0:00

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

0:06

and intracranial vasculature is so good that it's pretty

0:10

rare that we would require performance of a conventional

0:14

arteriogram for diagnosis of dissection or

0:18

diagnosis of pseudoaneurysms.

0:20

However,

0:21

arteriograms are performed as part of the therapeutic

0:25

decision-making with regard to aneurysms

0:28

or with regard to dissections.

0:31

This patient did get an arteriogram

0:34

after the motor vehicle collision,

0:35

having demonstrated a dissection of

0:39

the left vertebral artery. The arteriogram,

0:42

which was performed with selective catheterization

0:45

of the blood vessels to the neck and brain,

0:48

demonstrates an area of enlargement and widening

0:52

and irregularity in the left vertebral artery

0:56

on the selective injection.

0:57

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

1:03

we can see on the affected side that there

1:08

is ballooning out of the vascular lumen.

1:12

Depending upon how irregular that ballooning out

1:15

is and how distorted the vascular lumen is,

1:19

the interventionalist will decide whether or not the

1:22

patient is a good candidate for stenting or not.

1:26

As I said,

1:27

if this is a source for emboli

1:30

leading to stroke intracranially,

1:32

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

1:36

stenting as opposed to administering medical therapy which

1:40

is generally in the form of antiplatelet drugs.

1:43

Let me show a couple of the three-dimensional

1:46

reconstructions of the pseudoaneurysm and dissection.

1:50

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

1:54

one can see the irregularity to the proximal lumen of the

1:58

blood vessel and then the ballooning out of the vessel into

2:02

the pseudoaneurysm, with small areas of irregularity that

2:06

could potentially be the source for

2:08

future stroke with clot formation.

2:11

In this example,

2:13

we have the blood vessel again,

2:16

laid out nicely with the small area of luminal narrowing

2:20

proximal to the pseudoaneurysm.

2:22

And coming out of the pseudoaneurysm,

2:24

you see that there is

2:26

some luminal narrowing compared to the more

2:28

normal luminal diameter, more distally.

2:31

And these are nicely demonstrated with

2:34

the underlying anatomy of the bone,

2:38

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

2:43

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

2:45

of narrowing proximal to the pseudoaneurysm.

2:50

In this case,

2:51

the patient had demonstrated normal flow to the distal

2:57

vessels of the vertebral basal artery circulation,

2:59

with no evidence of clots.

3:01

And yet, despite that small stroke

3:04

that the patient incurred

3:06

in the far lateral left cerebellum,

3:08

the decision was made not to stent this patient,

3:11

but to treat the patient medically.

3:13

This patient did very well on medical therapy.