraction angiography (DSA) assesses revascularization in pediatric moyamoya patients after surgery, but MRI and angiography (MRI/A) may provide comparable data. To evaluate DSA and MRI/A with respect to clinical utility in postoperative follow-up, complication profile, and relative cost at 1 year. All pediatric moyamoya patients who received bilateral indirect revascularization between 2011 and 2020 were retrospectively reviewed at 1 institution. Patients who underwent MRI/A-only, DSA-only, or both after 1 year were compared. Eighty-two patients were included. At 1 year, patients who underwent either MRI/A (n = 29) or DSA (n = 40) had no significant differences in detection rate of new at-risk hypovascular territories (6.9% vs 2.5%, P = .568) or need for subsequent revascularization beyond the mean 40 ± 24-month follow-up period (3.4% vs 5.0%, P > .9). Among patients who underwent both MRI/A and DSA (n = 13), both studies identified the same at-risk territories. No patients experienced MRI/A-related complications, compared with 3 minor DSA-related complications. The use of MRI/A yielded a 6.5-fold reduction in cost per study vs DSA at 1 year. Using DSA to follow moyamoya patients after indirect revascularization is generally safe but associated with a low rate of minor complications and a 6.5-fold greater financial cost relative to MRI/A. These data support changing practice to eliminate the use of DSA when following routine bilateral moyamoya cases in the absence of clinical symptoms or specific concerns. Using MRI/A as the primary postoperative follow-up modality in this select population provides noninferior care and greater patient access, while reducing cost and potentially decreasing risk.

Modern treatment of massive hemothorax

Introduction and objective: Hemothorax is an umbrella term for pathologies with an extremely wide range of etiology and severity. Most commonly it is of tramuatic origin, frequently iatrogenic (intervention, blood coagulation altering therapy) and rarely unknown. Depending on the cause, volume, and dynamics, it requires a patient-adapted treatment determined by access to certain therapeutical methods. We aim to provide a practical overview of these. Methods: Retrospective analysis of patients treated for haemothorax at the Thoracic Surgery Department of Borsod-Abaúj-Zemplén County Teaching Hospital in the period 1 January 2017–31 December 2021 has been performed. We used the hospital’s database to collect data. In this paper, we analyze the cause of hemothorax, method of treatment, the efficacy of chosen therapeutic modality, duration of hospital stay, complication rate, 30-day survival. Results: 77 patients were treated with hemothorax, 57 male, 20 female patients. Average age was 53,4 (23–90, SD:14,9) years. Surgery was performed in 31 cases, with 10 cases needing reintervention. In 7 cases, multimodal approach was chosen, with chest wall stabilization. Average hospital stay: 14 (2–79) days. 30-day survival: 95%. Discussion: Thoracic drainage is our first therapeutic choice. The methods used in the treatment of hemothorax in our practice have been extended with the use of digital subtraction angiography (DSA), which yields immediate and effective bleeding control. We performed video-assisted thoracoscopic surgery (VATS) in increasing numbers. Conclusions: As long as the intensity of bleeding and patient’s general status allows it, after drainage, the first therapeutic option – when accessible – should be DSA bleeding control. In cases which do not resolve after drainage, VATS evacuation of hematoma is a safe method used in the treatment of hemothorax. In the past 5 years, we used thoracoscopy in increasing numbers while treating this entity. Based on our results and the literature, we can safely state that the use of thoracoscopy in the treatment of hemothorax is a safe and reliable option in eligible patients, and the results are comparable with those treated by thoracotomy.

Theoretical comparison of energy-resolved and digital-subtraction angiography.

X-ray coronary angiography is a sub-optimal vascular imaging technique because it cannot suppress un-enhanced anatomy that may obscure the visualization of coronary arterydisease. The purpose of this paper is to evaluate the theoretical image quality of energy-resolved x-ray angiography (ERA) implemented with spectroscopic x-ray detectors (SXDs), which may overcome limitations of x-ray coronaryangiography. We modeled the large-area signal-difference-to-noise (SDNR) of contrast-enhanced vasculature in ERA images and compared with that of digital-subtraction angiography (DSA), which served as a gold standard vascular imaging technique. To this end, we used calibrated numerical models of the response of cadmium telluride SXDs including the effects of charge sharing, electronic noise, and energy thresholding. Our models assumed zero scatter, no pulse pile up and small signals such that image contrast is approximately linear in the area density of contrast agents. For DSA, we similarly modeled x-ray detection by cesium iodide energy-integrating detectors using validated numerical models. For ERA, we investigated iodine and gadolinium (Gd) contrast agents, two-material and three-material decompositions, analog charge summing for charge sharing correction, and optimized image quality with respect to the tube voltage and energy thresholds assuming cadmium telluride SXDs with three energybins. Our analysis reveals that a three-material decomposition using iodine contrast agents will require x-ray exposures that are approximately 400 times those of DSA to achieve the same SDNR as DSA in coronary applications, and is therefore not feasible in a clinical setting. However, three-material decompositions with Gd contrast agents have the potential to provide SDNR that is ∼45% of that of DSA for matched patient air kerma. For two-material decompositions that suppress soft-tissue, ERA has the potential to produce images with SDNR that is 50%-75% of that of DSA for matched patient air kermas but lower levels of tube loading. Achieving these SDNR levels will require the use of analog charge summing for charge sharing correction, which increased SDNR by up to a factor of 1.7 depending on the contrast agent and whether or not a two-material or three-material decomposition wasassumed. We conclude that three-material ERA implemented with Gd contrast agents and two-material ERA implemented with either iodine or Gd contrast agents, should be investigated as alternatives to DSA in situations where motion artifacts preclude the use of DSA, such as in coronaryimaging.

Cerebral Digital Subtraction Angiography in Acute Intracranial Hemorrhage: Considerations in Critically Ill Children

Cerebrovascular disorders are an important cause of morbidity and mortality in children. Although minimally invasive, cerebral digital subtraction angiography (DSA) has been shown to be safe in children and is a valuable, and perhaps underutilized, technique for the diagnosis and management of pediatric cerebrovascular disorders in the critical care setting. Through a case-based approach, we explore the utility of DSA in critically ill children with acute intracranial hemorrhage (ICH). We discuss the use of DSA in the acute management of aneurysm and arteriovenous malformation rupture as well as cerebral vasospasm. Those caring for critically ill children with acute ICH should consider cerebral DSA as part of a comprehensive approach to the diagnosis and management of these conditions.

Digital subtraction angiography in cerebrovascular disease: current practice and perspectives on diagnosis, acute treatment and prognosis

Digital Subtraction Angiography (DSA) is the gold-standard imaging modality in acute cerebrovascular diagnosis. The role of DSA has become increasingly prominent since the incorporation of endovascular therapy in standards of care for acute ischemic stroke. It is used in the assessment of cerebral vessel patency; however, the therapeutic role of DSA from a prognostic standpoint merits further investigation. The current paper provides an update on current practice on diagnostic, therapeutic and prognostic use of DSA in acute cerebrovascular diseases and various indications and perspectives that may apply, or limit its use, in ongoing surveillance or prognosis. Pre-clinical and clinical studies on the aspects, including but not limited to the morphology of cerebrovasculature in acute ischaemic stroke, are required to delineate and inform its prognostic role.

Utility of skull X-rays in identifying recurrence of coiled cerebral aneurysms.

ObjectiveA high rate of cerebral aneurysm recurrence following endovascular coiling has prompted the use of digital subtraction angiography (DSA) for interval follow-up. However, the utility of skull x-rays as an alternative screening method for aneurysm recurrence is unproperly characterized.MethodsRetrospective review of a prospective registry of ruptured and unruptured cerebral aneurysms. Anteroposterior and lateral skull x-rays were obtained immediately at the end of the procedure and at 6-month follow-up. Aneurysm recurrence was defined by comparing post-procedure and 6-month DSA imaging. A true positive was defined as a change in coil mass morphology on at least one projection with aneurysm recurrence on DSA, and a true negative defined as a stable coil mass on both projections and no recurrence on DSA. Receiver operating characteristic area under the curve (AUC) statistics was used to assess the performance of skull x-rays in identifying aneurysm recurrence.ResultsA total of 118 cerebral aneurysms were evaluated with DSA imaging and skull x-rays. A change in coil mass morphology on one projection of skull x-rays correctly detected all true recurrences with a sensitivity of 100% (95% confidence interval [CI], 91-100%). Skull x-rays failed to identify a stable aneurysm coil mass in 15 cases, with a specificity of 79% (68-88%). Skull x-rays performed with AUC 0.8958 (95% CI, 0.8490-0.9431) in identifying aneurysm recurrence.ConclusionsThe findings of our study suggest that skull x-rays may represent a low-cost, non-invasive screening tool to rule out aneurysm recurrence, which can potentially aid in decreasing the utilization of DSA in the follow-up of patients with coiled cerebral aneurysms.

On the Use of Digital Subtraction Angiography in Stereoelectroencephalography Surgical Planning to Prevent Collisions with Vessels

Stereoelectroencephalography (SEEG) consists of the implantation of microelectrodes for the electrophysiological characterization of epileptogenic networks. To reduce a possible risk of intracranial bleeding by vessel rupture during the electrode implantation, the stereotactic trajectories must follow avascular corridors. The use of digital subtraction angiography (DSA) for vascular visualization during planning is controversial due to the additional risk related to this procedure. Here we evaluate the utility of this technique for planning when the neurosurgeon has it available together with gadolinium-enhanced T1-weighted magnetic resonance sequence (T1-Gd) and computed tomography angiography (CTA). Twenty-two implantation plans for SEEG were initially done using T1-Gd imaging (251 trajectories). DSA was only used later during the revision process. In 6 patients CTA was available at this point as well. We quantified the position of the closest vessel to the trajectory in each of the imaging modalities. Two thirds of the trajectories that appeared vessel free in the T1-Gd or CTA presented vessels in their proximity, as shown by DSA. Those modifications only required small shifts of both the entry and target point, so the diagnostic aims were preserved. T1-Gd and CTA, despite being the most commonly used techniques for SEEG planning, frequently fail to reveal vessels that are dangerously close to the trajectories. Higher-resolution vascular imaging techniques, such as DSA, can provide the neurosurgeon with crucial information about vascular anatomy, resulting in safer plans.

Optimizing Limb Salvage in Shotgun Injuries to the Extremities in Civilian Trauma

Vascular trauma in civilian settings has often resulted in high rates of amputation or mortality. Although treatment was individualized, patients were managed according to the following protocol: (1) Clinical evaluation and identification of those patients that require immediate exploration. (2) Determination of ankle-ankle indices, with a threshold of 0.9 mandating further evaluation. (3) Liberal use of computed tomography angiography (CTA) evaluation of injuries. (4) Selected use of digital subtraction angiography with an attempt to treat via endovascular means if there is thought to be a reasonable likelihood of success. (5) Liberal use of fasciotomy. (6) Reconstruction of arterial injury with contralateral reversed saphenous when available. (7) Postoperative follow-up with noninvasive arterial studies. Hypothesis: Protocol-driven early assessment and intervention can lead to excellent limb salvage in patients with civilian gunshot wound to the extremities. We retrospectively reviewed our gunshot database from 2012 to 2017 for patients with noniatrogenic penetrating vascular extremity injuries. Data analyzed were demographics, mode of injury, vessels injured, physical examination, arteriography findings, ischemic time, type of arterial and venous repair, morbidity, mortality, graft patency and functional outcome. Postoperative follow-up was done with noninvasive arterial studies. Sixteen patients sustained extremity injuries inflicted by shotguns. Fifteen (94%) underwent preoperative arteriography or CTA, revealing occult arterial injury in nine patients. One patient had soft tissue only and the other five who underwent CTA had no evidence of vascular injury. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. Eighty-one percent underwent fasciotomy at time of surgery. Fasciotomy occurred in 100% of patients with combined arterial and venous injuries (100%) versus 25% with isolated arterial injury. Arterial continuity was restored by interposition grafting with reversed saphenous vein (100%). There were no deaths or amputations at in-office follow-up, which ranged from 6 months to 7 years. Two patients had saphenous nerve injures, one of which fully recovered and the other patient ambulated with a cane due to nerve injury. A protocol of preoperative imaging with either arteriography or CTA for extremity shotgun injuries, use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates of 100% after shotgun vascular trauma to the extremities.

Association between Enlarged Perivascular Spaces and Internal Carotid Artery Stenosis: A Study in Patients Diagnosed by Digital Subtraction Angiography

Objective: An enlarged perivascular space (EPVS) is an imaging marker of cerebral small vessel disease, and its relationship with large artery disease is elusive. We investigated the EPVS in patients with internal carotid artery stenosis (ICAS) with the use of digital subtraction angiography (DSA) and tested the relationship between the degree of EPVS and the degree of ICAS; as well as the relationship between the degree of EPVS and white matter hyperintensity (WMH). Method: A total of 202 patients with or without ICAS diagnosed by DSA were enrolled. The maximal ICAS rates, the degrees of EPVS and WMH were measured. The patients’ clinical characteristics and laboratory parameters were recorded. Univariable analysis and multivariable regression were used to test their correlations. In a unilateral stenosis subgroup, the EPVSs in the ipsilateral hemisphere of stenosis and in the contralateral hemisphere were compared. Results: According to univariable analysis, there were significant differences in age (P = .000), Hg1bc (P = .035) and folic acid (P = .008) among the subgroups based on the degrees of EPVS in the basal ganglia (BG). Age (P = .000) and the level of fibrinogen (P = .018) differed statistically among the subgroups based on the degrees of EPVS in the white matter (WM). The correlation between the degrees of WM-EPVS and the ICAS levels was tested with a gamma test: G = .280, P = .001. The ordinal multivariable regression model showed that age was independently associated with both BG-EPVSs and WM-EPVSs. A current smoker status was also independently associated with WM-EPVSs. ICAS level was associated with the severity of WM-EPVSs after adjusting for other risk factors. The degree of BG-EPVS was not correlated with the degree of stenosis. (P = .101). In 59 patients with unilateral ICAS, as tested by the Wilcoxon signed ranks test, the WM-EPVS scores in the ipsilateral hemisphere of stenosis were higher than those in the contralateral hemisphere. (P = .004), but there was no difference in BG-EPVSs (P = .070). Both BG-EPVSs and WM-EPVSs were independently correlated with WMH. Conclusions: BG-EPVSs and WM-EPVSs have different risk factors. WM-EPVSs but not BG-EPVSs are correlated with ICAS.

Fusion Imaging Significantly Reduces Contrast and Radiation Exposure During Standard EVAR

Background: Standard endovascular aortic repair (EVAR) is frequently performed with few data regarding utilization of 2D-3D fusion imaging (FI). Purpose: To evaluate a) feasibility and safety of 2D-3D FI to guide limb deployment during EVAR and b) efficacy of this technique compared to standard use of digital subtraction angiography (DSA) for guidance. Materials and Methods: Iliac limb deployment by guidance of 2D-3D FI (FUSION group, n=22 limbs) during EVAR was compared to (STANDARD group, n=23 limbs). Retrospectively, we analyzed feasibility (success-rate) and safety (patency of hypogastric artery; type Ib/III endoleak) of FI for limb deployment (FUSION group). Total contrast (ml) and median dose area product (mGy*cm2) per group to visualize the iliac bifurcation were compared. Results: In the FUSION group, limb deployment was performed in 19/22 limbs (86.4%) and all hypogastric arteries were patent at the end of the procedure. Median volumes of contrast per bifurcation were 13.0 ml (RANGE 13–13ml) in the STANDARD and 2.2ml (RANGE 0–13ml) in the FUSION group (p=0.002); median dose area products per bifurcation were 11951mGy*cm2 and 2593.1mGy*cm2 (p=0.001), respectively. Conclusion: Fusion imaging for guidance of limb deployment during standard EVAR is safe and feasible in the majority of procedures and can significantly reduce contrast volume and radiation exposure even if compared with optimal preparation by predicting optimal C-arm positions. Therefore, FI should be used whenever possible

Comprehensive Analysis of Invasive and Noninvasive Investigation Methods in Peripheral Artery Disease

Abstract Peripheral artery disease of the lower limbs is, in fact, an arterial pathology, by which the blood flow is reduced, due to the obstruction caused by the deposit of atheroma plaques.(1) This deposition occurs slowly, which leads to a slow progression of the disease, and thus, at the onset of symptomatology. The objective of the study was to make a comparison between the invasive and noninvasive paraclinical investigations performed in patients with peripheral arterial disease of the lower limbs in the E.C.C.H. Sibiu. In conclusion, between the two investigations (computed tomography angiography and digital subtraction angiography) there are no noticeable differences in the terminal aorta and iliac arteries, but in reducing the arteries calibre, the use of digital subtraction angiography is preferred, according to our study, although it is more invasive and exposed to complications.

Limitations of multidetector computed tomography angiography for the diagnosis of blunt cerebrovascular injury.

OBJECTIVE Blunt cerebrovascular injuries (BCVIs) following trauma carry risk for morbidity and mortality. Since patients with BCVI are often asymptomatic at presentation and neurological sequelae often occur within 72 hours, timely diagnosis is essential. Multidetector CT angiography (CTA) has been shown to be a noninvasive, cost-effective, reliable means of screening; however, the false-positive rate of CTA in diagnosing patients with BCVI represents a key drawback. Therefore, the authors assessed the role of DSA in the screening of BCVI when utilizing CTA as the initial screening modality. METHODS The authors performed a retrospective analysis of patients who experienced BCVI between 2013 and 2015 at 2 Level I trauma centers. All patients underwent CTA screening for BCVI according to the updated Denver Screening Criteria. Patients who were diagnosed with BCVI on CTA underwent confirmatory digital subtraction angiography (DSA). Patient demographics, screening indication, BCVI grade on CTA and DSA, and laboratory values were collected. Comparison of false-positive rates stratified by BCVI grade on CTA was performed using the chi-square test. RESULTS A total of 140 patients (64% males, mean age 50 years) with 156 cerebrovascular blunt injuries to the carotid and/or vertebral arteries were identified. After comparison with DSA findings, CTA findings were incorrect in 61.5% of vessels studied, and the overall CTA false-positive rates were 47.4% of vessels studied and 47.9% of patients screened. The positive predictive value (PPV) for CTA was higher among worse BCVI subtypes on initial imaging (PPV 76% and 97%, for BCVI Grades II and IV, respectively) compared with Grade I injuries (PPV 30%, p < 0.001). CONCLUSIONS In the current series, multidetector CTA as a screening test for blunt cerebrovascular injury had a high-false positive rate, especially in patients with Grade I BCVI. Given a false-positive rate of 47.9% with an estimated average of 132 patients per year screening positive for BCVI with CTA, approximately 63 patients per year would potentially be treated unnecessarily with antithrombotic therapy at a busy United States Level I trauma center. The authors' data support the use of DSA after positive findings on CTA in patients with suspected BCVI. DSA as an adjunctive test in patients with positive CTA findings allows for increased diagnostic accuracy in correctly diagnosing BCVI while minimizing risk from unnecessary antithrombotic therapy in polytrauma patients.

Normal anatomy and variations in the confluence of sinuses using digital subtraction angiography

Objectives: The configuration of the confluence of sinuses differs not only between individuals, but also between the two brain hemispheres, making the anatomical classification of this region difficult. In this study, we evaluated the anatomy of the confluence of sinuses and ascertained the accuracy and usefulness of digital subtraction angiography (DSA) in the evaluation of cerebral veins.Methods: Bilateral carotid and vertebral artery angiographies were performed in 500 adult patients to evaluate the anatomy of the confluence of sinuses and contributory venous sinuses. We appraised the anatomy of the sinuses adjacent to the confluence, the lateralization of venous draining into the transverse sinuses (TSs), the communications between the TSs, and the presentation of the occipital sinus (OS).Results: Based on the anatomical descriptions of Osborn’s Brain (Diagnostic Cerebral Angiography, 2nd edition), we delineated 10 different configurations of the confluence of sinuses that showed connections among the superior sagittal sinus, the straight sinus, and the left and right TSs. Right side dominant transverse sinus accounted for 49% of the cases. Direct communication between the TSs accounted for 46.4% of the cases. Indirect communication accounted for 51.6% of the case, and absence of communication between the left and the right TS accounted for 2%. Lastly, the presence of OS was observed in 6% of the cases.Conclusion: DSA promises to be an effective technique for studying the anatomy and normal variations of the confluence of sinuses, providing useful information for the diagnosis of cerebral venous diseases, and ensuring safer surgical procedures.

Correlation between angiographic transit times and neurological status on admission in patients with aneurysmal subarachnoid hemorrhage.

The use of digital subtraction angiography (DSA) for semiquantitative cerebral blood flow(CBF) assessment is a new technique. The aim of this study was to determine whether patients with aneurysmal subarachnoid hemorrhage (aSAH) with higher Hunt and Hess grades also had higher angiographic contrast transit times (TTs) than patients with lower grades. A cohort of 30 patients with aSAH and 10 patients without aSAH was included. Relevant clinical information was collected. A method to measure DSA TTs by color-coding reconstructions from DSA contrast-intensity images was applied. Regions of interest (ROIs) were chosen over major cerebral vessels. The estimated TTs included time-to-peak from 0% to 100% (TTP0-100), TTP from 25% to 100% (TTP25-100), and TT from 100% to 10% (TT100-10) contrast intensities. Statistical analysis was used to compare TTs between Group A (Hunt and Hess Grade I-II), Group B (Hunt and Hess Grade III-IV), and the control group. The correlation coefficient was calculated between different ROIs in aSAH groups. There was no difference in demographic factors between Group A (n = 10), Group B (n = 20), and the control group (n = 10). There was a strong correlation in all TTs between ROIs in the middle cerebral artery (M1, M2) and anterior cerebral artery (A1, A2). There was a statistically significant difference between Groups A and B in all TT parameters for ROIs. TT100-10 values in the control group were significantly lower than the values in Group B. The DSA TTs showed significant correlation with Hunt and Hess grades. TT delays appear to be independent of increased intracranial pressure and may be an indicator of decreased CBF in patients with a higher Hunt and Hess grade. This method may serve as an indirect technique to assess relative CBF in the angiography suite.

Serbian

Intracranial aneurysm is a focal, abnormal dilation of an artery of the brain. Magnetic resonance angiography (MRA) is a non-invasive technique for vascular imaging and is thus widely used for screening for intracranial vascular lesions. The aim of the study was to show the diagnostic accuracy of 3D Time-of-Flight (3D TOF) MRA in the detection of unruptured cerebral aneurysms with the use of digital subtraction angiography (DSA) as the gold standard. A total of 2.612 consecutive patients underwent 3DTOF MRA. It showed unruptured aneurysms in 94 (3.6%) patients. They included 68 women and 26 men ranging in age from 29 to 76 years (mean, 52.5 years). Twenty-six of them, 20 women and 6 men, underwent DSA. The Mann-Whitney U test was used for the correlation of size. Fisher’s test was used for the correlation of location. The statistical level of significance was set at p 0.05) of aneurysms between TOF MRA and DSA. MRA is an accurate and non-invasive method for diagnosis of unruptured intracranial aneurysms. The results of study show the compatibility of MRA findings, the location and the size of an aneurysm in comparison with the “gold standard” cerebral DSA. Acta Medica Medianae 2015;54(3):12-18.

Detection Rate of Intravascular Injections during Cervical Medial Branch Blocks: A Comparison of Digital Subtraction Angiography and Static Images from Conventional Fluoroscopy.

BackgroundThe most definitive diagnosis of neck pain caused by facet joints can be obtained through cervical medial branch blocks (CMBBs). However, intravascular injections need to be carefully monitored, as they can increase the risk of false-negative blocks when diagnosing cervical facet joint syndrome. In addition, intravascular injections can cause neurologic deficits such as spinal infarction or cerebral infarction. Digital subtraction angiography (DSA) is a radiological technique that can be used to clearly visualize the blood vessels from surrounding bones or dense soft tissues. The purpose of this study was to compare the rate of detection of intravascular injections during CMBBs using DSA and static images obtained through conventional fluoroscopy.MethodsSeventy-two patients were included, and a total of 178 CMBBs were performed. The respective incidences of intravascular injections during CMBBs using DSA and static images from conventional fluoroscopy were measured.ResultsA total of 178 CMBBs were performed on 72 patients. All cases of intravascular injections evidenced by the static images were detected by the DSAs. The detection rate of intravascular injections was higher from DSA images than from static images (10.7% vs. 1.7%, P < 0.001).ConclusionsAccording to these findings, the use of DSA can improve the detection rate of intravascular injections during CMBBs. The use of DSA may therefore lead to an increase in the diagnostic and therapeutic value of CMBBs. In addition, it can decrease the incidence of potential side effects during CMBBs.