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Show J. Clin. Neuro-ophthdlmol. 1: 251-253, IQI'lI. Editorial Intravenous Angiography In this issue of Joum,ll o( Clinic.11 Neurtl-ophthdlmology, Dr. R~lbE'rt Qut>nct'r rrt'sents s\)m(' prelimindry data on a new n('uwr,ldi\ll~}~i( l('chnique which I heli('ve is ,lnt> (If lht> ~rE'al('st dinic,.l advances in n{'uw-(lrhth.llm~,lo~y yE't hl JppeJr lln lhe sc{'ne. A few w~lrds of b,K"~round inhHm.ltion mdY be helpful to the r('Jder wh(l as yet h.ls h.ld no experience with this technique. First of dll, the method under consideration mdY dppedr under severdl ndmes, as: intr.lvenous dngiogrdphy, digitdl subtraction dngiogrdphy. or photogrdphic subtraction intravenous ,mgiogrJphy. AI the outs('!, IN it be ch.'dr that we art' nol tdlking dboul intravenous fluorescein .lngiography, with which most oph. thalmologists have been familiar for yedrs. You may be dsking-WelL whal Me you tdlking dboul? Read on, pledse. deM reader! About a yedr ago Dr. Robert TomSdk told us of d new gddget being used dt the Clevel'lOd Clinic cdlled digitdJ subtrdction angiogrdphy. BdSicdlly, this is a new neuroradiologic device in which d patient is given an intravenous dose of contrast agent, and by means of a digital compuler subtraction one obtains x-ray imdges of the gredt vessels in the neck. In other words, one might say that we are approaching seeing the results of dn drl('riOgram by giving dn injection in a vein! Now th.lt really sounds terrific! Evt'ryone knows of the morbidity, complicdtions, dnd expense of drteriography; but despite this there are so many patients who present to the ophthalmologist with only one or two bouts of amaurosis fugdx, a single trdnsienl ischemic attack, or the like, in whom we would love to know if the patient has surgical disease of the cdrotid bifurcation in the neck. Yet, the particular cliniCdI situation being encountered simply does not justify putting the patient in the hospital for a four-vessel study transfemoral ilrteriogram with subtraction. If we could (('ally SE'e thE' vessels in the neck, however, with an outpdtient procedure and only an intravenous injection and dt much less risk and expense, wouldn't that bE' something? Before you get too excited and rush out to order your new DSA (digital subtraction angiography) unit, you need to redHZ(' a few facts. First of all, tile unit costs half a million dollars or more. Second, if you order one, it will be back-ordered for montlls, dnd you will find d significant d('lay in obtaining it. TIlird, very few hospitals in the country have digitdl subtraction angiography at this moment. December 1961 WhE'n I heard how terrific this technique was, r imml'didtely dsked Dr. Qul'ncer, Professor of Nt'urorJdiology in our institution, how soon we could gl't it. Everyone who has had practicdl experience wilh thl' noninvasive mt'thods for studying the ~redt vt'ssels in the neck (ocular plethysmography, Doppler, ultrdsound, infrMed. and the likl') has redlized that one is usually opening a can of worms from the information standpoint when h(' gets such studies. Dr. Quencer told me il would probably be d year before we had this equipment available in our hosptial (and thus far his timing has been right on target!). However, despair turned into hope when J SolW d fantastic paper in tht' December 1980 issue of Rddiology. I urge every reader to either look at thai article or write promptly for a reprint. The paper. "Intravenous Angiography of the Extracrani,,1 Cerebral Arteries," WdS written by Maurice Ducos Lahitte, MD., et dl., and dppedred in RddjoJogy 137: 705-711, December 1980. For a rt'print, write to Dr. Maurice Ducos lahitle, INSERM-FRA:40, Service de Neurologie, CH.U.-Purpan. 31052 Toulouse- Cedex, France. Dr. Lahitte's article reports on intravenous angiography of the extrdcranidl cerebrdl arteries using a simple photographic subtraction technique. This was employed in 500 pdtients, 30% of whom were outpatients, some older than 80 years of dge, "nd gave good or excellent results in 800/0 of the cases. When I looked at the pictures in the drticlt' I w"s redlly impressed! The quality of the images seen redlly was just as good .lS those I hdd seen from the digit.ll subtraction studies. Obviously, Dr. whilte picked out some of his best pictures fM thE' pdper, but I realized thdt if pictures of the carotid dnd vertebra Is in the neck of such qUdlity could be obtained by simple photogrdphic subtr.lction, we really ought to give it a try! It should be mentioned here that subtr.lction techniques hdve been used in neurorJdiology for years and yeMs .lnd Yedrs. Jnd evt'ry h"spit"l in the country that doE'S (('rebrJI Jrterio.:rdphy probably hds bel'n doing sublr.lCtion ,mgio~rams for decades. Tht' prindpll's of thl' photogrdphic subtraction techniqul' art' simply outlined by Dr. Quencer in his paper in this issue, ,md therefore will not be further dmpJified h('fE'. I therefore asked Dr. Quencer to try some intravenous angiogr"ms for us on neuro-ophthalmologic outpdtients. Just a few instances of how help- 251 [dilori~l; IntrJvenous Angi~r.Jphy ful tht' technique hJS been to dille mighl be briefly summarized. Dr. Mitchell in our depJrtmt'nt SdW J physici.an's mllther in consult<ltion who hild r(,(,ently begun 10 h.lYe ppisodt'S of tr.lnsient ischemic .alt.acks in which she would not(' inlermiltpnt s('nsory symptoms in her right .arm e1nd Ipg. She then beg.an notintt tunsient episodP5 of blurred vision in her ri~ht eye. She SdW a physicidn, who wisely recognized th.u she w.as hdving trdnsient ischemic dttJcks. .and since the n('urologic symptoms in the rittht-sidcd extremitips stdrted first, hE' obl.ainE'd d left carotid arteriogr.am, dnd this w.as perfectly norm,,\. ThE' pdtient was thE'n plelced on e1ntico.agul" nts. but the bouts of e1molurosis fugax in her ri~hl eyE' persisted. When Dr. Mitchell SolW the pJtient we discussed the problem, .and it WolS obvious thilt the right sidE' of hE'r circulation nE'eded to bp visuollized since she had hild only a left cilfotid olrteriogrilm to that point. The sitUoltion WilS presented to her, and .an intrdvenous ilngiogram olS an outpatient was presented to her. olod .an intrdvenous .angiogr.am i1S an outpJtient procedure WdS proposed. She WdS told thdt this might or might not be of sufficient qu.ality to allow the assessment we needed. If it did give adequ.ate results. however, she might be sp.1red having another arteriogr.am to visualize the right side of the circulation. She readily i1greed. and when Dr. Quencer did the study the results were beautiful! The picturP5 showed that the left side was quite normal (which we alre.ady knew), but it also showed nicely that although the colrotid bifurution on the right was normal, high in the neck the right internal cilfotid elrtery becelme very, very nMrow. Thus, we knew from this sludy thelt 1) she did helve stenotic cdrotid disease on the right, 2) she did not need an endarterectomy at the right carotid bifurc.ation. dnd 3) she might well be a candidilte for a supcrficiill temporill-middle cerebral bypass procE'dure on the right. All of this came from eln ;nlrdvenous study done as an outpeltient! Subsequent uses are illustrated in Dr. Quencer's paper. However, a few other points should be made. This technique is primelrily of use for looking at the greelt vessels in the neck; i.e.• it is not the best WelY to look ilt the intrdCreln;.aJ situJtion at all. However. I believe IhE're will be incrPdsing effet':tiveness for the method even with intracrelniJI problems. We SilW d leidy who pr~nted with doubl", vision due to a unil..ter.ll VI nerve p.cllsy who held been seen by eln excellent neurologist who obtained el computed tomogrelphic <en SCJn without and with enhelncement, Jnd these were both reportE'd .as noemel!. When WP SilW her. the c1iniul impression WelS el dur.al sinus fistula. WE' elskt'd our neuroreldiologists 10 get .In intrelvenous dngiogrdm on this peltienl, centering their elttention (10 the c,,"vernous sinus on Ihe side of the VI nerve , pdlsy, and to use double or even triple subtraction if necesSilry. to see if we could visualize a dural sinus fistula. Wow! The pictures came back and were beautiful, showing a huge superior opthalmic vein on that side as big as your little finger and also some innedse in the size of the superior opthalmic vein even on the opposite side; and the piClurP5 (olithough not quite of the quality to publish In a textbook) really were i1dequoite to est,ablish elnd confirm Ihe clinical dielgnosis of a dural sinus fistulel. This obviated the necessity for an arteriogrelm in this particul,ar palient, since we would have el«led to follow her for a dural sinus fistula. even if we hild known this by arteriography! An elderly p.atient presented with cortic.al blindness due to a bilelterill hemianopia. Although little could be done for him. an intravenous angiogram WilS obtilined which showed a total occlusion of one vertebral utery at its origin in the neck. This gave additional useful and confinnatory information as to the pathogenesis of his problem. was done as an outp.atient procedure. and did not necessit. ate hospitellization and the expense elnd risk of oIrteriography in this gentlemeln. One final use should be ciled. A 65-year-old lady complained of transient ischemic symptoms in the left carotid distribution. This included trelnsient problems in the right-sided extremities and episodic visuell disturbances in the left eye. She had d bruit over the left celrotid in the neck. She had been hypertensive for ye.afS. had a nephrectomy in 1965, followed by el myocardi..1infarction 6 months loiter. Arteriogrelphy had been attempted recently by competent neurologists on two different occasions-a left brachial injection elnd a triln5femorell elrteriogrelm-i1nd both had been technicellly unsuccessful. When we SelW her, it was elgreed Ihilt her symptoms were in left carotid distribution, i1nd eln intr.avenous angiogram WelS advised. The study was technically VE'ry satisfelctory; it showed iI stenotic lesion in the left internal carotid artery narrowing the lumen a bit more than 50% elnd which definitely appeared a surgically accessible lesion. Here OUlpeltient intravenous angiography eSI.ablished the didgnosis in a peltient in whom ellteriogrdphy had f.ailed on two elttempts. At a recent Neuro-ophthalmology Meeting al the CI('Vel.and Clinic. an update of digital subtraction dngiogrelphy in that institution was given. It WdS pointed out that thE' vasculM surgery section there is now performing carotid endarterectomies on some p.cltients simply on the basis of the digital subtrdction .angiogram and without having to submil tht' peltient to a confinneltory preoperative arteriogram, and that elpproach has been used in elbout 200 peltients to date. It is not the purpose of this article to see how folf we can push intravenous angiography. It is simply 10 let you know that if conventional cerebral arte- 1ournil1 of Clinicill Neuro-ophlhillmo1ogy riograms are done in your hOSpit.ll, then Yl)U dl' not need any ddditionJI equipment to \lbt.1in ~ood photographic subtr.lction intr.wenous .ln~iOKrJm". All you need to do is hl show this editoriJI. lht' article by Dr. Quencer, Jnd the reprint ffllm Dr. Lahitte to your radiologist .md implore, be~. Jnd entreat him or her simply to try the te\'hnique on a few of your p.ltiE'nts. These .m.' th(' ('I()-yeJr-old ladies with one bout of .lmJourosis fUK.I" in thc right eye, for inst.mce. in wh\lm Y\lU find J perfectly negdtivE' E'''.lmin.1tion. put YllU w.lnt III t',,cludt' J surgical It'sillll in hN ned,. Fin.llly. if your rddiologist hdS dny m(\fC qUt'stil,ns .1hout te\"hnique h.lve him or her lislE'n 10 NeUr\l-\lphlhJlmolo~y Tdpes. vol. Ill. #11. for April 10:\1. Dr. Quencer is interviewed on thdl tapt' Jnd givl.'s t'lO;dct instructions vl.'rb.llly on how to do it. so th.lt your r.ldiolagist can listen to the tapt' en routt' to the hospit.lJ one morning and then go in Jnd comfortably perform this procedure. I believe intrdvenous .mgiogrdphy is going to put the usual nonin\'dsive tests out of business! It is so much better to be db Ie actually to see the vt'ssel wdll dnd its lumen and dlso to obtain a view of the December 1961 Smith .lOrtic Mch dnd the vertt'brals as well. like all other modalities, tht' techniquE' probdbly will increase r.lpidly in quality. As digitdl subtraction angiography b('comes less ex.pensivt', of better quality, and more r\'adily i1vdilable, it may put photographic subtrJction i1ngioKraphic out of busint'ss. However, the' point of this editorial is to let you know that right therE' in your loc.ll hospital you can get a view of tht' greilt vessels in your pdtient's neck that Oldy well be of i1dequJtt' quality to give you .Ill the inforOldtion you reJlly need without hdving to do .In drtt'riogrolm. rleilse let us hear from you as to how you do with this. Finally, if all else fails, holvt' your rddiologist contdct Dr. Robert Quencer, Professor of Neurorildiology, UnivNsity of Miami School of Medicine, Miami, Florida, telephone (305)325-6894, and I believe he Cdn dnswer dny other questions thdt arise. I prdy thdt the intrdvenous dngiogram will be of good quality <lnd hE'lpful to the p<ltient, and I hilve found that this also is of definite and greilt help in getting good studies. ]. Lawton Smith, M.D. 253 |