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Technic and Value of Percutaneous Vertebral Angiography
Technic and Value of Percutaneous Vertebral Angiography DONALD B. FRESHWATER
THE general acceptance of vertebral angiography has been somewhat slow for two principal reasons: relatively infrequent indication and difficulty of technic. It is the purpose of this paper to delineate the present usefulness of this procedure and to report a reasonable technic. Lindgren 6 has an admirable review of the early development of technic in his excellent report on vertebral angiography. The usefulness of any diagnostic test must be assessed from both sides of the ledger-lesions it rules out as well as lesions it reveals. This is emphatically true in vertebral angiography and we count as a minor triumph any posterior fossa exploration saved by arteriographic demonstration of inoperability. In our cases there were at least three such instances and a fourth in which postoperative arteriography revealed that suboccipital craniectomy could have been avoided. On the positive side of the ledger are those cases of intracranial aneurysm and vascular anomaly successfully treated principally as a result of careful arteriographic localization. In addition, there is certainly the possible value of vertebral angiography in tumors of the occipital region as well as in instances in which evaluation of the vascularity of a tumor may be helpful. It should be said at once that angiography in no way supplants ventriculography in the confirmation of classical expanding posterior fossa lesions. The neurosurgeon must be familiar with vessel-displacement phenomena, some of which are diagnostic of an expanding lesion (and others suggestive or even misleading), so that an angiogram which is negative for vascular lesions may correctly reveal a neoplasm. When a reasonable facility in performing vertebral angiography has been gained, acknowledging that there may be failures, we believe that the indications for this study are as follows: 1. Spontaneous subarachnoid hemorrhage, failing demonstration of the lesion by bilateral carotid angiography. 2. Intracranial bruit under the same conditions. 3. Atypical cerebellopontine angle syndromes. a. Atypical acoustic neuromas. 801
802
Donald B. Freshwater
4. Syndromes of obscure etiology involving midbrain and hindbrain. 5 5. Cerebellar tumor with associated vascular irregularity in fundior family history of hemangioblastomas. Angiography has theoretical value in cerebellar hematomas (Ecker 4) and platybasia. I have had no experience with the former. In the latter an Arnold-Chiari deformity is well assessed for its surgical indication by pneumoencephalography, and the bony deformity by stereographic roentgenograms of the skull. Arteriographic aid in platybasia is a possibility but we have not utilized it in this condition. TECHNIC
Simplicity is certainly the greatest single virtue of any technic. Skill comes with experience and cumbersome equipment often is unnecessary.
Fig. 219. The offset needle routinely in use in percutaneous carotid angiography and needle of first choice in vertebral angiography (available at Thomas W. Reed Co., Boston, Massachusetts).
At the Lahey Clinic, ordinary 10 cc. syringes and a two-way pet cock (Luer-Lok) are used, and are rinsed and filled with either citrate solution or 35 per cent diodrast. Several sharp 18 gauge needles are available so that the sharpest one can be chosen (the ease with which the needle penetrates the patient's skin is as good a test as any, albeit its poor timeliness). Because the entire procedure is usually made easier, I try to place an offset needle8 (Fig. 219) into the vertebral artery low in the neck. This needle is made from an 18 gauge needle mounted in heavier gauge shafts for stability and has been in routine use in this clinic in percutaneous carotid arteriography. A three dimensional knowledge of the anatomy of the artery must be acquired for consistent success. The vertebral artery lies low in the neck, just dorsal to the common carotid artery, which can usually be palpated. With the patient under pentothal anesthesia, the needle is introduced medial to the carotid, after which the transverse process and then the foramen of the vertebral artery which should underlie the carotid are sought. Gentle advancement and withdrawal will permit an atraumatic search for this foramen. When it is found, the needle is slowly advanced into it (Fig. 220).
r
r
P ercutaneOU8 Vertebral Angiography
803
The needle, open pet cock and syringe of 5 cc. of citrate solution are a unit during the arterial puncture and the appearance of arterial blood forcefully entering the syringe is the only indication of proper arterial puncture. A smoothly functioning syringe is essential. A freely flowing arterial puncture, tested with small amounts of citrate solution injected as forcibly as the diodrast is to be injected insures successful arteriography. The element of chance plays a certain role here and there is no method that will insure a central position of the needle in the arterial lumen. However, extension of the neck apparently fixes the artery against the wall of its foramen, and I have had more success with this maneuver than with any other.
Fig. 220. Needle and two-way pet cock, and 10 cc. syringe of citrate solution as assembled for puncture. Vertebral puncture has been made; simple exchange of syringes can be made and diodrast injected.
Following successful arterial puncture, the syringe is changed and 10 cc. of 35 per cent diodrast 14 is rapidly injected, the x-ray exposure being called for with approximately 1 cc. of diodrast still in the syringe. The pet cock is closed, a syringe of 5 cc. of citrate solution substituted, the arterial flow checked, and a small amount of citrate injected to admix with blood in the needle. A stereoscopic adjustment is then made and the above procedure is repeated. Stereoscopic views are of extreme importance, particularly in the lateral projection, and do not significantly prolong the procedure. The position of the patient and the x-ray technic do not vary from those described by Poppen9 for carotid arteriography except for the greater extension of the head at the time of vertebral arterial puncture. Next, the anteroposterior views are made and it is my belief that both the tmbmentovertex and Chamberlain-Towne projections should be se-
'1
804
Donald B. Freshwater
cured. The former can be done without any great change in the patient's extended head position by placing cassette and grid (Lysholm) carefully beneath the occiput and adjusting the x-ray tube and position of the patient's stretcher. The contrast injection is then made similar to the foregoing. Extreme extension of the head and low angulation of the tube are necessary for satisfactory views but may be hampered by the relative inflexibility of the patient's neck. Another serious drawback is the inevitable exposure of the surgeon's hands to the direct x-ray beam. Despite these handicaps the most satisfactory anteroposterior demonstration of the intracranial portion of the vertebral, the posteriorinferior cerebellar and the first part of the basilar arteries is obtained with this view. The Towne view is made next and, although of less hazard to the surgeon and greater ease to the roentgenologist, it entails a reversal of the patient's head to a sharply flexed position. Extra help is required in the careful withdrawal of support from beneath the patient's shoulders and slow flexion of the patient's head and gentle placement on the gridcassette. The tube is then realigned for the Towne view and the patient's head is momentarily held in extreme flexion by a lead-gloved assistant while the injection and exposure are made. The needle is left in situ while the films are developed and examined so that repeat or later phase views can be obtained if indicated. At any time in the procedure if doubt exists as to the integrity of the arterial puncture, a halt can be called until the exposed films are examined. Improper arterial visualization is almost invariably due to a faulty puncture and readjustment of the needle will often bring success. In cases in which vertebral arteriography is of extreme importance, it has been necessary at times to make numerous adjustments to obtain satisfactory films. There have been no ill effects from this since extra-arterial injection almost unfailingly enters the venous rete! surrounding the vertebral artery. There are numerous cases where persistence is the sine qua non. Failure to obtain proper puncture with the offset needle indicates use of a standard 18 gauge needle. I have had most success in inserting the needle between the second and third or third and fourth transverse processes in the manner described by Sugar, Holden and Powell 12 (although I do not use their equipment). It is considerably more difficult to keep the straight needle in position unless it has been' placed well inside the foramen. PITFALLS IN INTERPRETATION OF ANGIOGRAMS
The interpretation of the angiograms is as much the responsibility of the neurosurgeon as it is that of the roentgenologist. Figures 221 to 225 illustrate several obvious lesions which can be visualized better
805
Percutaneous Vertebral Angiography
than they can be described. Attention should be called to several pitfalls: 1. The bifurcation of the basilar artery into right and left posterior cerebral arteries as viewed in the true lateral projection strongly resembles an aneurysm. We have noted this many times and have corrected such an impression by the stereoscopic lateral and anteroposterior views. Recently, this possible error has been mentioned by Ecker.4 2. Impaction of the basilar artery against the clivus is not always
a
b
Fig. 221. a, Lateral and b, anteroposterior vertebral arteriogram~showing large. fusiform aneurysmal dilation of left vertebral and basilar artery in a 45 'year old man. Patient had sudden onset of vertigo, headache, nausea, vomitin·g, ataxia and right hemiparesis, followed shortly by diplopia. Examination revealed: mixed extra-ocular palsies, paresis of the left seventh and of the right fifth cranial nerves, right hemiparesis, right hemihypalgesia and mild ataxia.
present in expanding posterior fossa lesions and is often apparent in the normal. Slight variation from the true lateral can be very misleading. Again, stereoscopic views are helpful. 3. Protrusion of the posterior-inferior cerebellar artery downward beneath the rim of the foramen magnum4, 11 gives support to the diagnosis of tonsillar herniation but again can be an accident of x-ray projection or simply be within the normal anatomic range. 4. Curvatures, as seen in the submentovertex view, of the vertebral or basilar arteries are the rule rather than the exception and one should be cautious in ascribing even the most exaggerated curve to displacement by a tumor mass.
806
Donald B. Freshwater
5. N onfilling of a vessel or branch of a vessel alone is not sufficient evidence to establish a diagnosis of thrombosis. Eventually, with greater and greater experience in vertebral angiographic interpretation controlled by surgical or postmortem confirmation, an evaluation of the significance of some of the more obscure observations will be obtained. As compared to the growing~experience
Fig. 222.
Fig. 223.
Fig. 222. Lateral vertebral arteriogram showing large, fusiform aneurysmal dilatation of the basilar artery in a 54 year old man. Patient had sudden onset of vertigo, headache, nuchal rigidity and ataxia. Cerebrospinal fluid was xanthochromic. Fig. 223. Anteroposterior vertebral arteriogram showing large saccular and fusiform aneurysmal dilatation of left vertebral and basilar artery in a 49 year old man. Diagnosis was first made at the time of exploration for supposed acoustic neurinoma. Following demonstration by vertebral arteriography of a normal right vertebral artery, the left vertebral artery was ligated (by J. L. Poppen) in the neck with marked relief of suboccipital headache.
in carotid angiography, 3 • 4. 7. 10. 13. 15 only a relatively small number of cases of vertebral angiography are presented. The technic of obtaining this study must, of course, come first so that it can be made applicable in more and more of the puzzling occipital and suboccipital problems. Results
Vertebral angiography has been performed at the Lahey Clinic entirely by the percutaneous method over the past two years. In that ·time, 51 patients underwent 57 successful procedures. In another 17 pa-
Percutaneous Vertebral Angiography
807
tients, unsatisfactory visualization occurred and second attempts were considered unwarranted. Thus, there was an 83 per cent success in the procedure, 75 per cent of the patients having been satisfactorily studied. Of the 51 patients studied, 10 had definite vascular lesions. Four of these were treated surgically with good to excellent results. Four were
Fig. 224. Lateral vertebral angiogram showing arterial angioma filling from posterior cerebral artery in a young woman with a history of repeated sontaneous subarachnoid hemorrhage. Bilateral carotid angiography was negative. Symptoms were relieved by intracranial clipping.
spared useless craniotomy which was otherwise indicated. In 2 a clinical diagnosis of thrombosis was confirmed. The complications of percutaneous vertebral angiography as described are few, possibly less than in the carotid study. Only one complication (injury to the sixth cervical root) occurred from the use of the offset needle low in the neck, but this technic has been used only relatively recently. A forceful injection of diodrast into the cervical subarachnoid
808
Donald B. Freshwatcr
space might well be lethal even if the cord were not impaled by the needle. Directing the needle deeply in a medial direction is unwise. In our experience, hematoma from vertebral puncture has never been observed. Inadvertent puncture of carotid or jugular vessels in the search for the vertebral artery may lead to hematoma as seen occasionally in percutaneous carotid angiography. Such punctures are controllable by gentle pressure and have never been of serious import. Sugarll reported no hematomas in his series but mentioned one cervical
a
b
Fig. 225. a, Lateral and b, anteroposterior vertebral arteriograms taken before operation showing arteriovenous aneurysm of left superior cerebellar artery in a 53 year old man. Patient had had previous negative exploration elsewhere for aneurysm assumed to be on the anterior cerebral artery. Normal bilateral carotid angiograms made at the same session as the above vertebral angiograms.
cord lesion (Brown-Sequard) and one death. He attributed the death of a severely cerebro-arteriosclerotic patient to vasoconstriction caused by diodrast, which resulted in ischemia of the brain stem. Bloor2 and others pointed out that many investigators believe that diodrast primarily has a vascular dilating effect. However, a severely sclerotic cerebral vessel probably has lost whatever power of constriction or dilatation it once may have had. The mortality rate emphasizes the added dangers of any arteriographic procedure in the aged. Some writers have been inclined to be skeptical of the value of vertebral angiography, claiming that the few lesions found are beyond hope of surgical correction. Such an attitude is not only defeatism but factually unfounded. In the relatively infrequent use we have made of
809
Percutaneous Vertebral Angiography
vertebral angiography at the Lahey Clinic, an obvious vascular lesion has been demonstrated in over 20 per cent of the patients. Over half of these patients have been cured or greatly benefited by a surgical attack. An additional percentage was saved a major procedure, which was otherwise indicated by clinical findings. The accompanying illustrations and captions should be convincing evidence (Figs. 223, 224, 225 and 226). Percutaneous vertebral angiography can be a rapidly executed diagnostic procedure and most of the time it is in no way more formidable than carotid angiography. The present limited indications may well
b
a
Fig. 226. a, Lateral and b, anteroposterior vertebral angiograms taken after operation reveal complete control of aneurysm, shown in Figure 225, a and b, by intracranial clipping (by J. L. Poppen). Patient was relieved of symptoms.
expand as future experience reveals new and factually sound interpretations. SUMMARY
A technic for securing visualization of the cerebral vessels supplied by the vertebral artery is outlined. Present indications and complications are mentioned. Interpretation is briefly considered and resulting benefits to the patient are discussed and illustrated. REFERENCES 1. Anderson, R.: Diodrast studies of vertebral and cranial venous systems to show their probable role in cerebral metastases. J. Neurosurg. 8: 411-. 422 (July) 1951.
810
Donald B. Freshwater
2. Bloor, B. M., Wrenn, F. R., Jr. and Margolis, G.: An experimental evaluation of certain contrast media used for cerebral angiography; electroencephalographic and histopathological correlations. J. N eurosurg. 8: 585-594 (Nov.) 1951. 3. Dowling, J. L.: Cerebral angiography in neurosurgery. I. The angiographic appearances in cerebral tumours. II. The angiographic appearances in intracranial aneurysms. Australian & New Zealand J. Surg. 20: 11-24 (Aug.) 1950. 4. Ecker, A.: The normal cerebral angiogram. Springfield, Illinois, Charles C Thomas, 1951, 190 pp. 5. Guthkelch, A. N.: Large saccular aneurysm of intracranial part of vertebral artery. Brit. J. Surg. 37: 107-108 (July) 1949. 6. Lindgren, E.: Percutaneous angiography of the vertebral artery. Acta radiol. 33: 389-404 (May) 1950. 7. List, C. F.: Cerebral angiography. Radiology 55: 327-329 (Sept.) 1950. 8. Parhad, M. B. and Poppen, J. L.: A new percutaneous needle for arteriography. J. Neurosurg. 7: 591-592 (Nov.) 1950. .9. Poppen, J. L.: Diagnosis of intracranial aneurysms. Am.J. Surg. 75: 178-186 (Jan.) 1948. 10. Roach, J. F.: Cerebral angiography. Am. J. M. Sc. 219: 559-569 (May) 1950. 11. Sugar, 0.: Angiography in diagnosis of tumors of the posterior fossa. Arch. ". Neurol. & Pyschiat. 65: 405-406 (Mar.) 1951. , 12. Sugar, 0., Holden, L. B. and Powell, C. B.: Vertebral angiography. Am. J. Roentgenol. 61: 166-182 (Feb.) 1949. 113. Uihlein, A.: Cerebral angiography. Proc. Staff. Meet., Mayo Clin. 26: 133-139 (Apr. 11) 1951. 14. ·Vey, F. and Boddy, K: Cerebral angiography. Radiography 15: 56-60 (Mar.) 1949. 15. Wise, R. E., Hughes, C. R. and Hannan, J. R.: Cerebral arteriography. Am. J. Roentgenol. 64: 239-254 (Aug.) 1950.
THE general acceptance of vertebral angiography has been somewhat slow for two principal reasons: relatively infrequent indication and difficulty of technic. It is the purpose of this paper to delineate the present usefulness of this procedure and to report a reasonable technic. Lindgren 6 has an admirable review of the early development of technic in his excellent report on vertebral angiography. The usefulness of any diagnostic test must be assessed from both sides of the ledger-lesions it rules out as well as lesions it reveals. This is emphatically true in vertebral angiography and we count as a minor triumph any posterior fossa exploration saved by arteriographic demonstration of inoperability. In our cases there were at least three such instances and a fourth in which postoperative arteriography revealed that suboccipital craniectomy could have been avoided. On the positive side of the ledger are those cases of intracranial aneurysm and vascular anomaly successfully treated principally as a result of careful arteriographic localization. In addition, there is certainly the possible value of vertebral angiography in tumors of the occipital region as well as in instances in which evaluation of the vascularity of a tumor may be helpful. It should be said at once that angiography in no way supplants ventriculography in the confirmation of classical expanding posterior fossa lesions. The neurosurgeon must be familiar with vessel-displacement phenomena, some of which are diagnostic of an expanding lesion (and others suggestive or even misleading), so that an angiogram which is negative for vascular lesions may correctly reveal a neoplasm. When a reasonable facility in performing vertebral angiography has been gained, acknowledging that there may be failures, we believe that the indications for this study are as follows: 1. Spontaneous subarachnoid hemorrhage, failing demonstration of the lesion by bilateral carotid angiography. 2. Intracranial bruit under the same conditions. 3. Atypical cerebellopontine angle syndromes. a. Atypical acoustic neuromas. 801
802
Donald B. Freshwater
4. Syndromes of obscure etiology involving midbrain and hindbrain. 5 5. Cerebellar tumor with associated vascular irregularity in fundior family history of hemangioblastomas. Angiography has theoretical value in cerebellar hematomas (Ecker 4) and platybasia. I have had no experience with the former. In the latter an Arnold-Chiari deformity is well assessed for its surgical indication by pneumoencephalography, and the bony deformity by stereographic roentgenograms of the skull. Arteriographic aid in platybasia is a possibility but we have not utilized it in this condition. TECHNIC
Simplicity is certainly the greatest single virtue of any technic. Skill comes with experience and cumbersome equipment often is unnecessary.
Fig. 219. The offset needle routinely in use in percutaneous carotid angiography and needle of first choice in vertebral angiography (available at Thomas W. Reed Co., Boston, Massachusetts).
At the Lahey Clinic, ordinary 10 cc. syringes and a two-way pet cock (Luer-Lok) are used, and are rinsed and filled with either citrate solution or 35 per cent diodrast. Several sharp 18 gauge needles are available so that the sharpest one can be chosen (the ease with which the needle penetrates the patient's skin is as good a test as any, albeit its poor timeliness). Because the entire procedure is usually made easier, I try to place an offset needle8 (Fig. 219) into the vertebral artery low in the neck. This needle is made from an 18 gauge needle mounted in heavier gauge shafts for stability and has been in routine use in this clinic in percutaneous carotid arteriography. A three dimensional knowledge of the anatomy of the artery must be acquired for consistent success. The vertebral artery lies low in the neck, just dorsal to the common carotid artery, which can usually be palpated. With the patient under pentothal anesthesia, the needle is introduced medial to the carotid, after which the transverse process and then the foramen of the vertebral artery which should underlie the carotid are sought. Gentle advancement and withdrawal will permit an atraumatic search for this foramen. When it is found, the needle is slowly advanced into it (Fig. 220).
r
r
P ercutaneOU8 Vertebral Angiography
803
The needle, open pet cock and syringe of 5 cc. of citrate solution are a unit during the arterial puncture and the appearance of arterial blood forcefully entering the syringe is the only indication of proper arterial puncture. A smoothly functioning syringe is essential. A freely flowing arterial puncture, tested with small amounts of citrate solution injected as forcibly as the diodrast is to be injected insures successful arteriography. The element of chance plays a certain role here and there is no method that will insure a central position of the needle in the arterial lumen. However, extension of the neck apparently fixes the artery against the wall of its foramen, and I have had more success with this maneuver than with any other.
Fig. 220. Needle and two-way pet cock, and 10 cc. syringe of citrate solution as assembled for puncture. Vertebral puncture has been made; simple exchange of syringes can be made and diodrast injected.
Following successful arterial puncture, the syringe is changed and 10 cc. of 35 per cent diodrast 14 is rapidly injected, the x-ray exposure being called for with approximately 1 cc. of diodrast still in the syringe. The pet cock is closed, a syringe of 5 cc. of citrate solution substituted, the arterial flow checked, and a small amount of citrate injected to admix with blood in the needle. A stereoscopic adjustment is then made and the above procedure is repeated. Stereoscopic views are of extreme importance, particularly in the lateral projection, and do not significantly prolong the procedure. The position of the patient and the x-ray technic do not vary from those described by Poppen9 for carotid arteriography except for the greater extension of the head at the time of vertebral arterial puncture. Next, the anteroposterior views are made and it is my belief that both the tmbmentovertex and Chamberlain-Towne projections should be se-
'1
804
Donald B. Freshwater
cured. The former can be done without any great change in the patient's extended head position by placing cassette and grid (Lysholm) carefully beneath the occiput and adjusting the x-ray tube and position of the patient's stretcher. The contrast injection is then made similar to the foregoing. Extreme extension of the head and low angulation of the tube are necessary for satisfactory views but may be hampered by the relative inflexibility of the patient's neck. Another serious drawback is the inevitable exposure of the surgeon's hands to the direct x-ray beam. Despite these handicaps the most satisfactory anteroposterior demonstration of the intracranial portion of the vertebral, the posteriorinferior cerebellar and the first part of the basilar arteries is obtained with this view. The Towne view is made next and, although of less hazard to the surgeon and greater ease to the roentgenologist, it entails a reversal of the patient's head to a sharply flexed position. Extra help is required in the careful withdrawal of support from beneath the patient's shoulders and slow flexion of the patient's head and gentle placement on the gridcassette. The tube is then realigned for the Towne view and the patient's head is momentarily held in extreme flexion by a lead-gloved assistant while the injection and exposure are made. The needle is left in situ while the films are developed and examined so that repeat or later phase views can be obtained if indicated. At any time in the procedure if doubt exists as to the integrity of the arterial puncture, a halt can be called until the exposed films are examined. Improper arterial visualization is almost invariably due to a faulty puncture and readjustment of the needle will often bring success. In cases in which vertebral arteriography is of extreme importance, it has been necessary at times to make numerous adjustments to obtain satisfactory films. There have been no ill effects from this since extra-arterial injection almost unfailingly enters the venous rete! surrounding the vertebral artery. There are numerous cases where persistence is the sine qua non. Failure to obtain proper puncture with the offset needle indicates use of a standard 18 gauge needle. I have had most success in inserting the needle between the second and third or third and fourth transverse processes in the manner described by Sugar, Holden and Powell 12 (although I do not use their equipment). It is considerably more difficult to keep the straight needle in position unless it has been' placed well inside the foramen. PITFALLS IN INTERPRETATION OF ANGIOGRAMS
The interpretation of the angiograms is as much the responsibility of the neurosurgeon as it is that of the roentgenologist. Figures 221 to 225 illustrate several obvious lesions which can be visualized better
805
Percutaneous Vertebral Angiography
than they can be described. Attention should be called to several pitfalls: 1. The bifurcation of the basilar artery into right and left posterior cerebral arteries as viewed in the true lateral projection strongly resembles an aneurysm. We have noted this many times and have corrected such an impression by the stereoscopic lateral and anteroposterior views. Recently, this possible error has been mentioned by Ecker.4 2. Impaction of the basilar artery against the clivus is not always
a
b
Fig. 221. a, Lateral and b, anteroposterior vertebral arteriogram~showing large. fusiform aneurysmal dilation of left vertebral and basilar artery in a 45 'year old man. Patient had sudden onset of vertigo, headache, nausea, vomitin·g, ataxia and right hemiparesis, followed shortly by diplopia. Examination revealed: mixed extra-ocular palsies, paresis of the left seventh and of the right fifth cranial nerves, right hemiparesis, right hemihypalgesia and mild ataxia.
present in expanding posterior fossa lesions and is often apparent in the normal. Slight variation from the true lateral can be very misleading. Again, stereoscopic views are helpful. 3. Protrusion of the posterior-inferior cerebellar artery downward beneath the rim of the foramen magnum4, 11 gives support to the diagnosis of tonsillar herniation but again can be an accident of x-ray projection or simply be within the normal anatomic range. 4. Curvatures, as seen in the submentovertex view, of the vertebral or basilar arteries are the rule rather than the exception and one should be cautious in ascribing even the most exaggerated curve to displacement by a tumor mass.
806
Donald B. Freshwater
5. N onfilling of a vessel or branch of a vessel alone is not sufficient evidence to establish a diagnosis of thrombosis. Eventually, with greater and greater experience in vertebral angiographic interpretation controlled by surgical or postmortem confirmation, an evaluation of the significance of some of the more obscure observations will be obtained. As compared to the growing~experience
Fig. 222.
Fig. 223.
Fig. 222. Lateral vertebral arteriogram showing large, fusiform aneurysmal dilatation of the basilar artery in a 54 year old man. Patient had sudden onset of vertigo, headache, nuchal rigidity and ataxia. Cerebrospinal fluid was xanthochromic. Fig. 223. Anteroposterior vertebral arteriogram showing large saccular and fusiform aneurysmal dilatation of left vertebral and basilar artery in a 49 year old man. Diagnosis was first made at the time of exploration for supposed acoustic neurinoma. Following demonstration by vertebral arteriography of a normal right vertebral artery, the left vertebral artery was ligated (by J. L. Poppen) in the neck with marked relief of suboccipital headache.
in carotid angiography, 3 • 4. 7. 10. 13. 15 only a relatively small number of cases of vertebral angiography are presented. The technic of obtaining this study must, of course, come first so that it can be made applicable in more and more of the puzzling occipital and suboccipital problems. Results
Vertebral angiography has been performed at the Lahey Clinic entirely by the percutaneous method over the past two years. In that ·time, 51 patients underwent 57 successful procedures. In another 17 pa-
Percutaneous Vertebral Angiography
807
tients, unsatisfactory visualization occurred and second attempts were considered unwarranted. Thus, there was an 83 per cent success in the procedure, 75 per cent of the patients having been satisfactorily studied. Of the 51 patients studied, 10 had definite vascular lesions. Four of these were treated surgically with good to excellent results. Four were
Fig. 224. Lateral vertebral angiogram showing arterial angioma filling from posterior cerebral artery in a young woman with a history of repeated sontaneous subarachnoid hemorrhage. Bilateral carotid angiography was negative. Symptoms were relieved by intracranial clipping.
spared useless craniotomy which was otherwise indicated. In 2 a clinical diagnosis of thrombosis was confirmed. The complications of percutaneous vertebral angiography as described are few, possibly less than in the carotid study. Only one complication (injury to the sixth cervical root) occurred from the use of the offset needle low in the neck, but this technic has been used only relatively recently. A forceful injection of diodrast into the cervical subarachnoid
808
Donald B. Freshwatcr
space might well be lethal even if the cord were not impaled by the needle. Directing the needle deeply in a medial direction is unwise. In our experience, hematoma from vertebral puncture has never been observed. Inadvertent puncture of carotid or jugular vessels in the search for the vertebral artery may lead to hematoma as seen occasionally in percutaneous carotid angiography. Such punctures are controllable by gentle pressure and have never been of serious import. Sugarll reported no hematomas in his series but mentioned one cervical
a
b
Fig. 225. a, Lateral and b, anteroposterior vertebral arteriograms taken before operation showing arteriovenous aneurysm of left superior cerebellar artery in a 53 year old man. Patient had had previous negative exploration elsewhere for aneurysm assumed to be on the anterior cerebral artery. Normal bilateral carotid angiograms made at the same session as the above vertebral angiograms.
cord lesion (Brown-Sequard) and one death. He attributed the death of a severely cerebro-arteriosclerotic patient to vasoconstriction caused by diodrast, which resulted in ischemia of the brain stem. Bloor2 and others pointed out that many investigators believe that diodrast primarily has a vascular dilating effect. However, a severely sclerotic cerebral vessel probably has lost whatever power of constriction or dilatation it once may have had. The mortality rate emphasizes the added dangers of any arteriographic procedure in the aged. Some writers have been inclined to be skeptical of the value of vertebral angiography, claiming that the few lesions found are beyond hope of surgical correction. Such an attitude is not only defeatism but factually unfounded. In the relatively infrequent use we have made of
809
Percutaneous Vertebral Angiography
vertebral angiography at the Lahey Clinic, an obvious vascular lesion has been demonstrated in over 20 per cent of the patients. Over half of these patients have been cured or greatly benefited by a surgical attack. An additional percentage was saved a major procedure, which was otherwise indicated by clinical findings. The accompanying illustrations and captions should be convincing evidence (Figs. 223, 224, 225 and 226). Percutaneous vertebral angiography can be a rapidly executed diagnostic procedure and most of the time it is in no way more formidable than carotid angiography. The present limited indications may well
b
a
Fig. 226. a, Lateral and b, anteroposterior vertebral angiograms taken after operation reveal complete control of aneurysm, shown in Figure 225, a and b, by intracranial clipping (by J. L. Poppen). Patient was relieved of symptoms.
expand as future experience reveals new and factually sound interpretations. SUMMARY
A technic for securing visualization of the cerebral vessels supplied by the vertebral artery is outlined. Present indications and complications are mentioned. Interpretation is briefly considered and resulting benefits to the patient are discussed and illustrated. REFERENCES 1. Anderson, R.: Diodrast studies of vertebral and cranial venous systems to show their probable role in cerebral metastases. J. Neurosurg. 8: 411-. 422 (July) 1951.
810
Donald B. Freshwater
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