Interactive Transcript
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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.
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