DIGITAL SUBTRACTION ANGIOGRAPHY IN CEREBROVASCULAR DISEASE AND PERSPECTIVE.pptx

Brief information about Cerebral DSA

1. DIGITAL SUBTRACTION ANGIOGRAPHY IN CEREBROVASCULAR DISEASE AND PERSPECTIVE IN DIAGNOSIS DR. DEVASHISH GUPTA

2. INTRODUCTION Fluoroscopic technique for visualization of blood vessels (Gold standard) Accurately determine the size and location of vascular lesions, detecting tandem arterial lesions and assessing the collateral circulation Demonstration of vascular anatomy by direct injection of iodinated contrast medium into the vessel. Radioopaque structures ( eg. bones) are subtracted digitally from image SIX VESSEL ANGIOGRAPHY 1. Right ICA 2. Left ICA 3. Right ECA 4. Left ECA 5. Right vertebral artery 6. Left vertebral artery

3. INDICATIONS 1. Primary vascular disease Vaso-occlusive disease Aneurysm AV malformations Arteriovenous fistula 2. Vascular assessment of tumors 3. Congenital vascular condition 4. Interventional procedures Mechanical thrombectomy Intra- arterial thrombolysis Angioplasty and stenting

4. CONTRAINDICATIONS Bleeding diathesis Thrombogenic conditions Skin infections Abnormal renal function Cardiac condition Allergy to iodinated contrast agents Pregnancy Non palpable pulse

5. APPROACH TO CASE OF ISCHEMIA INFARCTION

6. TECHNIQUE OF DSA Adequate hydration with 4hr fasting prior to procedure Informed consent Sterilisation of site followed by local anesthesia Site of puncture: Right femoral artery using Seldinger technique Inject 2500U heparin (0.5ml) and flush sheath with saline Desired catheter is taken and angiography is started

7. TECHNIQUE Location and palpation of femoral artery LA infiltration Arterial Puncture Placement of arterial sheath

8. ICA (AP XRAY)

9. ICA (LATERAL XRAY)

10. VERTEBRAL ARTERY (AP XRAY)

11. VERTEBRAL ARTERY (LATERAL XRAY)

12. CEREBRAL VEINS (AP XRAY)

13. CEREBRAL VEINS (LATERAL XRAY)

14. ACUTE CEREBRAL ISCHEMIA- INFARCTION DSA used as a prelude to intraarterial thrombolysis or mechanical thrombectomy Major vessel occlusion: Interruption of contrast column Abrupt vessel cut off Meniscus sign Tapered or rat tail narrowing Tram track appearance with trickle of contrast around intraluminal thrombus Less common signs: Hyperemia with vascular blush around infracted zone (Luxury perfusion) Early draining veins (AV shunting with contrast appearing in veins draining the infarct while remainder of circulation is in later arterial or early capillary phase)

15. ACUTE CEREBRAL ISCHEMIA- INFARCTION Early arterial phase: Abrupt vessel cut off (MCA) and Bare area of devascularised brain

16. ACUTE CEREBRAL ISCHEMIA- INFARCTION Retrograde filling of distal MCA branches from collaterals from ACA and PCA

17. ACUTE CEREBRAL ISCHEMIA- INFARCTION Capillary phase: Blush in ACA/PCA territory Venous phase: Persistent contrast in MCA branches with Luxury perfusion at bare area

18. ACUTE CEREBRAL ISCHEMIA- INFARCTION Complete occlusion of left ICA to level of CCA

19. VENOUS INFARCTION DURAL SINUS THROMBOSIS Occluded (non filling) sinus Slow flow with or without clot in adjacent cortical veins Delayed emptying of cortical veins: Hanging in space appearance SUPERFICIAL VEIN THROMBOSIS Thin round or tubular layer of contrast surrounding thrombus DEEP CEREBRAL VENOUS THROMBOSIS Absent opacification of deep venous system

20. VENOUS INFARCTION

21. NON ATHEROSCLEROTIC VASCULOPATHIES Dissection Carotid web Reversible cerebral vasoconstriction syndrome (RCVS) Vasculitis Recreational drug use Moya moya disease Fibromuscular dysplasia (FMD)

22. ARTERIAL DISSECTION Pearl-and-string sign Double-lumen sign Short, smooth, tapered occlusion Pseudoaneurysm formation

23. CAROTID WEB Focal linear shelf like filling defect along the wall

24. RCVS Multifocal narrowing and beaded appearance Near complete resolution at follow up

25. MOYA MOYA DISEASE Progressive bilateral stenosis of the distal internal carotid arteries, extending to the proximal ACA and MCA, with development of an extensive collateral (parenchymal, leptomeningeal, and transdural ) network at the base of the brain like a cloud or puff of smoke Suzuki’s 6 angiographic stages: (1) stenosis of the carotid fork, (2) appearance of moyamoya vessels at the base of the brain, (3) intensification of moyamoya vessels, (4) minimization of moyamoya vessels, (5) reduction of moyamoya vessels (6) disappearance of moyamoya vessels (collaterals only from external carotid arteries)

26. FIBROMUSCULAR DYSPLASIA “ String of beads ” angiographic appearance

27. VASCULITIS TAKAYASU ARTERITIS: Long segment smooth stenosis SLE: Irregular beaded appearance

28. VENOUS INFARCTION

29. POST INTERVENTION

30. REFERENCES Bradley and Daroff’s Neurology in clinical practice 2, 8 th edition 2021 Osborne’s brain Imaging, pathology and anatomy, 2 nd edition AIIMS MAMC PGI comprehensive textbook of diagnostic radiology Vol 1, 1 st edition Peter Fleckenstein Anatomy in diagnostic imaging, 3 rd edition McCarty JL, Leung LY, Peterson RB, Sitton CW, Sarraj A, Riascos RF, Brinjikji W. Ischemic infarction in young adults: A review for radiologists. Radiographics . 2019 Oct;39(6):1629-48. Narsinh KH, Kilbride BF, Mueller K, Murph D, Copelan A, Massachi J, Vitt J, Sun CH, Bhat H, Amans MR, Dowd CF. Combined use of X-ray angiography and intraprocedural MRI enables tissue-based decision making regarding revascularization during acute ischemic stroke intervention. Radiology. 2021 Apr;299(1):167. Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. Western Journal of Emergency Medicine. 2011 Feb;12(1):67.