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Arteriographic Evaluation of Dissection

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I would say that modern CTA and MRA evaluation of the neck

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and intracranial vasculature is so good that it's pretty

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rare that we would require performance of a conventional

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arteriogram for diagnosis of dissection or

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diagnosis of pseudoaneurysms.

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However,

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arteriograms are performed as part of the therapeutic

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decision-making with regard to aneurysms

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or with regard to dissections.

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This patient did get an arteriogram

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after the motor vehicle collision,

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having demonstrated a dissection of

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the left vertebral artery. The arteriogram,

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which was performed with selective catheterization

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of the blood vessels to the neck and brain,

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demonstrates an area of enlargement and widening

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and irregularity in the left vertebral artery

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on the selective injection.

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If we look at some of the characteristics of the vessels,

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we can see on the affected side that there

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is ballooning out of the vascular lumen.

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Depending upon how irregular that ballooning out

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is and how distorted the vascular lumen is,

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the interventionalist will decide whether or not the

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patient is a good candidate for stenting or not.

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As I said,

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if this is a source for emboli

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leading to stroke intracranially,

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it's more likely that it will be treated urgently with

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stenting as opposed to administering medical therapy which

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is generally in the form of antiplatelet drugs.

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Let me show a couple of the three-dimensional

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reconstructions of the pseudoaneurysm and dissection.

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So here on this three-dimensional color-coded examination,

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one can see the irregularity to the proximal lumen of the

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blood vessel and then the ballooning out of the vessel into

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the pseudoaneurysm, with small areas of irregularity that

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could potentially be the source for

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future stroke with clot formation.

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In this example,

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we have the blood vessel again,

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laid out nicely with the small area of luminal narrowing

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proximal to the pseudoaneurysm.

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And coming out of the pseudoaneurysm,

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you see that there is

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some luminal narrowing compared to the more

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normal luminal diameter, more distally.

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And these are nicely demonstrated with

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the underlying anatomy of the bone,

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both in the lateral view, as well as the AP view.

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This just gives you a little bit better sense of the degree

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of narrowing proximal to the pseudoaneurysm.

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In this case,

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the patient had demonstrated normal flow to the distal

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vessels of the vertebral basal artery circulation,

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with no evidence of clots.

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And yet, despite that small stroke

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that the patient incurred

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in the far lateral left cerebellum,

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the decision was made not to stent this patient,

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but to treat the patient medically.

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This patient did very well on medical therapy.

Report

Description

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Vascular Imaging

Vascular

Trauma

Neuroradiology

Interventional

Head and Neck

Fluoroscopy

Emergency

Carotid Space

CT

Brain

Angiography

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