CEREBRAL ANGIOGRAPHY IN NEUROSURGICAL · Cerebral angiography has established itself as a valuable...

362

CEREBRAL ANGIOGRAPHY INNEUROSURGICAL EMERGENCIES

R. MYLES GIBSON, M.D., M.SC., F.R.C.S.Senior Registrar, Department of Neurological Surgery, The General Infirmary at Leeds

MICHAEL D. SUMEULING, B.Sc., M.B., CH.B., M.R.C.P., D.M.R.D., F.F.R.Research Fellow in Radiodiagnosis, University of Leeds

Cerebral angiography has established itself as avaluable diagnostic method in neurosurgicalclinics. Since the introduction of this procedureby Moniz in I927 the technique and the contrastmedia used have been modified and improved.Consequently the standard and diagnostic valueof the radiograms obtained have been improvedwith, simultaneously, a reduction in the risksinvolved to the patient.

Angiography has played an important role inthe surgical management of spontaneous sub-arachnoid haemorrhage and is now accepted asthe routine method of investigation of such cases.The role of surgery in a case of spontaneous intra-cranial haemorrhage is to save the patient's life, topromote as full a recovery of function as possibleand to prevent a further haemorrhage. Surgicalintervention cannot succeed in the case of a masslesion which kills the patient within 24 hours.However, in those that survive, surgical evacuationof haematomas may avert death by cerebral com-pression, diminish the severity of the hemiparesisand speed the rate of recovery. Often the aneurysmcan be successfully obliterated, thus preventinganother haemorrhage. Angiography is essential inorder to demonstrate the aneurysm or angioma,revealing its vessel of origin, its precise situationand size. Angiography may also demonstrateintracranial clots, the degree and extent of vaso-spasm, and furthermore may be used to show towhat extent the circulation in one hemisphere canbe maintained throughout the circle of Willis,when ligation of the parent carotid artery is thetreatment of choice.

Carotid angiography is a valuable investigationof cases of cerebral neoplasms where the clinicalsigns indicate the cerebral hemisphere involved.Angiography in such cases is generally acknow-ledged to be less disturbing to the patient thanventriculography. Occasionally, too, it may pro-vide useful information about the particular type

and size of the cerebral tumour, depending on thevascular pattern of the lesion, and so facilitate adefinitive surgical approach.While the part played by carotid angiography

in the above condition is well recognized andaccepted, it is further submitted that angiographycarried out under the proper conditions of clinicalassessment has a valuable part to play in theelucidation of some ' emergency' clinical prob-lems of altered consciousness.There are, of course, many causes of coma or

impaired consciousness. Such cases upon admis-sion to hospital must be subjected to carefulclinical scrutiny and the general causes of impairedconsciousness such as diabetes, hypoglycaemiccoma, uraemia, hepatic failure, alcoholism, poison-ing, meningitis, recent head injury, eliminated.The three main requirements in unravelling thecause of the coma are an account from relativesor a witness of the patient's conduct prior to theloss of consciousness, a description of the modeof onset, and a thorough physical examination,including blood-pressure recordings, urinalysisand blood examination. This overall concept ofthe investigation of altered consciousness must beborne in mind to avoid errors in diagnosis andtreatment. None the less, a busy general hospitaladmits a significant number of patients sufferingacute or subacute alteration of consciousness, orhemiplegia, due primarily to disorders of thenervous system. These include spontaneous intra-cranial haemorrhage due either to rupture of ananeurysm or angioma, already mentioned, or toso-called primary cerebral haemorrhage withintracerebral clot, occlusion of the carotid arteryin the neck or in the intracranial portion, sub-dural haematoma, brain tumour and intracranialabscess.Much can be done to help patients, admitted to

hospital in coma or semi-coma, who are sufferingfrom these conditions. In the past, neurosurgical

copyright. on O

ctober 4, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.416.362 on 1 June 1960. D

ownloaded from

http://pmj.bmj.com/

June I960 GIBSON and SUMERLING: Cerebral Angiography in Neurosurgical Emergencies 363

aid has depended primarily on accurate clinicalassessment supplemented by multiple exploratoryburr holes, and, if indicated, needling of the brainwith a brain cannula. Occasionally ventriculo-graphy would be performed to locate or define aspace-occupying lesion. Without detracting fromthe value of exploratory burr holes this is a blindprocedure often involving multiple incisions overthe cranial vault, and is frequently unrewarding.Furthermore, ventriculography in the very illpatient may well precipitate disaster. Angio-graphy, on the other hand, may contribute amore precise and localized diagnosis and permit aplanned, logical and definitive surgical approachto evacuate intracranial space-occupying lesions,and to relieve intracranial pressure or vascularocclusion. It is possible that in the near futurethe use of pulsed ultrasound may detect massspace-occupying intracranial lesions rapidly andwithout hazard, but the value of this method is asyet undetermined, and in any event it yields noinformation as to the source of the lesion or siteof a vascular occlusion.

Carotid angiography, especially in the ill patient,is not without risks, but these are minimal underproper conditions of case assessment and co-operation between neuroradiologist and neuro-surgeon, and the benefit to the patient far out-weighs the risk. The hazards of angiography haverecently been well reviewed by Riishede3 and areworth briefly summarizing.

i. Deleterious effects of faulty or indiscriminateneedle puncture-arterial spasm, intimal dissec-tion and haematoma.

2. Injection of an unnecessarily large volume ofradio-opaque medium may have a direct actionon the cerebral tissues and may produce cerebraloedema or infarction of brain tissue. An un-necessarily large volume of dextrose solutioninjected to maintain needle patency while waitingbetween injections of media is also harmful, aswell as bad practice, and can be eliminated byplanned team work which enables speedy andsafe angiography to be carried out.

3. The medium may have general toxic orallergic effects on the cardiovascular, excretoryor other systems.Most of the complications have followed the

use of Diodone in relatively large amounts andoften under general anaesthesia. These factors areof considerable importance in space-occupying le-sions where cerebral oedema and mass shift ofintracranial structures can take place rapidly,sometimes with serious and irreversible conse-quences. Fortunately, considerable advances havebeen made in the development of radiographicmedia in recent years. The modern media(notably Urografin, Diagonal and Hypaque) are

less toxic and irritant.' Moreover, they containmore iodine per molecule and so give bettercontrast per unit volume or conversely permitadequate visualization on a smaller total dosageinjected.Technique

Carotid angiography may be required at anytime of day or night, and it is therefore necessaryto have a radiological team available for emer-gency calls. An emergency sterile drum con-taining the necessary equipment is maintained,and this should include Gentile needles of varioussizes, polyvinyl connections, steel bowls, syringes,gauze, swabs and sheets. Solutions of 2% Xylo-caine, ampoules of 6o% Urografin and bottles of5% Dextrose perfusing fluid are always available.

In most patients sedation is necessary; weprefer Omnopon I/6-I/3 gr. and Scopolamine1/300-I/150 gr. rather than Pethidine or Chlor-promazine as the latter drugs are less predictablein action, and are more likely to produce a fallin the systemic blood pressure. A clear airwaymust be maintained and suction apparatus mustbe available since patients may vomit, particu-larly those with raised intracranial pressure.The tissues are infiltrated with 2% Xylocaine

and the carotid artery is punctured with a No. i8Gentile needle attached to a polyvinyl connectionfilled with perfusing fluid. A clear puncture isparticularly desirable as these patients are oftencritically ill. Modern media have greater contrastand less irritant action, and the injection of4-6 ml. of 6o% Urografin produces angiogramsof adequate quality. Two serial antero-posteriorfilms are first exposed to determine any shift ofthe anterior cerebral artery. This is followed bya second injection of medium with the exposureof three serial films. Correct positioning of thehead is essential. Some movement of the headmay take place, but this almost invariably happensat the end of the injection, and the first filmshows good diagnostic detail.

Helpful information is usually furnished by anangiogram of one side, but on occasions it hasbeen necessary to perform bilateral carotid angio-graphy. In some patients where the provisionaldiagnosis is uncertain before angiography, orwhere extracranial carotid occlusion is suspected,it is important to insert the needle into thecommon carotid artery low in the neck. Filmsshowing the carotid bifurcation may then beobtained, and in both antero-posterior and lateralviews if necessary.

Blood pressure should be recorded before andafter injections of media. Falls of pressure occurparticularly where an aneurysm is present, andsuch falls if severe may precipitate infarction.2

A2

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/

364 POSTGRADUATE MEDICAL JOURNAL June I960

..........

FIG. i.-Right carotid angiogram. Antero-posteriorfilm. The anterior cerebral artery is shifted tothe left.

The whole procedure should be done as quicklyas possible, consistent with safety, and the im-portance of good team work cannot be over-stressed. Co-operation between the neurosurgeonand the radiologist in the planning of the pro-cedure and the immediate interpretation of thefilms is essential, and enables the theatre staff tobe alerted at an early stage. The patient maythen be transferred directly from the X-raydepartment to the operating theatre without delay.

Case No. IA housewife, aged 38 years, who enjoyed good

health until the evening of May 5, I958, whenshe developed a sudden violent headache in theright temporal region. She went to bed; half anhour later experienced paraesthesiae in the leftarm and after a further half-hour became un-conscious. During the course of the night shevomited several times. The following morningshe was admitted to the General Infirmary atLeeds. Lumbar puncture was performed, andthe C.S.F. was clear and the cells reported as7 lymphocytes, 50 red cells. Shortly after thelumbar puncture she developed stertorous breath-

FIG. 2.-The lateral film shows stretched vesselsaround an avascular space occupying lesion in theparieto-temporal area.

ing and had several generalized seizures. Shewas then referred to the Department of Neuro-logical Surgery. On examination at 7 p.m. onMay 6, I958, she was very ill with stertorousbreathing. The right pupil was larger than theleft and in the mid-dilated position. She re-sponded only to painful stimuli and made attemptsto ward off pin-pricks with the right limbs butnot with her left arm, and only infrequently withher left leg. Both plantar responses were ex-tensor.

Interrogation of the patient's relatives con-firmed the sudden onset of the patient's illnessand clinical examination, having excluded generalfactors, strongly suggested a cerebral catastropheinvolving the right cerebral hemisphere.

Right carotid angiography was performed underlocal anaesthetic. This showed a gross shift ofthe anterior cerebral artery from right to left(Fig. i), and in the lateral view (Fig. 2) the middlecerebral artery was displaced downwards. Thepattern of vascular displacement, and the stretch-ing of the vessels, suggested a moderate-sizedright parieto-temporal avascular space-occupyinglesion.

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/

June I 960 GIBSON and SUMERLING: Cerebral Angiography in Neurosurgical Emergencies 365

OperationShe was taken direct from the Department of

Radiodiagnosis to the operating theatre. Anendotracheal tube was passed and a tracheo-bronchial toilet effected. This improved the air-way and she was given oxygen and a light anaes-thetic. An extensive right lateral craniotomy wasperformed and a bone flap turned. The durawas slightly blue and very tense. It would havebeen dangerous to attempt opening the durawidely at this stage, and so a brain cannula waspassed into the parietal region of the brain. Atthe depth of I.5 cm. fluid blood was encounteredand easily aspirated. On account of its volumeaccurate measurement was impossible, but it wasestimated to be about 8o-ioo c.c. The dura wasthen widely opened as a flap hinged towards themid-line of the skull. The brain was now seento be slack and pulsatile. Having thus evacuatedthe space-occupying lesion and afforded thepatient a decompression against the possibilityof brain swelling, the bone flap was laid gentlyin place and the wound closed in layers. At thecompletion of the operation tracheotomy was per-formed. The patient was nursed through a periodof coma lasting ten days. She then slowly emergedfrom her coma, and was discharged from hospitaltwo months later. As might be expected fromthe findings at the operation she had a moderatelysevere left hemiparesis for which out-patientphysiotherapy and rehabilitation were arranged.

:. ...

FIGS. 3 and 4.-Right carotid angiogram. The anteriorcerebral artery is in the mid-line. A berryaneurysm has been demonstrated on the anteriorcommunicating artery. There is considerablestretching of the arterial tree due to hydrocephalus.There is outward displacement of the bone flap,seen more easily on the lateral view.

Followed up regularly at out-patients this ladyhas made an excellent recovery. She is able towalk with the aid of only a stick, and despite theweakness of the left arm she is capable of lookingafter her own house and family.

Case No. 2An I I-year-old schoolboy, admitted to the

General Infirmary at Leeds on February 23, I958.He had two attacks of spontaneous intracranialhaemorrhage, the first on February I3 and thesecond the day prior to admission, February 22.On examination he was a sick, restless child;there was evidence of a left hemiparesis. Examina-tion of the fundi disclosed early papilloedema.At this point it was felt unsafe to perform angio-graphy and multiple burr holes were made. Inthe right parietal region an intracerebral haema-toma of 14 C.C. was encountered at a depth of4.5 cm. and evacuated. Initially this helped thepatient, but within 24 hours he was displayingsigns of a marked rise of intracranial pressure.He was no longer responsive to pin-prick andthere was a marked increase of tone in the legsassociated with bilateral extensor plantar responses.Under a light anaesthesia, in which a high con-centration of oxygen was maintained, an extensiveright lateral bone flap was turned, the duraopened and the swollen brain decompressed. Atthe same time tracheotomy was performed, sinceit was anticipated that he would be in coma orsemi-coma for some time. Slowly he improved,becoming responsive to painful stimuli and thenmaking spontaneous movements of his limbs.

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/


This progress became interrupted about two anda half weeks later when it was noticed that thedecompression was bulging and the bone flapbeginning to ride.This patient had had two proven attacks of

subarachnoid haemorrhage complicated by anintracerebral haematoma and swollen brain. Sur-gery in the first instance was directed towardssaving the boy's life by removing the intra-cerebral clot and providing a satisfactory cerebraldecompression. That all was not well after twoand a half weeks was evident by the bulgingdecompression. The possibilities were those ofrenewed intracranial bleeding or haematoma col-lection, brain swelling, or hydrocephalus due todifficulty in C.S.F. disposal. Since the methodof surgical treatment differed in each case itbecame of vital importance to clarify the situation.Right carotid angiography was performed underlocal anaesthesia. This showed a classical pictureof hydrocephalus. The anterior cerebral arterywas swept high but there was no evidence of intra-cerebral haematoma. Displayed also was amoderate-sized anterior communicating aneurysm,the probable source of the spontaneous haemor-rhage (Figs. 3 and 4). Based on the informationfurnished by the angiography, a left frontal burrhole was made and continuous ventricular drain-age instituted for six days. Lumbar puncturewas also carried out daily. By these measureslarge quantities of blood-stained cerebrospinalfluid were removed and quickly the decompressionceased bulging and the bone flap settled intoproper position. There was no need to reopenthe craniotomy.

Over many months the boy slowly improvedand was finally discharged home. Mentally hewas fully alert and fit to resume his schooling.There was weakness of the legs, however, whichfor the present and immediate future requireshim to move from place to place in a wheelchair,but his re-education and rehabilitation are beingvigorously pursued.

Case No. 3A 75-year-old lady was admitted to the General

Infirmary at Leeds on August 21, 1958. She hadsustained a mild head injury ten days before andtwo days later was admitted confused and dis-orientated. She had become apathetic and finallystuporous, and had in addition several focal fitsinvolving the left limbs.The patient's general health was fair, urinalysis

revealed no abnormality, and the blood ureaestimation was within normal limits. The historyof mild head injury ten days previously was con-firmed and the possibility of subdural haematomaseemed strong.

....... ...P.e

FIG. 5.-Right carotid angiogram. The anterior cerebralartery is shifted to the left and there is an avascularsegment over the convexity. This appearance istypical of a subdural collection.

A right carotid angiogram was performed underlocal anaesthetic and this showed a marked shiftof the anterior cerebral artery from right to leftand a pattern of vessel displacement suggesting asubdural collection (Fig. 5). She was taken totheatre and a subdural haematoma evacuated onthe right side. Despite her age she made anexcellent recovery and within three weeks wasup and about and sent to the convalescent hospital.

Case No. 4A 57-year-old female patient was admitted to

the General Infirmary at Leeds as a ' stroke ' onDecember 3, 1958. One month previously shehad had an attack of uselessness of the right handand arm which recovered. The day before ad-mission she had a stroke involving the left hemi-sphere with dysphasia and flaccid weakness of theright arm and leg. On first examination it seemedthat the carotid pulsations were equal, but anhour or two later the left carotid pulsation wasclearly less good than the right.The traditional clinical subdivision of this dis-

order into cerebral haemorrhage, thrombosis and

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/


I

FIG. 6.-Left carotid angiogram. The common carotidartery is irregular and narrowed. The internalcarotid artery is practically occluded at its origin,only a little trickle of medium passing beyond.The external carotid artery is partially occluded atits origin.

embolism has been for long based on clinicalsigns and symptoms of alleged specificity. Thecommon discrepancy between the clinical diag-nosis and the post-mortem findings is a fact whichchallenges the usual diagnostic principles. Currentinvestigations show that a fair proportion of'strokes' may be due to carotid occlusions ormay have intracerebral clots. Angiography maytherefore facilitate a more precise diagnosis thanpreviously and point the way to possible surgicaltreatment.

Left carotid angiography under local anaes-thetic was performed and on account of theclinical findings the injection was made low intothe common carotid artery. The radiogramshowed a partial block at the carotid bifurcationwith a trickle of medium passing up the internal,carotid artery (Fig. 6).

FIG. 7.-Right carotid angiogram. This shows a com-plete occlusion of the internal carotid artery at itsintracranial bifurcation.

The patient was taken to the operating theatre,an atheromatous plaque at the bifurcation of thecarotid artery removed and patency of the in-terral carotid artery restored. Post-operativelyshe was much more alert and was withdrawingthe previously flaccid right limbs away frompainful stimuli. The outlook seemed favourable,but she unfortunately developed respiratory diffi-culty and, despite tracheotomy, died of a diffusebronchopneumonia.

In the light of subsequent experience and thatof others4 such a case as this would not be tackledsurgically, despite the radiological evidence of apartial carotid occlusion, in view of the densityand duration of the neurological signs whichsuggest extensive hemisphere infarction. Wherethe signs are minimal or transient, however, andthe angiography discloses a partial carotid occlu-sion, surgery may well yield a gratifying anduseful result.

Case No. 5A io-year-old schoolgirl. Two days before

admission to hospital she was buying sweets in ashop when she was suddenly taken ill, fell downand was apparently completely unresponsive.When she recovered shortly afterwards she wasnoticed to have some left-sided weakness but wasable to get home without difficulty. Later thesame evening the weakness had disappeared and,apart from the child being out of sorts, there wasnothing else remarkable. Thirty-six hours latershe began to be drowsy and apathetic and wasadmitted to the General Infirmary at Leeds.Examination revealed a marked left flaccid weak-ness and a mild left hemiparesis. During thecourse of a few hours following admission, how-

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/


FIG. 8.-Right carotid angiogram. The antero-posteriorfilm shows a shift of the anterior cerebral artery tothe left.

ever, she became extremely drowsy and the pulserate became slower.

This was a difficult diagnostic problem. Thedramatic onset, coupled with the initial left-sidedhemiparesis, suggested a cerebral accident, a vas-cular lesion or possibly a fit. There are manycauses of listlessness and drowsiness in childhood,but paediatric advice was sought and generalcauses of the illness eliminated. On account ofher deterioration, further investigation wasnecessary.Angiography showed a complete block of the

right internal carotid artery at the intracranialbifurcation (Fig. 7). She was taken to the operat-ing theatre, and under light general anaesthesiaan extensive right lateral craniotomy performed.When the bone flap had been reflected the durawas found to be tight, containing a very full andswollen brain. When the dura was opened thebrain looked swollen, pale and ischaemic. Anadequate and extensive decompression was per-formed. The patient made an excellent recovery.She had a mild residual weakness of the left legbut walked well. There was a moderate spasticweakness of the left hand and arm, but she wasable to use the hand and arm for everythingexcept fine movements. The child's mental stateand ability to learn were unimpaired and she hasreturned to normal schooling.

-'r.'^.

FIG. 9.-Right carotid angiogram. The lateral filmdemonstrates stretched vessels around an avascularspace-occupying lesion in the parietal area.

Ca;e No. 6Male patient, aged 37 years. This man enjoyed

good health and was leading an active business lifeuntil four days prior to admission at the GeneralInfirmary at Leeds on November 22, 1958.While climbing some steps at work he noticed hisleft leg was weak and he had to be assisted.Shortly afterwards he felt unwell and nauseated.During the next three or four days he had fluc-tuating weakness of both left limbs, in additionto headache and occasional sickness. There wasno previous history of ear trouble or of chestinfection. On examination he was apathetic andlistless, there was early papilloedema and a mildleft hemiparesis, motor and sensory. Carefulexamination of the patient revealed no source ofinfection. He had, however, a temperature aroundgg°F. The mild papilloedema, together withheadache, listlessness and vomiting suggested aspace-occupying lesion, and the lateralizing signspointed to right hemisphere involvement.

Right carotid angiography was performed underlocal anaesthesia, an initial film being taken lowin the neck to exclude the possibility of carotidocclusion. The films showed an avascular space-occupying lesion in the right parietal region, anda shift of the anterior cerebral artery from rightto left (Figs. 8 and 9). The patient was trans-ferred to the operating theatre, and an exploratoryright parietal burr hole made. Surprisingly, amoderate-sized cerebral abscess was found andevacuated; i c.c. of thorotrast contrast mediumwas inserted into the cavity to control furthertreatment (Fig. io). The abscess was successfullytreated by repeated aspiration and by antibiotics.The hemiparesis recovered completely and thepatient was discharged home perfectly fit in two

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/


FIG. io.-A post-operative film taken in the face downposition demonstrating the abscess cavity con-taining thorotrast and air.

and a half months, and he resumed his businessactivities.

SummaryThe value of cerebral angiography in neuro-

surgical emergencies is discussed. The authorsconsider that the procedure is relatively safe andmay provide much useful information, given goodco-operation between radiologist and neurologicalsurgeon.The technique and indications are described.

The importance of careful clinical assessment ofcases before proceeding to angiography is stressed.The method and its value are illustrated in sixpatients.

AcknowledgmentsWe wish to thank Mr. W. R. Henderson,

Professor N. M. Dott, Professor A. S. Johnstoneand Dr. J. M. Winn for advice during the courseof this work and the preparation of this paper.

REFERENCESI. BROADRIDGE, A. T., and LESLIE, E. V. (I958), Brit. J-

Radiol., 31, 556.2. BROWN, A. S. (19S5), Anaesthesia, 10, 346.3. RIISIIEDE, J. (I957), Acta psychiat. scand., Suppl. II8, Vol. 32.4. ROB, C., (I959) Proc. roy. Soc. Med., 52, 549.

ENDOCRINE TUMOURS(Postgraduate Medical Journal, March 1960)

Price 6s. 6d. post free

ISLET-CELL TUMOURS AND PEPTIC VIRILIZING SYNDROMESULCERATION Ivor H. Mills, Ph.D., M.D., M.R.C.P.James B. Gibson, M.D., M.R.C.P.(Edin.), andRichard B. Welbourn, M.A., M.D.(Camb.), BILATERAL POLYCYSTIC OVARIESF.R.C.S. David Ferriman, D.M., M.R.C.P.

ISLET-CELL TUMOUR OF THE PANCREAS, FEMINIZING TUMOURS OF THE TESTISWITH HYPOGLYCAEMIARobert S. Monro, F.R.C.S. P. Paton Philip, M.Chir., F.R.C.S.

PHAEOCHROMOCYTOMA CONN'S SYNDROMEJ. T. Wright, D.M., M.R.C.P. T. M. Chalmers, M.D., M.R.C.P.

Published by

THE FELLOWSHIP OF POSTGRADUATE MEDICINE

60, Portland Place, London, W.1

copyright. on O


http://pmj.bm

j.com/

Postgrad M


ownloaded from

http://pmj.bmj.com/

CEREBRAL ANGIOGRAPHY IN NEUROSURGICAL · Cerebral angiography has established itself as a valuable...

Documents

Transcript of CEREBRAL ANGIOGRAPHY IN NEUROSURGICAL · Cerebral angiography has established itself as a valuable...