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
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
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
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
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)
1: Superior sagittal sinus 2: Transverse sinus 3: Superior petrous sinus 4: Bulb of internal jugular vein 5: Internal jugular vein 6: Confluence of sinuses 7: Sigmoid sinus
8: Inferior veins of cerebellar hemisphere 9: Inferior vermis vein 10: Inferior petrous sinus
1: Superior sagittal sinus 2: Superior cerebral veins 3: Great cerebral vein (Galen) 4: Basal vein (Rosenthal) 5: Superior petrous sinus 6: Cavernous sinus 7: Inferior petrous sinus
8: Bulb of internal jugular vein 9: Thalamostriate vein10: Internal cerebral vein11: Straight sinus 12: Transverse sinus 13: Sigmoid sinus
Acute thromboembolic occlusion. Left internal carotid angiogram, early arterial phase, AP view, shows abrupt "cut-off" of the MCA . Lateral view, early arterial phase, shows normal filling of both ACAs and the ipsilateral PCA via a large PCoA. The MCA distribution is not opacified, leaving a large "bare area" of devascularized brain.
Later image shows that the large "bare area" remains unopacified. Cortical branches are seen high over the left parietal convexity with early retrograde filling of the distal MCA branches via pial collaterals from the ACA and PCA. Collateral flow is also seen from the posterior temporal PCA branches into the MCA territory. (8-42D) Later image shows slow retrograde filling into the MCA territory from ACA and PCA collaterals.
Capillary phase shows diffuse brain "blush" in ACA/PCA territories; contrast with "bare area" normally supplied by the MCA. Some MCA branches are filling slowly via retrograde flow from ACA/PCA pial collaterals. (8-42F) Venous phase shows persisting contrast in some MCA branches that have filled in retrograde fashion via pial collaterals and are slowly emptying. Note "blush" at border of "bare area" caused by "luxury perfusion."
ICA Occlusion- Frontal projection from left cerebral angiogram delineates complete occlusion of left ICA to level of CCA. Normal opacification of ECA noted
Cortical vein occlusion is shown with dural sinus thrombosis. (L) Coronal NECT in a 62y woman with headache, left-sided weakness shows a hyperdense SSS st and thrombus in the adjacent vein of Trolard ſt. (R) CTV shows "empty delta" sign in the SSS , filling defects in the vein of Trolard. (9-31) Close-up view of lateral DSA in the same case shows thrombus in SSS and vein of Trolard .
Traumatic cervical ICA dissection. DSA shows the left ICA with greater than 50% luminal narrowing (arrows) with carotid terminus occlusion and lack of left anterior circulation filling (dashed circle).
Carotid web in a 47-yearold woman with left cerebral infarction. (a, b) Coronal maximum intensity projection CT angiogram (a) and preintervention DSA image (b) show a focal linear shelflike filling defect (arrow) along the wall of the left ICA origin, consistent with a carotid web. (c) Postintervention DSA image shows that the web is no longer present.
RCVS in a 30-year-old woman who presented with sudden-onset headache and no recent trauma. (a) DSA image shows multifocal narrowing (arrows) and beaded appearance of the anterior cerebral arteries and MCAs. (B) Follow-up DSA image at 10 days shows near-complete resolution.
Known moyamoya in a young patient with prior watershed infarcts. Anteroposterior DSA image shows right ICA and proximal MCA steno-occlusive disease of the carotid termini (arrowheads), with extensive small collateral lenticulostriate arteries (arrow).
Lateral left carotid angiogram in a patient with fibromuscular dysplasia. Note “string of pearls” appearance at around the C2 level.
Angiograms of a patient with Takayasu arteritis demonstrating long, smooth stenotic lesions of the left subclavian artery and involvement of other branches of the aortic arch vessels.
Lateral carotid angiogram demonstrates irregular beading appearance (arrowheads) of large and medium branches of the anterior, middle, and posterior cerebral arteries in a patient with systemic lupus erythematosus
Sagittal NECT reformatted from the axial source data shows dense thrombus ſt extending throughout the entire deep venous (Galenic) system. The SSS appears normal. (D) Venous phase of the lateral carotid DSA in the same case shows normal cortical veins and SSS , vein of Trolard . The ependymal veins, ICVs, vein of Galen, and straight sinus are unopacified because they are completely filled with thrombus.
Left MCA occlusion. (A) Initial lateral cerebral angiogram- Paucity of vessels in MCA distribution (B)- Repeat lateral angiogram after intra arterial lysis demonstrates recanalization of flow
Mechanical thrombectomy with recanalization of the basilar artery but the left posterior cerebral artery remains occluded. A, Axial and, B, sagittal noncontrast head CT images show hyperattenuated thrombus (arrow) in the distal basilar artery. C, Coronal CT angi- ography shows nonopacity of the distal basilar artery (arrow). Left vertebral arteriogram in frontal projection, D, before and, E, after mechanical thrombectomy demonstrate recanalization of the basilar artery but occlusion of the left posterior cerebral artery (arrows). F, Axial diffusion-weighted imaging and, G, apparent diffusion coefficient map show acute infarct in the bilateral posterior cerebral artery territories with increased susceptibility in the left posterior cerebral artery (arrow on H) and, H, axial susceptibility-weighted imaging, mitigating against further mechanical thrombectomy attempts.
Mechanical thrombectomy in intracranial atherosclerotic disease. A, Noncontrast head CT image on the axial plane shows multiple areas of subtle hypoattenuation in the right middle cerebral artery (MCA) distribution. B, Noncontrast head CT image on the axial plane shows calcified lesion in the right M1 middle cerebral artery (arrow). C, Time to maximum of residue function map on the axial plane shows large area of tissue at risk in the right MCA territory. Right common carotid arteriograms of, D, frontal and, E, lateral projections before attempted thrombectomy show occlusion of the distal M1 segment of the right MCA (arrow; thrombolysis in cerebral infarction score of 0). Right internal carotid arteriograms of, F, frontal and, G, lateral projections after three thrombectomy passes show antegrade flow through a high-grade stenosis (arrow) in the right distal M1 MCA
A: Initial DSA showing thromboembolic occlusion of the right distal internal carotid artery (ICA). B: Mechanical thrombectomy of the right distal ICA and middle cerebral artery (MCA), which achieved complete recanalization. C: Diffusion-weighted MRI revealing an acute infarction in the right insula and basal ganglia. E: The patient suffered a second stroke 6 days after the index stroke; DSA revealing embolic occlusion of the left proximal MCA. F: The left MCA was successfully reopened after mechanical thrombectomy G: Follow-up diffusion weighted MRI revealing a slightly increased signal intensity in the left basal ganglia.
