bhargavi
Guru
- Messages
- 161
- Location
- Middletown, DE
Diagnostic Cerebral and Spinal Angiography
Pre Procedure Diagnosis: Spinal cord congestion
Post Procedure Diagnosis: Spinal Dural Arteriovenous Fistula
Attention was turned back to the right common femoral artery. Dr. S. interventional cardiologist and head of the Cath Lab assisted me in obtaining access to the right common femoral artery. A 5 french sheath was placed and connected to a continuous heparinized flush. 3000 units IV Heparin given as per protocol.
Counting from above there are 7 cervical vertebral bodies, there are 12 rib bearing thoracic vertebral bodies and 5 lumbar vertebral bodies. Next a 5 French 65 cm cobra C2 diagnostic catheter was inserted over guidewires.
Using standard neuro angiographic protocols diagnostic cerebral angiography commenced as follows:
Right Internal Carotid Artery (RICA)
Injection of the right internal carotid artery was performed in AP and a lateral whole head views. This demonstrated a normal course and caliber of the visualized right internal carotid artery. The right ophthalmic artery is identified. The right middle cerebral artery is identified, the right and left anterior cerebral arteries are identified and the right posterior communicating artery is identified. The right anterior choroidal artery is identified. There is no evidence of aneurysm, AVM, dural fistula, nor shunting lesion. Venous drainage is normal.
Right Occipital Artery
Selective injection of the right occipital artery was performed in AP and lateral whole head views. The occipital artery on the right come off the proximal right ICA. Injection demonstrated a normal course and caliber of the right occipital artery. No shunting is observed. There is some reflux seen into the right ICA. Venous drainage is normal.
Right External Carotid Artery (RECA)
Injection of the right external carotid artery was performed in AP and lateral whole head views. This demonstrated normal course and caliber of the right external carotid artery. No shunting is observed. Venous drainage is normal.
Right Vertebral Artery (RVA)-Cervical
Injection of the right vertebral artery was performed in the cervical plane. The vessel is diminutive, as it courses superiorly, there is no evidence of vessel damage. No shunting is seen, multiple muscular branches are identified.
Right Vertebral Artery (RVA)-Intracranial
Injection of the right vertebral artery was performed with visualization of the intracranial circulation in AP and lateral planes. The right vertebral artery ends in the right PICA. No aneurysm or shunting lesion observed. Venous drainage is normal.
Right Costocervical artery
Injection of the right costocervical trunk was performed in AP views. This demonstrated normal course and caliber of the right Costocervical trunk and its associated arteries. No shunting observed.
Right Thyrocervical artery
Injection of the right thyrocervical trunk was performed in AP views. This demonstrated normal course and caliber of the right thyrocervical trunk and its associated arteries. No shunting observed.
Left Common Carotid Artery (LCCA)-Cerebral
Injection of the Left common carotid artery was performed in AP and lateral whole head cerebral views. These demonstrated a normal course and caliber of the left common carotid artery, the proximal left internal carotid artery and the proximal left external carotid artery. There is no evidence of significant flow-limiting stenosis. Visualized branches of the left external carotid artery are normal, no shunting is observed. The left internal carotid artery is normal as it courses superiorly, there is no evidence of vessel damage or flow-limiting stenosis. The left middle cerebral artery, left anterior cerebral artery, and left posterior communicating artery are all identified. There is no evidence of aneurysm, AVM, dural fistula, or a shunting lesion. Venous drainage is normal.
Left Vertebral Artery (LVA)-Intracranial
Injection of the left vertebral artery was performed with visualization of the intracranial circulation in AP and lateral planes. The visualized portions of the cervical left vertebral artery are normal. The left vertebral arteries V3 and V4 segments are noted to be normal without any evidence of flow-limiting stenosis. The basilar artery is observed and is patent. Bilateral superior cerebellar arteries are identified, there is a duplication on the left. Bilateral posterior cerebral arteries are identified. The left PICA opacifies. There is no evidence of aneurysm, AVM, dural fistula, no shunting lesion. Venous drainage is normal.
Left Subclavian Artery-Cervical view
Injection of the left subclavian artery was performed in the cervical plane. The left subclavian artery is normal. The proximal left vertebral artery is visualized. There is no flow limiting stenosis at the origin of the left vertebral artery. The left thyrocervical and costocervical trunks and their associated vessels are opacified. There is no evidence of a shunting lesion.
Thoracic aortogram
A pigtail catheter was placed at the T3 level. An aortogram was performed. This was of low quality, however one can see opacification of multiple thoracic segmental and radicular arteries. No evidence of shunting is observed.
Thoracic Aortogram
A pigtail catheter was placed at the T6/7 level and an Aortogram was performed. This was of low quality, however one can see opacification of multiple thoracic segmental and radicular arteries. No evidence of shunting is observed.
Thoracic aortogram
A pigtail catheter was placed in the mid thoracic aorta. Aortogram was performed. This was of low quality, however 1 can see opacification of multiple thoracic segments on radicular arteries. No evidence of shunting is observed.
Right common iliac artery-Distal
Distal injection of the right common iliac artery demonstrates opacification of the median sacral artery. There is no direct shunt seen however, there is early venous drainage noted with a large arterialized spinal vein seen coursing superiorly towards the middle of the run.
L4 segmental artery-common trunk
Injection of the ostium of the L4 bilateral radicular arteries was performed. There appears to be a common trunk to both the right and left segmental arteries at the L4 level. This showed opacification of the right and left L4 segmental and intercostal arteries. There is no evidence of shunting.
L3 segmental artery-common trunk
Injection of the ostium of the L3 bilateral radicular arteries was performed. There appears to be a common trunk to both the right and left segmental arteries at the L3 level. The force of the injection pushed the catheter out of the ostium however there is opacification of the right and left L3 segmental and intercostal arteries. There is flash filling of the L2 level above and L4 level below, with bilateral segmental intercostal arterial opacification. There is no evidence of shunting.
L2 segmental artery-common trunk
Injection of the ostium of the L2 bilateral radicular arteries was performed. There appears to be a common trunk to both the right and left segmental arteries at the L2 level. The force of the injection pushed the catheter out of the ostium however there is opacification of the right and left L2 segmental and intercostal arteries. There is flash filling of the L1 level above and L3 and L4 level below, with bilateral segmental intercostal arterial opacification. There is no evidence of shunting.
Right renal artery
Injection right renal artery demonstrated no evidence of shunting, with normal proximal renal artery arterial anatomy.
Right common iliac artery-proximal
Proximal injection of the right common iliac artery, using a 5 french 65cm Mickelson catheter demonstrates opacification of there right internal iliac artery. There is a midline shunting lesion seen being fed via the left lateral sacral artery. There is early venous opacification of a radiculomedullary vein at the region of the low sacum. There is swift flow superiorly via arterialized spinal veins.
Right internal illiac artery
Proximal injection of the right common iliac artery, using a 5 french 65cm Mickelson catheter demonstrates opacification of there right internal iliac artery. There is a midline shunting lesion seen being fed via the left lateral sacral artery. There is early venous opacification of a radiculomedullary vein at the region of the low sacum. There is swift flow superiorly via arterialized spinal veins.
Multiple injections were then performed from the same right internal iliac artery with visualization of the thoracic and cervical region. These demonstrated a large diffuse arterialized venous network that courses superiorly ending in the cervical region consistent with arterialization of radiculomedullary and spinal veins.
Spinal supply was not observed on this angiographic study. Given the patient's renal impairment we had reached the primary number for this procedure and it was then concluded.
Right Common Femoral Artery
Injection of the right common femoral artery demonstrates a puncture site above the bifurcation. No evidence of vessel damage. This injection also opacified the right internal iliac artery with visualization of the above described fistula.
IMPRESSION:
1- A shunting lesion was identified. This is angiographically consistent with a spinal dural AV fistula of the Sacral region with extensive ascending perimedullary venous drainage. The main arterial supply is from the right lateral sacral artery. There is early venous filling of an adjacent radiculomedullary vein with noted arterialization of spinal veins as they course superiorly.
Pre Procedure Diagnosis: Spinal cord congestion
Post Procedure Diagnosis: Spinal Dural Arteriovenous Fistula
Attention was turned back to the right common femoral artery. Dr. S. interventional cardiologist and head of the Cath Lab assisted me in obtaining access to the right common femoral artery. A 5 french sheath was placed and connected to a continuous heparinized flush. 3000 units IV Heparin given as per protocol.
Counting from above there are 7 cervical vertebral bodies, there are 12 rib bearing thoracic vertebral bodies and 5 lumbar vertebral bodies. Next a 5 French 65 cm cobra C2 diagnostic catheter was inserted over guidewires.
Using standard neuro angiographic protocols diagnostic cerebral angiography commenced as follows:
Right Internal Carotid Artery (RICA)
Injection of the right internal carotid artery was performed in AP and a lateral whole head views. This demonstrated a normal course and caliber of the visualized right internal carotid artery. The right ophthalmic artery is identified. The right middle cerebral artery is identified, the right and left anterior cerebral arteries are identified and the right posterior communicating artery is identified. The right anterior choroidal artery is identified. There is no evidence of aneurysm, AVM, dural fistula, nor shunting lesion. Venous drainage is normal.
Right Occipital Artery
Selective injection of the right occipital artery was performed in AP and lateral whole head views. The occipital artery on the right come off the proximal right ICA. Injection demonstrated a normal course and caliber of the right occipital artery. No shunting is observed. There is some reflux seen into the right ICA. Venous drainage is normal.
Right External Carotid Artery (RECA)
Injection of the right external carotid artery was performed in AP and lateral whole head views. This demonstrated normal course and caliber of the right external carotid artery. No shunting is observed. Venous drainage is normal.
Right Vertebral Artery (RVA)-Cervical
Injection of the right vertebral artery was performed in the cervical plane. The vessel is diminutive, as it courses superiorly, there is no evidence of vessel damage. No shunting is seen, multiple muscular branches are identified.
Right Vertebral Artery (RVA)-Intracranial
Injection of the right vertebral artery was performed with visualization of the intracranial circulation in AP and lateral planes. The right vertebral artery ends in the right PICA. No aneurysm or shunting lesion observed. Venous drainage is normal.
Right Costocervical artery
Injection of the right costocervical trunk was performed in AP views. This demonstrated normal course and caliber of the right Costocervical trunk and its associated arteries. No shunting observed.
Right Thyrocervical artery
Injection of the right thyrocervical trunk was performed in AP views. This demonstrated normal course and caliber of the right thyrocervical trunk and its associated arteries. No shunting observed.
Left Common Carotid Artery (LCCA)-Cerebral
Injection of the Left common carotid artery was performed in AP and lateral whole head cerebral views. These demonstrated a normal course and caliber of the left common carotid artery, the proximal left internal carotid artery and the proximal left external carotid artery. There is no evidence of significant flow-limiting stenosis. Visualized branches of the left external carotid artery are normal, no shunting is observed. The left internal carotid artery is normal as it courses superiorly, there is no evidence of vessel damage or flow-limiting stenosis. The left middle cerebral artery, left anterior cerebral artery, and left posterior communicating artery are all identified. There is no evidence of aneurysm, AVM, dural fistula, or a shunting lesion. Venous drainage is normal.
Left Vertebral Artery (LVA)-Intracranial
Injection of the left vertebral artery was performed with visualization of the intracranial circulation in AP and lateral planes. The visualized portions of the cervical left vertebral artery are normal. The left vertebral arteries V3 and V4 segments are noted to be normal without any evidence of flow-limiting stenosis. The basilar artery is observed and is patent. Bilateral superior cerebellar arteries are identified, there is a duplication on the left. Bilateral posterior cerebral arteries are identified. The left PICA opacifies. There is no evidence of aneurysm, AVM, dural fistula, no shunting lesion. Venous drainage is normal.
Left Subclavian Artery-Cervical view
Injection of the left subclavian artery was performed in the cervical plane. The left subclavian artery is normal. The proximal left vertebral artery is visualized. There is no flow limiting stenosis at the origin of the left vertebral artery. The left thyrocervical and costocervical trunks and their associated vessels are opacified. There is no evidence of a shunting lesion.
Thoracic aortogram
A pigtail catheter was placed at the T3 level. An aortogram was performed. This was of low quality, however one can see opacification of multiple thoracic segmental and radicular arteries. No evidence of shunting is observed.
Thoracic Aortogram
A pigtail catheter was placed at the T6/7 level and an Aortogram was performed. This was of low quality, however one can see opacification of multiple thoracic segmental and radicular arteries. No evidence of shunting is observed.
Thoracic aortogram
A pigtail catheter was placed in the mid thoracic aorta. Aortogram was performed. This was of low quality, however 1 can see opacification of multiple thoracic segments on radicular arteries. No evidence of shunting is observed.
Right common iliac artery-Distal
Distal injection of the right common iliac artery demonstrates opacification of the median sacral artery. There is no direct shunt seen however, there is early venous drainage noted with a large arterialized spinal vein seen coursing superiorly towards the middle of the run.
L4 segmental artery-common trunk
Injection of the ostium of the L4 bilateral radicular arteries was performed. There appears to be a common trunk to both the right and left segmental arteries at the L4 level. This showed opacification of the right and left L4 segmental and intercostal arteries. There is no evidence of shunting.
L3 segmental artery-common trunk
Injection of the ostium of the L3 bilateral radicular arteries was performed. There appears to be a common trunk to both the right and left segmental arteries at the L3 level. The force of the injection pushed the catheter out of the ostium however there is opacification of the right and left L3 segmental and intercostal arteries. There is flash filling of the L2 level above and L4 level below, with bilateral segmental intercostal arterial opacification. There is no evidence of shunting.
L2 segmental artery-common trunk
Injection of the ostium of the L2 bilateral radicular arteries was performed. There appears to be a common trunk to both the right and left segmental arteries at the L2 level. The force of the injection pushed the catheter out of the ostium however there is opacification of the right and left L2 segmental and intercostal arteries. There is flash filling of the L1 level above and L3 and L4 level below, with bilateral segmental intercostal arterial opacification. There is no evidence of shunting.
Right renal artery
Injection right renal artery demonstrated no evidence of shunting, with normal proximal renal artery arterial anatomy.
Right common iliac artery-proximal
Proximal injection of the right common iliac artery, using a 5 french 65cm Mickelson catheter demonstrates opacification of there right internal iliac artery. There is a midline shunting lesion seen being fed via the left lateral sacral artery. There is early venous opacification of a radiculomedullary vein at the region of the low sacum. There is swift flow superiorly via arterialized spinal veins.
Right internal illiac artery
Proximal injection of the right common iliac artery, using a 5 french 65cm Mickelson catheter demonstrates opacification of there right internal iliac artery. There is a midline shunting lesion seen being fed via the left lateral sacral artery. There is early venous opacification of a radiculomedullary vein at the region of the low sacum. There is swift flow superiorly via arterialized spinal veins.
Multiple injections were then performed from the same right internal iliac artery with visualization of the thoracic and cervical region. These demonstrated a large diffuse arterialized venous network that courses superiorly ending in the cervical region consistent with arterialization of radiculomedullary and spinal veins.
Spinal supply was not observed on this angiographic study. Given the patient's renal impairment we had reached the primary number for this procedure and it was then concluded.
Right Common Femoral Artery
Injection of the right common femoral artery demonstrates a puncture site above the bifurcation. No evidence of vessel damage. This injection also opacified the right internal iliac artery with visualization of the above described fistula.
IMPRESSION:
1- A shunting lesion was identified. This is angiographically consistent with a spinal dural AV fistula of the Sacral region with extensive ascending perimedullary venous drainage. The main arterial supply is from the right lateral sacral artery. There is early venous filling of an adjacent radiculomedullary vein with noted arterialization of spinal veins as they course superiorly.