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PubMed2005

Evaluation of a distal pericallosal aneurysm visualized with 3-dimensional digital subtraction angiography: case report and treatment implications.

BACKGROUND: Digital subtraction angiography (DSA) is considered the gold standard in the evaluation of cerebrovascular structures. Recently, 3-dimensional DSA (3D-DSA) has been increasingly used to obtain detailed information about the morphology and dimensions of intracranial aneurysms. We report the case of a patient who presented with a distal pericallosal artery aneurysm, which appeared by 2D imaging to be a fusiform, possible mycotic aneurysm. This was then revealed to be a saccular bifurcation aneurysm by 3D-DSA. This additional information changed the treatment plan for this patient from medical management to a surgical approach. CASE DESCRIPTION: The patient is a 56-year-old man with a history of hypertension and alcohol abuse with withdrawal seizures, who presented with a large intracranial hemorrhage on initial computed tomography scan. After stabilization with intracranial pressure management, the patient underwent magnetic resonance angiography and 4-vessel DSA. These initial studies showed a distal, fusiform pericallosal aneurysm consistent with a mycotic aneurysm. Rotational DSA was then used to generate 3D images of the structure that revealed a saccular bifurcation aneurysm. This enabled the decision to offer operative treatment rather than conservative medical management. DISCUSSION: This report highlights the value of 3D-DSA in establishing the appropriate treatment plan for patients with unique cerebral aneurysms. The higher resolution images used in this case provided information that was crucial in shifting the treatment focus from medical management, for what appeared to be a mycotic aneurysm by traditional DSA, to surgical intervention, for a clear hemodynamic aneurysm at a vessel bifurcation seen with 3D-DSA. Accurate pre-interventional evaluation and differential diagnosis are critical to designing the most effective lowest risk treatment plan. The standard method in the diagnosis of cerebral aneurysms has been DSA. Yet, higher resolution images of unclear or high-risk aneurysms are often required to guide clinical decision making. The emergence of new, less invasive endovascular techniques for securing intracranial aneurysms has placed greater emphasis on precisely defining the shape and dimensions of an aneurysm. Three-dimensional DSA is currently the highest resolution imaging modality available for the evaluation of intracranial aneurysms. CONCLUSION: 3D-DSA was used to evaluate a small, distal pericallosal artery aneurysm and revealed a saccular bifurcation aneurysm not visualized with magnetic resonance angiography and conventional DSA. This additional resolution permitted the team to consider a surgical approach for a patient who would otherwise have been treated medically. This high-resolution technique is particularly useful in guiding clinical decision making in the context of aneurysms that carry a relatively broad differential diagnosis, potentially high interventional risk, and unclear morphology.

Alcohol Withdrawal Seizures↗

PubMed1994

[The anomalous pulmonary venous connection. A study of 24 children by digital subtraction angiography].

OBJECTIVE: To assess the accuracy of Digital Subtraction Angiography (DSA) in the demonstration of the morphology of Anomalous Pulmonary Venous Connexion (APVC) in children. DESIGN OF THE STUDY: Prospective study of cases series between January 1989 and July 1992. SETTING: Referral-based Paediatric Cardiology Department of a Tertiary Care Center. PATIENTS: Twenty-four consecutive children with anomalous pulmonary venous connection. METHODS: All pts had clinical and 2D-Echo investigation prior to cardiac catheterization. In all cases selective injections of 0.5 to 1 ml/kg undiluted hypo-osmolar contrast were performed in branch pulmonary arteries and high quality DSA images were recorded. Subtracted images were stored in video and cut films for detailed analysis. RESULTS: 16 pts had total APVC: 11 to Superior Vena Cava (SVC), 2 to Coronary Sinus and 3 to Inferior Vena Cava (IVC). Eight pts had partial APVC: 3 to SVC, 1 to Right Atrium, 3 to IVC (scimitar syndrome), and 1 pt had mixed PAVC. In 8 pts of the whole group, DSA contributed significantly to the final morphologic diagnosis and completed or corrected information obtained by 2D-Echo. In all 18 pts submitted to surgery, the DSA diagnosis was confirmed at operation. CONCLUSION: DSA is a very useful technique (and even more informative in video images) for anatomic evaluation of pts with APVC and has clear indication when clinical and 2D-Echo findings are not typical.

Angiography, Digital Subtraction↗

PubMed1988

Assessment of aortocoronary bypass graft patency by intra-arterial digital subtraction angiography compared to selective graft angiography.

The value of digital subtraction angiography (DSA), in assessing aortocoronary bypass graft patency, was evaluated by studying 22 consecutive patients with 54 aortocoronary saphenous vein bypass grafts, who had postoperative angina pectoris. Each patient underwent selective graft angiography and non-gated DSA. The DSA consisted of a run of 15 to 20 frames, taken at 2.3 frames per second during injection of diluted contrast in the ascending aorta, performed after a test exposure was made. Thirty-two of the 54 grafts (59%) were patent. Thirty of the 32 grafts were seen to be patent by both selective graft angiography and DSA. In addition, a further two grafts were found to be patent on DSA, but were not able to be selectively catheterised and were not seen on the conventional aortogram. Selective graft angiography revealed four tight proximal graft stenoses, of which one only was seen on DSA; and poor distal run-off in five grafts, two of which showed up as late filling grafts on DSA. In summary, the accuracy of intra-arterial DSA in assessment of bypass graft patency was excellent. All grafts seen to be patent on selective graft angiography were also seen by DSA alone and in addition two grafts which could not be selectively catheterised were found to be patent. However, in patients with postoperative chest pain, selective graft angiography is probably required as non-gated intra-arterial DSA does not provide sufficient information to assess graft stenoses, distal flow and the native coronary vessels.

Adult↗

PubMed1984

Intraarterial digital subtraction angiography in hypertensive azotemic patients.

Ten intraarterial digital subtraction angiography studies in nine azotemic patients were reviewed to assess the technical adequacy and the effect of contrast load on renal function. All studies were of diagnostic quality. In only two of 10 studies was there a mild transient deterioration in the degree of renal insufficiency. Intraarterial digital subtraction angiography is a reliable method that can be used to evaluate the renal arteries, even in the presence of azotemia.

Aged↗

PubMedDate not supplied

Postoperative multidetector computed tomography angiography after aneurysm clipping: comparison with digital subtraction angiography.

OBJECTIVES: To evaluate the usefulness of multidetector computed tomography angiography (MDCTA) as a noninvasive diagnostic modality for the detection of aneurysm remnants after clipping of intracranial aneurysms. METHODS: Thirty-eight patients who had aneurysm clipping and had undergone MDCTA and digital subtraction angiography (DSA) were enrolled in this study. In 16 of the 38 patients, MDCTA was performed with 16-channel MDCTA, in 20 patients with 4-channel MDCTA, and in 2 with both. Two neuroradiologists evaluated the image quality of MDCTA with a 3-point rating scale and the presence of the residual aneurysm sac with a 5-point rating scale. Receiver operating characteristic analysis was used to measure the diagnostic performance of MDCTA. RESULTS: Forty-nine surgically clipped aneurysms were evaluated in this study. The overall diagnostic accuracy of MDCTA was 88.1% (95% confidence interval: 0.761-0.954). The ability of 16-channel MDCTA to discriminate between surgical clips and parent vessels was superior to that of 4-channel MDCTA (P=0.005). CONCLUSION: Multidetector computed tomography angiography is a valuable noninvasive diagnostic modality for the assessment of aneurysm remnants in patients after aneurysm clipping.

Adult↗

PubMed1984

Arterial digital subtraction angiography with particulate intravascular embolization and angioplasty.

The authors are reporting their experience with arterial digital subtraction angiography to monitor particular intravascular embolization in hypervascular tumors and malformations and angioplasty. Arterial digital subtraction angiography may reduce the time of waiting for regular film developing and subtraction. The smaller amount of contrast material being used in arterial digital subtraction angiography minimizes the discomfort to the patients. It also prevents further renal damage in those patients with poor renal function. The arterial digital subtraction angiography may detect the early warning signs of embolotherapy. From the past experience, the authors have found that arterial digital subtraction angiography should be considered as a better alternative way to performing the particulate embolization and angioplasty than being monitored by conventional angiography.

Adult↗

PubMed2000

Software development for registration of digital subtraction angiography (DSA) images in uterine fibroid embolization.

The ISIS Center at Georgetown University Medical Center has developed a comprehensive program for image-guided procedures in the spine. As part of this program, ISIS has developed a software application known as I-SPINE (ISIS's Spine Procedure Imaging Navigation Engine). I-SPINE is a Windows NT application, which is based on the Analyze/AVM libraries. The software architecture follows the Microsoft Foundation Classes (MFC) single document, multiple view paradigm. This has allowed the developers to add new visualization modules to I-SPINE that aid physicians in procedures outside the spine. One such procedure I-SPINE has been expanded for is uterine fibroid embolization. The idea is that by registering and subtracting post-embolization angiographic images from pre-treatment images the resulting image can be used to quantify the embolization effect on the fibroid circulation and predict the treatment response. The I-SPINE digital subtraction angiography (DSA) module allows the interventional radiologist to open a series of pre and post-embolization DSA images that shows the vascular structures of the uterus and the fibroid or fibroids. From these images, the radiologist selects an appropriate image from each series. The selected images are then hand registered using pixel shifting. Once the images are registered, the pixels are subtracted resulting in an image that shows the embolized arteries that were supplying the fibroids.

Angiography, Digital Subtraction↗

PubMed2000

MRA versus digital subtraction angiography in acute subarachnoid haemorrhage: a blinded multireader study of prospectively recruited patients.

We performed a blinded multireader study comparing MR angiography (MRA) with digital subtraction angiography (DSA) in 34 prospectively recruited patients who presented with acute subarachnoid haemorrhage (SAH). Two observers independently reviewed the MRA and DSA studies some months after clinical presentation. Presence of an aneurysm was rated on a 4-point confidence scale. Cases in which the initial interpretation of the observers varied were jointly reviewed to reach a consensus opinion. DSA was deliberately chosen not to represent the reference standard and the clinical course and surgical findings were used to explain significant differences between the consensus readings of MRA and DSA. Diagnostic confidence and interobserver agreement were, overall, higher on DSA than on MRA studies (kappa DSA = 0.64 versus kappa MRA = 0.52 with 95% CI for delta = kappa DSA-kappa MRA [-0.06, 0.31]). With both methods, discrepancies between observers were due to aneurysms overlooked rather than false-positive readings by one observer. Diagnostic accuracy therefore improved when the readings of the two observers were combined, particularly for MRA. Intermethod agreement was only fair and similar for both readers (kappa reader 1 = 0.37 versus kappa reader 2 = 0.32 with 95% CI for delta = kappa reader 1-kappa reader 2 [-0.02, 0.11]). Both interobserver and intermethod agreements improved when the data were analysed on a per-study (positive or negative study) rather than on a per-aneurysm basis. Differences in the consensus reading were due to five aneurysms (four single and one multiple) detected only with MRA and five (two single and three multiple) detected only with DSA. MRA and DSA should be regarded as complementary in the investigation of patients with acute SAH. DSA can no longer be regarded as the reference standard.

Adult↗

PubMed2001

Carbon dioxide digital subtraction angiography: the practical approach.

CO(2) has developed into a viable alternative to iodinated contrast for digital vascular imaging. Because CO(2) is a gas, it has a unique set of properties that affords certain advantages over iodinated contrast in a variety of settings. However, if CO(2) is used inappropriately, these same properties are associated with a unique set of rare but potentially harmful events. Therefore, it is essential that these unique characteristics be understood in order to employ a few simple precautionary measures. Fortunately, there is a delivery system currently available that is readily assembled and easy to use that ensures the appropriate administration of CO(2). This system, combined with experience, can reduce the greater labor intensity sometimes associated with CO(2) digital subtraction angiography. When it is used appropriately, CO(2) digital subtraction angiography alone or in combination with iodinated contrast offers diagnostic and interventional rewards that are not available with traditional intravascular contrast examinations.

Angiography, Digital Subtraction↗

PubMedDate not supplied

Initial experience with helical CT and 3D reconstruction in therapeutic planning of cerebral AVMs: comparison with 3D time-of-flight MRA and digital subtraction angiography.

PURPOSE: We report our initial experience with helical CT and CT angiography (CTA) in evaluating cerebral arteriovenous malformations (AVMs) in comparison with time-of-flight MR angiography (MRA) and digital subtraction angiography (DSA). METHOD: Twelve AVMs were studied with CTA, non-gadolinium-enhanced MRA, and DSA. Reconstructed images were obtained in three display methods (maximum intensity projection, shaded surface black and white, shaded surface color). Shaded surface color display was obtained by assigning different colors to vessels and "presumed" nidus. The number of feeding arteries and draining veins associated with each AVM was independently counted in each modality. The relative ease of depicting the nidus and vessels was also determined in each display method. AVM nidus dimensions were measured on CTA and MRA source images and interobserver differences were compared. RESULTS: CTA-reconstructed images depicted more veins but fewer arteries than MRA. Shaded-surface color displays best delineated vessels and nidus. Nidus dimension measurement was possible on CTA in all AVMs but impossible on MRA in four AVMs due to interference by methemoglobin (three AVMs) and phase artifact (one AVM). The interobserver difference in nidus dimension as measured on CTA was significantly smaller than that on MRA. CONCLUSION: Reconstructed CTA images and CTA source images seem to be valuable adjuncts or alternatives to MRA.

Adolescent↗

PubMed2001

[Diagnosis of cerebral aneurysm using 3-dimensional digital subtraction angiography].

Recent rapid advancement in the technology of magnetic resonance angiography and 3-dimensional computed tomography angiography has opened the door to a less-invasive diagnostic routine for the treatment of cerebral aneurysms. However, from the viewpoint of decision making concerning which treatment to use; conservative therapy; surgical intervention; or endovascular treatment, much more precise information is necessary. Recent progress of rotation digital subtraction angiography has introduced 3-dimensional digital subtraction angiography. In the past year, 28 cases involving 39 aneurysms have been studied using 3-dimensional angiography. This study was carried out, using a rotating C-arm, which rotates 220 degrees in 5.8 seconds. All raw data gathered was transferred to the workstation for image reconstruction. The purpose of this study was to evaluate the clinical potential of 3-dimensional digital subtraction angiography for the diagnosis of the cerebral aneurysms.

Angiography, Digital Subtraction↗

PubMed1992

Magnetic resonance angiography compared to intra-arterial digital subtraction angiography in patients with subarachnoid haemorrhage.

In order to evaluate the sensitivity and specificity of magnetic resonance angiography (MRA) in spontaneous subarachnoid haemorrhage, 14 patients with recent haemorrhage verified by CT or lumbar puncture were investigated with both selective intra-arterial digital subtraction angiography (IA-DSA) and MRA by two independent teams, each having the same preangiographic information. The results were compared with each other and whenever possible (all positive cases except one) with those of surgical intervention. Seven patients were identified by MRA and IA-DSA as having a single aneurysm on the circle of Willis, 1 an aneurysm of the posterior inferior cerebellar artery 1 an aneurysm of the internal carotid artery (siphon) and 2 patients with two aneurysms on the circle of Willis. MRA and IA-DSA both failed to demonstrate aneurysms in 2 cases. Three patients had negative results on both methods and no surgical intervention was attempted. The aneurysms ranged from 0.3 to 1.5 cm in size. In most cases there was agreement between MRA and DSA, leading us to believe that, if the proper protocols are followed, MRA is a powerful alternative to other established methods in the detection of intracranial aneurysms. At this stage it will not replace IA-DSA prior to surgery, but the ability to obtain various projections using 3D MRA may improve surgical planning.

Adolescent↗

PubMed1993

Three dimensional time-of-flight magnetic resonance angiography in carotid artery surgery: a comparison with digital subtraction angiography.

Three dimensional time-of-flight magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA), considered the gold-standard technique, were compared for pre- and postoperative evaluation of the carotid bifurcation. Images of suitable quality of 194 bifurcations were available with both techniques. Percentage stenosis was graded into 5 groups: A = 0-29%, B = 30-59%, C = 60-89%, D = 90-99%, E = 100% (occlusion). Preoperative MRA (126 bifurcations) overgraded the stenosis in 14 cases and undergraded it in 11. The two techniques agreed in 101 cases and the extent of misgrading was never more than one category. Regression analysis showed a good correlation between the two methods. Severe ulceration was better identified by DSA. As far as the surgical indication was concerned, MRA had a sensitivity of 92.6% and a specificity of 98.3%. In 68 operated cases, postoperative MRA and intraoperative completion angiography showed a satisfactory endarterectomy with no residual stenosis in any of the cases. In conclusion, MRA seems an accurate modality for imaging of carotid bifurcations. Significant limitations still exist for an adequate demonstration of intracranial circulation.

Adult↗

PubMed2003

Assessment of peripheral arterial occlusive disease: comparison of multislice-CT angiography (MS-CTA) and intraarterial digital subtraction angiography (IA-DSA).

PURPOSE: The aim of the study was to assess the arterial vascular system of the lower extremities in patients with peripheral arterial occlusive disease using Multislice-CT angiography (MS-CTA) and to compare the results with the standard of reference, intraarterial digital subtraction angiography (IA-DSA). MATERIALS AND METHODS: MS-CTA and IA-DSA of the lower extremities were carried out on 23 patients with peripheral arterial occlusive disease (Fontain Stage IIb: 18, III: 3, IV: 2). MS-CTA comprised a 4 x 2.5 mm collimation, 15 mm table feed/rotation, 0.5 sec rotation time and 3 mm slice thickness (1.5 mm reconstruction increment). Delay time was determined by bolus tracking. 150 ml of contrast media were injected intravenously at a flow rate of 3 ml/sec. Maximum intensity projection (MIP) reformations were performed using a semi-automatic vessel tracking program. MS-CTA (axial and MIP-reformatted images) and IA-DSA were reviewed by two radiologists. The grade of vascular stenosis as well as occlusion were rated on a scale of 0 to 3 (0=0-50% stenosis, 1 = 51-75% stenosis, 2 = 76-99% stenosis, 3 = occlusion). RESULTS: For MS-CTA, the mean delay time was 30.2 s (23-40 s), mean scan time was 37.4 (33-42 s). Data analysis was based upon a total of 1136 vascular segments for both methods (568 each). A comparison of all the evaluated segments in both techniques revealed a MS-CTA / IA-DSA 86.3% match. Out of 442 segments proximal the trifurcation, 386 were correctly assessed in MS-CTA (87.3%) and distal the trifurcation, 101 out of 126 segments were rated correctly (80.2%). In MS-CTA, an overall confidence interval of 95% can be achieved in 83.2% to 89.0% for correctly rated stenosis grading. CONCLUSIONS: In patients with peripheral arterial occlusive disease, MS-CTA of the lower extremity is a promising minimal-invasive method for detection of relevant arterial stenoses. However, the technique was limited to routine diagnostic purposes due to severe calcifications and time consuming reconstruction procedures.

Aged↗

PubMed1984

Digital subtraction angiography for the evaluation of persistent uterine trophoblastic disease.

In three patients with persistent uterine trophoblastic disease, follow-up after primary chemotherapy was undertaken by digital subtraction angiography. It was found that the angiographic appearance of the intramural uterine lesions was comparable with that obtained by conventional pelvic angiography. Digital subtraction angiography may be applicable as an easy, safe, and valuable diagnostic method for gestational trophoblastic disease in place of conventional pelvic angiography because it is a relatively noninvasive procedure that can be performed on outpatients.

Adult↗

PubMedDate not supplied

The application of i.v. digital subtraction angiography to cranial disease in children.

All intracranial IV digital subtraction angiographic examinations performed over the past 2 years were reviewed retrospectively to ascertain the uses and limitations of this technique for the evaluation of pediatric intracranial disease. Of the various abnormalities studied, this imaging technique was particularly useful in diagnosing venous and dural sinus abnormalities; in screening for suspected large aneurysms, vascular malformations, and major arterial occlusive disease; and in preoperative vascular mapping. IV digital subtraction angiography has selected usefulness in confirming brain death, in evaluating cerebral ischemia, in identifying vascular abnormalities underlying intracranial hemorrhage, and in evaluating vascularity and sinus extension of masses. The IV route for digital subtraction angiography is not useful in diagnosing segmental arterial occlusive or small-vessel disease, nor is it useful in preoperative localization of specific arterial supply to arterial venous malformations, aneurysms, or neoplasms. IV digital subtraction angiography can be performed successfully in children of all ages with minimal patient morbidity. For most patients, the diagnostic information obtained was adequate without the need for standard cerebral arteriography.

Adolescent↗

PubMedDate not supplied

Intraarterial digital subtraction angiography of spinal arteriovenous malformations.

Intraarterial digital subtraction angiography (DSA) in two patients with spinal dural arteriovenous fistulas demonstrated the major feeding arteries and the venous drainage of the respective malformations. However, the dural component of the malformations--which distinguishes them from intradural malformations--could not be recognized, nor was normal cord vasculature demonstrated. In a patient with an intradural arteriovenous malformation (AVM), only major arterial feeders were demonstrated. Intraarterial DSA provides essential anatomic information with an increased margin of safety in spinal AVMs, but supplemental selective arteriography, conventional or digital, also is currently required.

Angiography↗

PubMedDate not supplied

Evaluation of prototype equipment for digital subtraction angiography in diagnosing intracranial lesions.

Two prototype units for digital subtraction angiography have been developed by Japanese manufacturers. Their performance in demonstrating various intracranial lesions in 121 patients was evaluated. Comparison with conventional selective catheter angiography was possible in 77 patients. Digital subtraction angiography proved useful in preoperative evaluation of pituitary tumors when transsphenoidal surgery was being considered; demonstration of faint tumor stains which might be missed on conventional angiography; demonstration of larger aneurysms, arteriovenous malformations, and tumors as a screening technique; demonstration of abnormalities involving the dural sinuses; and follow-up of patients after surgery or embolization.

Brain Diseases↗