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Show j. C/in. NE'uro-ophthdlmol. 1: 255-260, IQ81. Intravenous Angiography for Extracranial Disease ROBERT M. QUENCER, M.D. J. LAWTON SMITH, M.D. Abstract The preliminuy results of our experience with inlravenous ,mgiogr.iphy for visualization of the aortic arch, carotid and vertebr.il arteries in the neck is presented, This procedure is SAfe, can be done as an outp.itient study, and is felt to surpass all other methods of eV.ilualing the great vessels in the neck, short of cerebral arteriography, The study utilizes a simple photographic subtraction technique, gives images comparable to those produced with digital angiography, and can be performed in any hospital angiographic suite. We believe that intravenous angiography will largely replace all other noninvasive methods for evaluating patients suspected of having carotid or vertebral vascular disease. (oil I (b) Figures loll-lb. M~fhod of PholOgrdphie SublrdCljon dnd Normdllnlravt'nou. Artt'rit'~r.lph",. Thi~ ~t'qu('n,'t' l'f Il'ur flims d"n",,,· strates the steps used in photographic ubtraction, Film # I (a) I. an oblil/uC vi"w of th" ""(~ and i. la""n ,'ne ~('(,,"d pro,'r t" vascular opa ,f,cdtion (b t. Note in F'R' Ib how poorly th" v('ssel, ,n th" nee" dr(' ~r"n. Over the years, both direct and indirect methods have been used to evaluate patients for extracranial vascular disease involving the great vessels in the neck. These studies have included ophthalmodynamometry, orbital plethymosgraphy, thermogra- From the Departments of RddioJogy dnd Neurolo~iedl Surl:ery (RMQ) .lind the Depdrtment of Ophthalmology, Bascom Pdlmrr Eye Institute OLS). University of Midmi School of Ml.'dicinc. Midmi. Florida. December 1981 phy, ultrasound, and direction.)1 Doppler techniques. and they have dll been used in .10 dtlempt to eliminate the morbidity associdted with cerebral arteriography, Unfortunately, the informdtion derived from these noninvasive procedures not only varies significdntly depending on the experience of the person performing the study, but also the andtomical informdtion derived from the study frequently is insufficient to allow definitive mandgement of the patient 255 Figures le_h'. following completi'm of the study, • photoguphie subtractIon Ie) is made of the fm;t f,lm (.) In whIch there is a rever5.11 of the image seen in Fig. la. Films band care lhen superimposed. and in a dark room an une~p05ed sheet of subtrdctlon f,lm IS pldced Over both films b .od .-. Thl."Se three Illms dfe Ihen exposed to 01 light source for dpproxlmdtely 20 s«onds. whIch resulls in 01 summdtion imdge or the lindl subtrdctlon F,lm (d). ~ole how the bone overlying the vessels has been "subtracted" out and how well both right (R) dnd left ILl carotid arteries dre seen. The right verleb'dl.rtery IRVAI is seen behind the right carotid dnd c." be followed superiorly to the C, level In Fig. ld. the smdller left verl...bralartery ..annN be s......n b...cause it IS supeTlmposed upon the ngh' common urot,d .nd right e,,'...m.l carotid Jrtt'ry. In J simIlar mdnner, the Jntenuf pt>stenur 5ublfa,-hon fIlm ( ... ) w.>s "bl.,ned. The mid ..nd luwer portions uf the "t:ht v... rt...br.1 ..tery I.>rr,'whe.. ds/ Me wp<'r1mposed ...n the "t:ht ':ommon <.>wlld '>""ry Th... UPlX'r port",n uf the ,,~ht vertebr.>I."ery (RVA) IS belief ~("('n Th"lef, vertebr.>l.rtery flVA! wh,.-h was n,', wdl Seen In r'l: Id" w,·11 d,·m"n,tr.ted '" f'l: Ie. Th" I~'> n,>rn,.1 ,,,t,.v,·n,, ... '.>"t:,u\o:'drn- ""I,' In b"th fll:" I J .>nd te Ih""""",th. n"nukl·r.tt-d. ""n,ten"t" ,"'''lId Hlel1No .>nd the p_",-n.-v "f !.>r'lh vrrlrbralart..."e... A compromise between the hi~hly spt'cific but invJsive C('r('hrJl JrtcriogrJm Jnd the mJrginJlly useful noninvasive studies mentioned ,lbnv(' is J rro\<·dur(· lI'rml'd intrJvenOUS .mgiogrJphy. Dj~i1,[ .."f,t,·.•• I."n .Hl~:i"gr.lrhv is currently undergo-ing extt'nsive investigdtion in selected neuroradiology departments; however, the equipment is expensive and is not reddily available in many hos~ pitdls. Our dttention was dttracted to the use of photographic subtraction intravenous angiogrdphy Journ.!1 of Clinlcdl Neuro-ophthalmology by the report of Lahitte et aI.' Ov{'r ttll' rust t.> months we have eVillu.lted 14 pJtients with this procedure and h,we found it both effectiv(' .llld 5<1f('. Th(' r('sults of this initiJI study ,:Ire diswss('d below. With th(' patient lying supin(' l)n In Jn~ill~r.lphic table, a 5.7-cm 14-g,lUg(' polyethyl('nt" c.lth{'ter is placed in a large Jnte("uhitJI vein. If .1 vein of sufficient size to Jccomml,ldJte the (JthetN is mlt present in the Jrm, then J femllr.ll vein pun("ture is performed. As described by LJhitte et .Il. ' the cir("ulation time is determined. usin~ .m intrJvenous injection of 5 cc ot sodium dehydrochol.lte (Decholinel. The c.lotheter is Jtt.lched to J poW('f injector which h.loS J lOO-cc syringe. The syring(' is RC LV filll.'d with 75 ("(" RenogrJffin 76 on top of which is 1.lyNed 25 cc of D5W. This 25 cc of D5W follows the contrdst injection dnd serves to push the contr, lst through the vascular system without ddding to thl.' totJI contr.lost load. The inje("tion rate is 10 n"/second. and filming commen("es 4 seconds before the ("alculated circulJtion timl.' (e.g., if the circulJtion time is 17 se("onds, filming SliHtS 13 seconds after thl.' injection begins). The filming is one film per se("ond for 10 seconds, with the first film tdken prior 10 the arriv,ll of contrdSI material. This film (film #1) is needed for the photogrdphic <;ubtril("tion shown in Figure J. Biplane filming over the neck dnd dortic drch is performed with .I straight Jnteroposterior tube position on the frontdl x-ray tube Jnd .I JOO tube .mgulation on the lateral tube (Figs. Id ilnd Ie). The position of the pdtient for the next run depends '" Figures l~ ~nd lb. C~rol;d Artery ekc/us;on, Anlt'r1or pl'sl<'rior t J) sh"w~ n,.nv,"uJ),UI",n ,:1 'he lef, .'·Jr,,'id ,'rtef)' ~ue I,> ''''e1usion Jt ils origin. Tht' curvt'd Jfrow In Fig. 2J shows wh"rt the left CJr<>tid Jrltry should be Jt Ihe r, lev('!. rhe r'l:ht ,'J",tod .>rtl'ry tReAt ~nd bolh v<'rttbr~1 ~rtt'rit"li CRV .nd LVI .r't' norm.l. Th.· IJ'er.11 p) shows minor irrl'l:ulJnh('s IJrfllwhe.IJsl JI,,"t' the postl'rior .Ild .Ilterior w~lls of the right cuotid .artery CRCAI.a1 ,ts biFurcJtioll. Dt'Cember 1981 2S7 Figure). C~rotid Artery N~rrowln8. With the p~henl in the left postNl(If ...bliquro posihon. the n~ht c~rotid ~rtery (RCAI ~bo"e the b,furc~hon 15 m~,kedly n~rrowed ..nd continue, to ldpt'r throughoullls cervIcal course l~ftowhe~d,) Nott tht compenS~ lory tnlMgemenl of the right dnd lroft "ertebr~l ~rterie5 (curved dHowsl Thert is ~ grt'~ter liMn 50% n~rrow"\g of the left c~rotld ~rtery (X14 Cm ~bo"e the left c~rotid to,furc.ltion fiRUre ~. Ultrr.rl,·d Ath,'''''' Irr,.'" l'I.I<ju,' A w,de ukC't o'fJler l",,,'w!,,,.•dl.r1,,,,>: 1h(' f""kr,,'r w"lI "f 1he 1.'f, CJ",tld .,rt,'rv" I," ~!,.t1 I..·, """'ll rh,' ,m'." "f "Knll" ,,,,t t .>rt't Id ~ ",.ry nJ rft>w",!o\ " .. I p ,,, .. ,y·.1 on which carotid artery is suspected of having significant disease. Either a left or right posterior oblique position is used, again with biplane filming. This sequence of filming means that no more than ISO cc of contrast is injected (two runs of 75 cc each), and the vessels are seen in four different projections. Results and Discussion In our 14 adult patients using this technique we have judged the study as giving either good or fair r('sults. ··Cood" indicates that the entire length of the carotid vertebral system in the neck and the aortic arch were seen well enough to visualize any pathology, "Fair" results indicate that all the major neck vessels were seen, and although the definition Figure S. Occludrd Left Vertebr..1 Artery. Anttrior pasttrior sh"w, 'It' frllln!: ('f the left vertebrdl drtery-it is occluded .It its ,utoeIJ"'Jn ('nRi" (curved urowl, The right cdf(ltid drtery. left cd'''hd Jrtery. ~nd right "ertebrdl uteries .Ire nOrTllJlI (the r"",mJl f",rtl('n of the right vertebr.ll ;5 superimposed on the pro't.lmJI right commo" cuotid .lrtery (strJlight ..rrows). Open 'riJngles show the c.lrotid bifurutions. }oum.ll of Clinical Neuro-ophthalmology Que-ncer, Smith • In four patients there were two diagnoses made on each study. nous angiography showed a mediastinal mass and a nonulcerated plaque of the right cdTotid artery. Table 1summarizes the diagnoses we have made with intravenous angiography. In no Cdses was it felt necessary to perform routine selective and Jortic arch dTteriogrdphy to confirm the didgnosis mdde on intravenous angiography. Digital intrdvenous angiographi will very lik~ly, within the next 5 years, be the radiographic method of choice for studying the major vdsculature throughout the body. This procedure utilizes intrdvenous injection of contrdst materidl in a manner similar to that described here, but in addition digital dngiography converts the analog data (the visual image) into a digital form (numerical representation). With this analog-to-digital conversion, TABLE I. Diagnosis by Inlravenous Angiography in 14 Palients· was sufficient to exclude significant ,lbnorm,llities, small atherosclerotic plaques may not h,we becn visualized. Using these criteria, we found f,lir re-suits in three cases and good results in II C,15es. In no cases was the definition of the vdscular structure so poor that significant lesions could hdve be-e-n missed. Six cases are selected dS e .lmple5 of this procedure: Case I (Fig. I): Right paratrigemindl syndrome ,md a right Homer's; intravenous .1ngiogrJphy, done to rule out abnormJlity of the right c.lfotid artery, was normal. Case 2 (Fig. 2): Previous right carotid endarterectomy; intravenous .mgiogrdphy performed to determine the status of the right carotid artery showed patency of the right carotid drtery dnd d clinicdlly unsuspected occlusion of the left carotid Jrtery at its origin. Case 3 (Fig. 3): Transient vision loss in right eye; intravenous angiography showed a long segment narrowing of the right carotid artery. Case 4 (Fig. 4): Asymptomatic left carotid bruit; intravenous angiography showed a wide ulceration within an atherosclerotic plaque. Ca.se 5 (Fig. 5): left OCCipital infarct on computed tomography; intravenous angiography showed an occluded left vertebral artery at its origin. Case 6 (Fig. 6): Old left hemispheric stroke, now with transient loss of vision on the right; intrave- Nonnal Cdrotid artery occlusion Vertebral artery occlusion > 50% carotid stenosis Ulcerating plaques AtherosclerotiC changes without significant stenosis or ulceration Mediastinal mass Dural arteriovenous fistula Number 5 1 2 3 2 4 I I {bl Figures 6a and 6b. Mediastinal Mass and Nonu/cNated Atherosclerotic Plaque. InjPcti<>n int<lth~'It'ft br.Khi.ll v('in showed no filling of the arteries in the neck because the innominatt' vt'in (IV) was betnl': compr('ss('d by ~ medlaSltn~1 m~ss (curv('d dHow_I. ThIS was causing a delay in flow to the right side of the heart. Note reflu~ into the iUKul~.r vein (IMge slr~ight drr~,w) Jlld into the pdraverteb~al venous plexus (arrowheads). A subsequent injection into the TIght brachIal vptn showt'd d nonulcerdhng plaqut' dlong the post(,Tlor wall of the right carotid artery (open arrowhead in FiR· 6b). December 1981 259 .1 finJI imdge Cdn be produccd which h..ls potentidily ~r(,J.ter detdiJ and contrdsl. However, this somt>wh..lt improv('d imdge quality comes at d si~nific. lnt fin..lncial cost, wherNs simplc photo~ rJphic subtrdction t('chniqucs involve virt<.ldHy no Jddition.ll cost, .md the study c..ln b(' performed in J routine ..Ingio~rdphy suite. We feel thJt intrdv('nous dngiogrdphy is d pro~ t>durc which should be employt>d mon" fr{'qucntJy in thE' eVdluollion of extrdcrdniolJ vdsculdr diSCdse. [t is folr solfer th.1n olrteriography olnd more dccurdte th.1n otht>r noninvdsivc tests which hdve bccn used in th(' pdSt. Neferences l. Lahitte, M.D., M.Hc-Vergnes, ,"P., Rascol, A., Guiraud, B., and Manelle, c.: Intrdvenous angiogrdphy of the extracranial cerebral arteries. Radiology 137: 705-711, 1980. 2. Christenson, P.c., Ouill, T.W., Fisher, H.D., Frost, M.M., Nudelman,S., and Roehrig, H.: Intravenous angiography using digital video subtraction: Intra_ venous cervicocerebrovascular angiography. Am. J. Neuroradio/. I: 379-386, 1980. Write for reprints 10: Robert M. Quencer, M.D., Department of Radiology R-l30, P.O. Bol( 016960, Miami, Florida 33101. Journal of Clinical Neuro-ophthalmology |
