VOL. 95, No. Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved THE By JOSEPH ‘if HE RELATION OF ARTERIAL TRAUMA COMPLICATIONS OF CEREBRAL ANGIOGRAPHY* H. ALLEN, M.D.,t complications raphy workers.7 have Most CARLOS of cerebral been investigated of the studies the literature have been this has it impossible made PARERA, 3. angiog- to serious complications termined. postmortem has Crawford’ has examinations been de- demonstrated may show that ex- phy and associated the artery when death 8 months after angiograsome of the cases were apparently with complications during or following angiography. tensive occurs 2 damage hours i. Death. 2. Neurologic symptoms angiographic These complications. and signs indicating of almost may be seen are: (a) or weakness, seizures; (c) or paresthesias; field defects or neuritis (caused damage to the brachial damage to the recurrent nerve causing From Neurological the Department Institute, of the (b) mo- needle plexus); (1) laryngeal hoarseness. of Radiology, Columbia-Presbyterian Columbia University, Medical Center, College New t Special ment cTI sub- heto or disor- certain Records should of the a careful with testing to the drugs also be kept of the the quantity of saline solution and contrast medium injected (and over what period). The roentgenograms taken should be carefully examined (in cases where there are focal or sensory(d) visual blindness; by arm or pulse and blood pressure, needling difficulties, evidence of arterial damage or extravascular injection of contrast material, These coma; the (due to anxiety), hypotension, ders of rhythm, heart failure. Arteriovenous fistula. used. in- part in axillary, causes of most complications, prospective study is required, of the patient for sensitivity Clinical any confusion brachial include on occasions. ischemia brachial, rupture of aneurysm, etc. In order to be reasonably compli- described. brain tor-hemiplegia, generalized numbness scotomata, * of of the M.D. POTTS, To this list one may add some less significant or very rare complications, such as drug sensitivity to minimal doses, partial or complete occlusion of the vessel by subintimal hemorrhage, thrombosis at the site of puncture, stimulation of the carotid sinus by palpation or needling, air embolism, increase of intra-arterial pressure causing to volvement (e) 7. to A great number cations have been the following: GORDON clavian artery is punctured). Tracheal compression by a neck matoma. 5. General or local allergic reactions the contrast medium or the local general anesthetic agents. 6. Cardiac complications: Hypertension determine not Evidence D. . and the causes of many of the complications. Nearly all of the authors suggest that some of the complications were associated with a difficult arterial puncture or the injection of some or all of the contrast material outside the lumen of the vessel, but the frequency with which extraluminal injections or difficult needle punctures are followed by and (where by many reported in retrospective M.D., TO complications) for evidence of air vessels or rupture of an aneurysm the injection of contrast material. The clinical status of the patient is like- wise disease important of Physicians York, New serious and Surgeons, and the and Blindness, iFs i brain Radiological Service of the York. Training Fellowship, NIH, National Institute of Neurological Diseases of Radiology, Vanderbilt University, School of Medicine, Nashville, Tennessee. Visiting Fellow in Radiology, NIH, National Institute of Neurological Diseases NB98-og. Now at Department of Neuroradiology, Institute of Neurological 845 since in the during and Blindness, Sciences, Madrid, NBi 167-os. Neuroradiology Spain. Now at Depart- Training Grant Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved 846 Joseph lic. i. ogram (arrow). another needle H. that the point tile unusually patient vulnerable D. moderate Gordon Potts object of how DFcL1RR, 1965 tile stud present of punctures tile vessel pared with tile incidence ill cases wilere the puncture and under “clean”. includes of to trau- extralu- material were complications. in cases was diffi- completely was comsimple An and retrograde angiograms anesthesia oband with and and hypaque angiography. 50 intravenous sitivity. Cournand After puncturing type of needle, of contrast shortl an medium that the the necessary, made and were was correctl vessel (Fig. i, zi tile position of center of the plane technique anteroposterior for the the drug ansen- the vessel with a 2 cc. injection needle was cent before unusual was taneous allterOposterior oid roentgenograms per cent an- of the contrast test dose was given to detect needle carotid, carotid medium giograph\ within complications was vertebral local or or wilere the needling of tile vessels cult or the ifljectiOn partl or outside the lumen of tile vessel tile injection The study was difficult 6o per vertebral Renografin the for giographies brachial S’I’UDV frequently sedation. used was minal injection of contrast associated wi til allgiograpilic the incidence of complications tained and of of angiograpil\. determine brachial, Parera of the roentgenograms showing I’RESENT lllatic Carlos neck after injection of 2 cc. of contrast medium. (A) Lateral roentgenthe needle lies against the posterior wall of the common carotid artery There is a small quantity of subintimal contrast medium. (B) Anteroposterior roentgenogram of case showing that the needle is pressing against the lateral wall of the artery. The point of the was positioned more medially before the main injection was made. Polaroid niav nlake to tile risks lile Allen, a and simul- lateral taken to Polarprove positioned and If found point of it near the vessel. A simultaneous was employed so that and lateral roen tgenograms bithe altered to the place B). the VOL. Arterial No. 95, Trauma Complications Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved with a single injection of Ten cc. was used for cain adults and 6 cc. for angiography; 35-45 cc. was usufor brachial roentgenograms angiography. included the neck vessels permitting, in carotid and vertebral angiography, the ready recognition of imperfect injections. It is important to note that only the placement the blood may flows be recognized back from the by the needle. ing of the injections the angiographer had performed many felt confident grossest that “clean” puncture flow of revealed blood; that errors he because manual tion. The Total a free back Polaroid material blood injection films was pressure of saline was tervals throughout the hand strength was measured and after the examination way sign on of reduction one side was a developing of the solu- recorded at in- examination and before, during, with a dynamo- meter. These objective strength ments were found helpful in the ognition of certain complications. ness of the hand strength measured sometimes hemiplegia. strength measureearly recA weakin this the of both of No. Examinations Right Carotid Left Carotid Right Brachial Left Brachial Right Vertebral Left Vertebral way Dur- partially subintimal. Almost all injections were made with a Taveras mechanical injector and between injections the tubing and needle were kept clear of clots by intermittent of No. Artery Injections 157 219 240 341 6 96 38 14 46 17 24 28 538 747 of needle of the however, the the contrast Ii TABLE could be obtained contrast medium. rotid angiography vertebral ally injected The lateral 847 earliest Gradual hands seen when the sedation was increased. This series includes data compiled from 400 patient visits for angiography: 538 examinations were performed and 41 patients made more than one visit. Unsuccessful examinations are included even if no contrast material was injected, but at least an attempt was made to puncture the artery. The angiographic examinations were April from done between 1964 and the the series were September 1963 and only cases eliminated those whose records were incomplete. 281 In gle vessel and were injected. are shown aminations the cc. in Table performed number injections one The number of exon each vessel and i. were sin- two vessels diagnoses of injections (excluding made before the roentgenograms Table instances in Jo! instances The angiographic taken) are the Polaroid 2 shown in ii. was COMPLICATIONS TABLE Angiographic Diagnosis I In were . No.of Cases Normal Vascular occlusive disease Aneurysms, arteriovenous malformations or follow-up studies on these intracerebral Total i death, ab14 400 538 and 19 complications recovered after time. The findings two described sented I. with communicating right internal neck showed in the are examinations there (3.9 per i permanent plegia patient CASE 9 dilatations, diagnosis) included The 104 or series of complications complications 55 cases Tumors Subdural, epidural hematomas Others (junctional scesses, questionable i6i 57 this 2! from a variable cases summarized most serious in more detail J.O., a female a hemorrhage cent) right which hemi- which period that showed in Table complications the of III. are below. aged 59 from a right years, preposterior aneurysm which was treated by carotid artery occlusion in the in 1955. Postoperative angiography no filling of the aneurysm from either Joseph 848 H. Allen, Carlos Parera Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved TABLE Case No. Acre i 5 2 6 Patient became unresponsive after main injection of contrast medium; death 36 hours later Right hemiparesis and patient became obtunded hours after ar- teriography; permanent 6 52 7 52 8 33 Weakness 3 6 6 68 57 io of left arm after attempted left vertebral injection; complete recovery in 4 days Aphasia, apraxia and confusion; recovered in 2 days Loss of vision in both eyes; gradual recovery over 2 days i Gordon Potts 1965 DECEMBER, III Subintimal Contrast Angiographic Diagnosis and Comments LCd No LCd No LV1I No No Normal LCd LCd Yes No Yes No Normal Cerebral atheroma RBII No No Cerebral atheroma RCA RBA No Yes LVII Yes Yes Atherosclerotic ease Left cerebellar toma No Yes No No Yes (total extravasation of contrast medium) Yes (wall of vessel irregular due to needle trauma) hemi- paresis and aphasia Transient right hemiparesis; complete recovery in 6 hours Aphasia, cleared in 24 hours Severe blood pressure drop during examination; recovered in a few hours Numbness of left side; complete clearing in 2 days Hives (lasted 2 days) D. Difficult Arterial Puncture Vessels Injected* Complication and LBA RCA aneurysm; precarotid ligation Left middle rysm cerebral the may left have aneu- vascular dis- hemangioblas- Left sided atherosclerosis Arteriovenous LCd LCA Right carotid vious right aneurysm and malformation; vertebral artery been accidentally punctured 69 II Aphasia 2 days and confusion; 12 68 Dysphasia, returned in 2 days 13 51 Blood pressure drop ing to normal in Confusion, dysphasia SI 14 sided i 66 i6 g 17 7 i8 o 19 38 o 20 21 in worse after examination; to pre-angiographic state weakness; i to 8o/6o, returnhour and mild right cleared in 6 hours Right arm weakness; complete clearing in 2 days Right arm weakness and confusion; cleared in 24 hours Low blood pressure at intervals for 24 hours Intermittent fall of blood pressure for hours Hives (lasted 12 hours) Blind spots, scotoma, nausea and vomiting lasting 4 hours Loss of voice, and hoarseness due to recurrent laryngeal involvement; recovered in 12 hours g #{149} LCA recovered Left carotid No LCd Yes LCd No RCI Yes No Normal RBA No Yes Atherosclerosis No Yes Normal LCd Yes Yes Normal RCI Yes Yes Unsatisfactory LCd Yes Yes Normal LCd RCA LCA No Yes No Yes Normal Right sphenoid ingioma Normal one Temporo-thalamic tumor LBA Lcd (retrograde injection) RCA LCd (both sides) No LVII RCA LVA RVA to be the Glioblastoma showed irregularity of artery near needle) No artery Right carotid artery Left vertebral artery Right vertebral artery LBA Left brachial artery RBA Right brachial artery The vessel italicized is presumed (roentgenograms concerned in the complication. (both sides) No angiogram ridge men- \OL. Arterial No. 95, Trauma Complications 849 : Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved 9 k ‘4 -I 2. 2. !I1i Tn1L .1 Vlc\\ 111 th fl I (h1.tJ nt. tii Sj?1 1 tCT’M 1 I H. side and the right internal carotid be completely occluded. developed headaches and a right shown to nerve lesion ization and angiography artery In third showed 1959 I jr. !t[Td 1 ltd \ (: 1 1 11111 ( )!w Immediately c was injected she The right leg was more spastic than the left and the left eye was deviated to the right. Fifteen miiiutes later tile patient was very restless but she could not move iler rigilt limbs as well as tile left. The right pupil was contracted to pinpoint and she was markedly ilypotensive. She gradually deteriorated and death occurred 36 hours later. cranial recanal- of the internal carotid artery. Because was no evidence of a further subarachnoid hemorrhage on this occasion, the patient was treated conservatively. One day before her final admission tile patient had a subarachnoid hemorrhage. zingiograp/zy. Two injections of 2 cc. of contrast material were Illade into tile left common carotid artery in order to check the needle position with Polaroid films and then the main injection of io cc. was made. Most of the contrast material during this last injection was there subintimally. .LU\t11 . injection tile patient became after this decerebrate. male aged 6 years, was had hypertension (up to 260/150) for i years. Seven days before admission the patient had a subarachnoid hemorrhage which was followed by aphasia and a right CASE known 2. L.\V., to have a 850 Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved hemiparesis, Angiography. raphy contrast both Joseph H. Allen, of which gradually A left common Carlos Parera angiog- was performed using a total of 22 cc. of medium. Frontal, lateral and oblique views showed a middle cerebral aneurysm with marked associated vascular spasm and a low convexity subdural hematoma (Fig. 2, zI, B and C). Four hours after the study the patient became obtunded, there was a more dense hemiplegia and the patient was more aphasic. Sixteen months later the patient still had some left sided weakness and severe aphasia but was ambulatory. DIFFICULT Where with the tured, ARTERIAL more needle the puncture attempts the artery was were was recorded way we have trauma inflicted jacent tissues. a crude on One artery hundred its ad- fourteen (21 per cent) of the 538 vessels injected, or where puncture was attempted, were classified as difficult; of these i ij. difficult punctures 10 (9.6 per cent) were associated with complications. Of the 2! cases showing angiographic complications, 7 (33 per cent) were difficult to puncture. SUBINTIMAL INJECTIONS In 38 of the 538 examinations (7.1 per cent) some subintimal or extraluminal contrast medium injection occurred and of these 9 showed all of the contrast medium outside the lumen of the vessel. Of the 2! cases showing cent) were intimal complications, recorded contrast as (62 13 having some per sub- medium. Of the ture or cases 2! 14 with had subintimal injection medium or both. It that, in some cases, was caused by angiographic either the com- a difficult of punccontrast seems almost certain an intimal dissection injection of saline occurred taken, it corded were associated lumen by subintimal only death in the series a subintimal injection carotid angiography patient who had the usually it is probable than those re- with the after would not be recognized. Therefore, that more complications as narrowing of dissection. was The associated when left was performed previously solu- much damage with a Cournand puncture but any narrowing is not usually seen had with common on the a right to the vessel type caused unless as by the puncture the catheter into the to opacify vessel wall at the tured. Serious point where allergic intravenous dium is test given. the complications in dose of Hypertension is vesthe is puncmay if the ly always be avoided about drug sensitivity a of needle only inserted a short distance sel or the reflux is sufficient near- patient is asked advance and the an contrast meis generally caused by apprehension be controlled by increased tension may be induced and may sedation. by painful generally Hypostimuli or needling, particularly of and may ephedrine. be corrected Most of the traumatic carotid intravenous sinus, serious neurologic ies appear to difficult sel or tions. tions have to the with more complications in this serbeen associated with or traumatic subintimal Presumably are caused ondary DISCUSSION plications, damage were least of the and if this 1965 DECEMBER, diffi- as indication the and angiograms Potts made punc- cult. It is recognized that what may be a difficult puncture for one operator may be easy for another, but by classifying it in this Gordon internal carotid artery ligated. It has sometimes been suggested that damage to the vessel does not occur when catheter techniques are used. However, it seems likely that the percutaneous insertion of a catheter into a vessel causes at PUNCTURE than before D. tion improved. carotid and or by punctures extravascular most of cerebral a traumatic of the vesinjec- these complicaischemia sec- examination. These complications should be greatly reduced by an atraumatic puncture. The direct toxic effects of the contrast medium undoubtedly cause some complications but these can be reduced by quantity of contrast ing repeated injecting injections the medium at smallest possible and by avoid- short intervals. VOL. When Downloaded from www.ajronline.org by 24.231.218.146 on 06/21/16 from IP address 24.231.218.146. Copyright ARRS. For personal use only; all rights reserved Arterial No. 95, the simultaneous biplane Trauma technique of filming is not used and each projection requires a further injection of contrast medium, larger quantities of the medium are employed toxic and effects The gest findings that, technique raphy it is to of the be expected that medium will increase. in when the a series simultaneous is employed with the of sugbiplane for cerebral injection cases the of Complications dium rare. D. 851 (other Gordon than reactions) Medical Center are M.D. Potts, Department allergic of Radiology Neurological Institute Columbia-Presbyterian 622 West i68th Street New York, New York 10032 angiogrelatively small quantities of contrast medium, over one-half of the complications are caused by trauma to the vessel or subintimal injection of contrast material. Presumably, as larger quantities of contrast material are injected during angiography, the importance of the toxicity of the contrast medium increases in relation to arterial trauma. SUMMARY In a series of 538 angiographic studies on 400 patients there were 21 complications including I death and I permanent hemiplegia. All of the remaining complications cleared within days. The evidence suggests that when simultaneous biplane angiography is used, and small quantities of contrast medium are injected, trauma to the artery and subintimal injection of the contrast material are the most common causes of complications, and that true toxic effects of the contrast me- The authors tance of Dr. tion of this wish to acknowledge M. Taveras Juan the in the assis- prepara- paper. REFERENCES I. 2. T. Pathological arteriography. 7. Neurol., Psychiat., 1956, 19, 217-221. CRAWFORD, J. R., FIELD, SURE, R. angiography Neurosurg., 3. cerebral Complications in 2,000 1962, 19, A. D., and KAPLAN, of Jr. cerebral of Neurosurg., J. T., and ROBERTSON, L., effects & DE of consecutive 775-78!. SAUScerebral 7. cases. A. E. Complications WALKER, angiography. Neurology, 4, 643-656. 4. . B. Cerebral KENDALL, Brit. 7. Radiol., D. W., LINDNER, and GURDJIAN, tions in patients Neurosurg., 1962, angiography using Conray. 1964,37, 8 1-589. HARDY, W. G., THOMAS, L. M., E. S. Angiographic complicawith cerebrovasculardisease. 7. 19, 179-185. 6. NEWTON, T. H., and COUCH, errors in arteriographic diagnosis carotid artery Radiology, occlusion. R. S. C. Possible of internal 1960, 75, 766-773. NING, R. H., JR., GOODELL, H., and DUNH. S. Complications of carotid arteriog- raphy. Arch. 7. PATTERSON, Neurol., 1964, JO, 5 13-520.