Claude Manelfe 1

Maurice Ducos de Lahitte2

Jean-Pierre Marc-Vergnes2

Andre Rascol 3

Alain Bonafe 1

Bernard Guiraud3

Evan Chambers 1

Received June 10, 198 1 ; accepted after revi­sion November 3 0 , 1981 .

Presented at the annual meeting of the Ameri­can Society of Neuroradiology, Los Angeles, March 1980.

1 Department of Neuroradiology, Centre Hos­pitalier Universitaire de Purpan, 3 1059 Toulouse Cedex, France. Address reprint requests to C. Manelfe.

2 National Institu te of Health and Medical Re­search (INSERM , U. 230) , Centre Hospitalier Univ­ersi taire de Purpan, 3 1059 Toulouse Cedex, France.

3 Department of Neuro logy, Centre Hospitalier Universitaire de Purpan, 3 1059 Toulouse Cedex, France.

AJNR 3 :287-293, May/ June 1982 0 195- 6 108 / 82 / 0303- 0287 $ 00.00 © American Roentgen Ray Society

28 7

Investigation of Extracranial Cerebral Arteries by Intravenous Angiography: Report of 1,000 Cases

Intravenous angiography is a safe , rapid , simple examination , which , with sonogra­phy, is complementary in selecting patients for conventional angiography. This exam­ination is not designed to replace conventional angiography, but, rather , to study high­risk stroke patients, patients with asymptomatic cervical bruit, or postoperative pa­tients. Improvements in contrast media , film subtraction , the use of oral anesthesia with viscous lidocaine, and the technique of cooling the contrast medium have made the procedure more successful. A review of 1,000 examinations was undertaken to determine the accuracy of the technique and to emphasize technical points. Excellent results, comparable to conventional angiography, were obtained in 50.3% patients and good results in 32% . Poor or uninterpretable results were obtained in 17.7% . These were secondary to either patient movement or the presence of venous reflux or stasis of contrast medium.

Despite the dynamic information provided by indirect or direct noninvasive techniques such as periorbital directional Doppler sonography , supraorbital plethysmography , ocular plethysmography , and carotid Doppler spectral analysis [1-4], accurate morphologic information is essential to eva luate and guide the treatment of patients with carotid artery atheromatous disease. Long-term follow­up examination of these patients using noninvasive technique will help us under­stand the natural history of carotid atheromatous lesions. These noninvas ive techniques should not replace angiography, but rather should help us se lect those patients that should be studied by angiography. However, the ri sks of conventional angiography of the great vessels of the neck frequently prevent the radiologist from using thi s examination in the investigati on of high-risk patients or patients with asymptomatic cervi cal bruit.

Intravenous angiography was first used for imaging the pulmonary vessels , the chambers of the heart, and the aorti c arch [5 , 6] . However, the poor contrast medium opacification obtained at the level of the main supraaorti c vessels and the rapid development of catheter techniques rapidly supplanted thi s method [7].

Improvements in contrast media and in radiologic imaging (subtracti on) allowed us to reactivate intravenous angiography in our institution in 1977 . Preliminary reports have emphasized the usefulness of thi s method in the evaluation of atheroscleroti c lesions of the supraaorti c vesse ls [8-1 0 ].

Our experience is based on 1,000 examinations to date. The purpose of this study is to present the current status of thi s technique and to emphasize some technical details .

Materials and Methods

Between June 1977 and February 1980, 1 ,000 patien ts (680 men and 320 women) were examined by intravenous angiography. They were 26-93 years old (mean, 62 years).

288 MANELFE ET AL. AJNR:3, May / June 1982

The examination was performed in patients with clinical symptoms of a stenotic or occlusive lesion of the great vessels. These included permanent or regressive stroke, transient ischemic attack, verte­brobasilar insufficiency, and cervical bruit. High-risk patients and postoperative controls were also included in this series. About 25% of the patients were ambulatory.

No patients requ ired general anesthesia or premedication . The only preprocedure orders were: (1) the patient should be fasting for at least 4-6 hr before examination and (2) adequate hydration should be maintained .

Percutaneous catheterization of the brachial or antecubital vein is performed with a Teflon needle (14 or 16 gauge Cathlon catheter). The femoral vein can also be used when the arm veins cannot be catheterized or when there is a marked jugular venous reflux. Arm to tongue circulation time is measured by injecting 3-5 ml of sodium dehydrocholate (Dycholium , Laboratoire Theraplix, Paris, France) through the needle in 1 sec . Circulation time (time between the

Contrast In i.

f Time 0

Filming (l / sec.)

Mask V i I ,/,

Circulation Time (sec.) End

Fig. 1 .-Contrast injection begins at time O. Radiographic seri es begins at one-half the measured circulation time at a rate of one film / sec during 8 sec.

A 8

injection and the first manifestation of a bitter taste at the base of the tongue) usually is 10-20 sec and tends to increase with age and in patients with mitral disease. Dycholium should not be used in patients with hepatobiliary disease. Next, 5 ml of 1 % viscous Xylocain (Laboratoire Roger Bellon, Neuilly, France) is administered orally to the patient. Xylocain induces local anesthesia at the base of the tongue and prevents the burning sensation produced by the contrast medium; local anesthesia lasts 1 -3 hr and does not pre­clude oral feeding afterward since the gag reflex is preserved .

An automatic pneumatic injector with two syringes (Caillon 602 V.D. , Medical France, Merignac, France) is used to inject 1 ml / kg body weight loxatalamate (Laboratoire Guerbet, Aulnay Sous Bois, France) (38 g iodine/ 100 ml; 2,100 mosmol / kg at 3rC) in 3-4 sec . The contrast medium is cooled and injected at a temperature of 10°-15°C.

Injection of the contrast medium begins at time 0 (fig. 1). A 50 ml macromolecular solution , or Dextran , is injected immediately after the contrast medium via the second syringe of the pneumatic injector. Saline or 5% dextrose can be used but it is less adequate .

Two radiographic series are then performed: one in the antero­posterior (AP) projection and the other in the right posterior oblique. A third projection, left posterior oblique, may also be necessary if the two previous projections are inadequate. The x-ray beam is centered on the thyroid cart ilage and the focus-film distance is 1 m as in conventional angiography . The patient is instructed to suspend his respiration 2-3 sec before the beginning of the radiographic series. A first film (mask) is exposed for subtraction at this time. A series consisting of eight films at a rate of one film / sec begins at

Fig . 2.-lntravenous angiogram. Anteroposterior (A) and right posterior oblique (8) projections. Su­praaortic vessels well demonstrated from origin to polygon of Willis. Internal ca rotid arteri es and si­phons (c losed arrows). Vertebral and basilar arteri es (open arrows).

AJNR :May/ June 1982 INTRAVENOUS ANGIOGRAPHY OF CEREBRAL ARTERIES 289

A 8 Fig . 3. -lnlravenous angiogram, right posterior

oblique projection . Normal appearance of inlernal, ex ternal, vertebra l, and basilar arteri es from upper ce rvica l reg ion to polygon of Willi s. Prox imal pari of intracranial branches fa irly well seen.

Fig. 4 .- 58-year-old hypertensive woman wi th gait disturbances, lefl hemiparesis, and lefl regressive visual loss. A, Intravenous angiogram, anteroposlerior projeclion . Occlusion of left common carotid artery with revascu larizati on of left external carot id arte ry (closed arrow) by muscular anastomoses o f ascending cervical arlery. Tight stenosis at origin 01 lefl vertebral artery (open arrow) associated with stenosis of adjacent part of subc lavian artery; ulcerated plaque o f right carot id bifurcation (arrowhead). S, Aortic arch via right ax illary catheterizat ion. Stump of occ luded left common carot id artery (short

closed arrow) may appear because of higher aortic arch pressure at aortography.

half of the circulation time after the injection of contrast. Our standard exposure factors are 65 kVp , 500 mA, and 0.25 sec. We use Kodak Lanex regular screens, 35 x 35 cm Kodak ortho G films for exposure, and Dupont de Nemours subtraction print films. The examination lasts about 20 min . The only postexamination order is that adequate hydration of the patient should be maintained.

Results

We classified the results into four groups: (1) excellent, (2) good , (3) poor, and (4) uninterpretable.

Excellent results were obtained in 503 patients (50.3%) demonstrating the upper part of the aortic arch, both prox­imal subclavian arteries, the brachiocephalic artery, the common, internal, and external carotid arteries, and the vertebral arteries from their origin to the base of the skull (fig . 2). The intracranial part of the internal carotid arteries and vertebrobasilar system up to the polygon of Willis were demonstrated in 25% of these cases (Fig. 3). These images are nearly comparable with those obtained by arch aortog­raphy (Fig. 4).

Good results were obtained in 320 patients (32%). The origin of the vertebral artery on the ipsilateral side of the injection was usually partialy masked by venous stasis of the contrast medium. (fig . 5) .

Poor results were seen in 125 cases (12 .5%). The rea­sons for these results included reflux into or stasis of con­trast medium in the external or internal jugular vein obscur­ing part of the origin of the arteries of interest and patient movement (swallowing) preventing adequate subtraction.

Uninterpretable results were noted in 52 cases (5.2 %). These results were secondary to severe venous reflux and stasis in the neck that subsequently obscured the main arteries.

Discussion

Intravenous angiography is a safe, simple, rapid method for screening vascular lesions of the supraaortic vessels . Lesions such as arterial stenosis , occlusion, or subc lavian steal syndrome can be diagnosed with an accuracy com­parable to arch aortography (Figs . 4, 6 , and 7).

Intravenous angiography represents the bridge between the noninvasive techniques (direct and / or indirect) [1-4] and conventional angiography. There are advantages and disadvantages of the noninvasive sonographic techniques, conventional angiography, and intravenous angiography in the evaluation of vascular lesions of the supraaortic vessels.

The distinct advantages of intravenous angiography over

290 MANELFE ET AL. AJNR :3. May / June 1982

Fig. 5.- 65-year-old woman with bilateral cervi­cal bru it. Righ t posteri or oblique projecti on. Mod­erate venous stasis obscures orig in o f ri ght ve rt ebral art ery (long arrow). No significant atheromatous le­sion of supraaorti c vesse ls but arterial wall changes on both vertebral arteries resemble fibromuscular dysplasia (short arrows).

conventjonal ang iography include: (1) the ri sks of arch aortography are reduced; (2) patients can be examined on an outpatient basis (2 5% of patients in our series were ambulatory) ; (3) the examination is simpler, time-saving, less costly, and can be easily repeated if necessary; (4) the number of conventional angiographic procedures performed as a " first order" diag nostic tool is reduced; and (5) intra­venous angiography can be combined with computed to­mography (CT) to carry out a complete evaluation of patients with cerebrovascular disease (i .e ., examination of the brain parenchyma).

The primary advantage of intravenous angiography over sonog raphy is that it provides more accurate morphologic information of the great vesse ls from their origin to their penetration into the skull. This is particularly the case for the vertebral arteri es, which are poorly investigated wi th sonog raphy. When extensive atheromatous disease is sus­pected. intravenous angiography can provide in the same session screening of the lesions not only of the major cerebral arteries but also of the aorta (fig . 8). In our institu-

tion, intravenous angiography and sonography are consid­ered to be complementary and aid us in the selection of patients for conventional angiography.

The main indications for intravenous angiography are similar to those proposed by Ackerman [2] for noninvasive diagnostic procedures: (1) high-risk patients presenting with transient ischemic attacks, minor deficit from a recent stroke, or good neurologic recovery from a completed stroke; (2) patients with asymptomatic cervical bruit ; (3) patients with asymptomatic cervical bruits who will be un­dergoing extensive surgery with possible intraoperative hy­potension; (4) patients with signs or symptoms that are equivocal for carotid or vertebral arterial disease; (5) post­operative controls after supraaortic vascular surgery (ca­rotid, subclavian , vertebral) , even if the patients are anticoa­gulated (fig . 7); and (6) follow-up of patients presenting with early hemodynamic changes or with scan evidence of ath­eroma.

Our successful examinations (82.3%) resulted from good techniques , including film subtraction. Cooperation of the patient (i .e ., apnea and immobility during filming) is essen­tial. Two technical details aid the patient in remaining im­mobile during seriography . These are: (1) use of oral anes­thesia with viscous lidocaine and (2) cooling of the contrast medium. The use of local anesthes ia at the base of the tongue prevents the burning sensation caused by the rapid intravenous injection of contrast medium , and it will also inhibit coughing . The anesthesia lasts 1-3 hr and does not prec lude oral feeding afterward since the gag reflex is preserved. The cough ing and burning sensations are also suppressed, or decreased, by cooling the contrast medium to 10°-15 °C. Cooling increases the viscosity of the contrast medium and, thus, improves the bolus effect. At 30°C, the viscosity of the contrast medium (sodium meg lumine ioxital­amate) is 15.4 centipoises; at 20°C, it is 17 centipoises; and at 10°C, it is 17.7 centipoises. As the temperature of the contrast material decreases , ionic dissociation of sodium sa lts diminishes. This, in turn , decreases the osmolality , thereby improving the patient's tolerance of the contrast medium [11]. Dilution of contrast medium is decreased when macromo lecular solution is used to flush the contrast instead of sa line or dextrose . Dextran so lution has a higher viscosity (6 centipoises) ; this provides a better bolus effect and reduces the time of contact between the hyperosmolar contrast and the venous wall , thereby improving patient tolerance.

Poor or un interpretable results in 17.7% of patients were secondary to the two main disadvantages of intravenous angiography. These are : (1) stasis or reflu x of contrast medium in the cervi cal veins on the ipsilateral side of injec­tion and (2) the necessity of using film subtraction in pati ents who may be moving. Venous stasis may mask part of the cervical arteries, primarily near the orig in of the right verte­bra l artery . The stasis , usually in the jugular or, less fre­quently, the innominate or subc lavian vein, may be transient. It may be present on one series and absent on the next ; thi s is probably rel ated to the rotation of the head (fig . 9) . Injection of the contrast medium either by the femoral vein route or by catheterization of the superior vena cava by the

AJNR :May / June 1982 INTRAVENOUS ANGIOGRAPHY OF CEREBRAL ARTERIES 29 1

A B Fig . 5.-Atheromatous carotid lesions on intravenous angiography. A,

Ulcerated plaque on left internal ca rotid artery (arrow) . B, Carotid stenosis

Fig . 7.- 42-year-old woman with vertebrobas ilar insufficiency. A, Preoperative intravenous angio­gram. Severe annular stenosis of proximal left sub­c lavian artery (arrow). B, Postoperati ve intravenous angiogram 1 year after endarterectomy. Normal fill­ing of left vertebral artery (arrow) .

A

brachial vein [12, 13] is indicated if the venous stasis is severe on the ipsilateral side of the injection on the first series. Slight compression of the external jugular vein with an adhesive tape transversely across the neck is used when reflux or stasis is present there.

c (arrow). C, Carotid occlusion (solid arrow). Ulcerated plaques on left carol id bifurcation (open arrows).

B

Fifty examinations were also performed wi th Hexabrix (Laboratoire Guerbet, Aulnay Sous Bois, France) (32 g iodine / 100 ml), a new hexaiod ized contrast medi um . There was no, or decreased , burning sensation, coughing, and nausea with Hexabri x, probably related to the lower osmo-

292 MANELFE ET AL. AJNR: 3, May / June 1982

A 8

A 8 Fig. 9 .- 65-year-old man with left asymptomatic cervica l bruit. Orig in o f

right vert ebral artery masked by venous reflux into jugular vein (solid arrows) on anteroposterior (A) and rig ht posterior oblique (B) views, but absent on

Fig. 8. - 85-year-old woman with right regressive hemiparesis, abdominal brui t, and severe arterio­pathy of the inferior limbs. A, Intravenous angio­gram, right posterior oblique project ion. Calcif ied atheromatous plaque on left intern al carotid artery (solid arrow) and severe stenosis near right ca rotid bifurcat ion (open arrows). No visualizati on of left vertebral artery. B, Abdominal aorta in same ses­sion. Severe atheromatous lesions of infrarenal aorta.

c left posterior oblique view (C). Stenosis at orig in o f left external ca rotid artery in A and B (open arrows ).

AJNR:May/ June 1982 INTRAVENOUS ANGIOGRAPHY OF CEREBRAL ARTERIES 293

lality (600 mosmol / kg at 3rC). Therefore, excellent sub­traction can be obtained . However, because of its lower iodine content, higher doses (2 ml/ kg) of Hexabrix have to be used to obtain good arterial opacificat ion .

Patient tolerance of intravenous angiography is generally excellent. Minor complications, such as extravasation and venous rupture during contrast injection , were observed in less than 2% of cases (18 patients). There have been no serious complications, including renal injury, since our pre­vious report [10].

Both intravenous angiography and sonography are con­sidered to be complementary and are useful for selecting vascular patients for conventional angiography of the great vessels of the neck. Intravenous angiography provides more accurate morphologic assessment of the great vessels than sonography and it is better tolerated than conventional angiography in high-risk patients. Neither intravenous an­giography nor sonography can replace conventional angiog­raphy, but, with the development of newer techniques of digital subtraction angiography [1 2-14], there may be fewer indications for performing conventional angiography. Our technique of intravenous angiography should be considered as an intermediary technique between conventional and digital angiography. However, the techniques of contrast injection and computer subtraction still have to be mastered.

ACKNOWLEDGMENT

We thank the technicians of the Department of Neuroradiology (Serge Arnaud, Roger Barthe, Marie-Jeanne Carcy, and Claudine Cassan) for their assistance, Jacqueline Pons for iconography , and Janine Gallien for typing the manuscript.

REFERENCES

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2. Ackerman RH. A perspective on noninvasive diagnosis of ca­rotid disease. Neurology (NY) 1979;29: 615-622

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5. Robb GP, Steinberg I. Visualiza tion of the chambers of the heart , the pulmonary c irculation and the great blood vessels in man. AJR 1939;41 : 1-17

6. Viallet P, Sendra L, Chevrot L, Aubry P, Combe P. Angiocar­diopneumographie elarg ie. Methode d 'opacification vasculaire generale par voie veineuse. Paris: Masson, 1959

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8 . Marc-Vergnes JP, Ducos de Lahitte M, Rascol A, Guiraud B, Manelfe C. Non-invasive assessment of extrac ranial arterial lesions by intravenous angiography. In Meyer JS, Lechner H, Reivich R, eds. Cerebral vascular disease 2, proceedings of the 9th International Salzburg Conference. Amsterdam: Ex­cerpta Med , 1979:88-89

9 . Rascol A, Ducos de Lahitte M, Manelfe C, Guiraud B, Marc­Vergnes JP. Nouveaux resultats et apport de I'ang iog raphie par voie veineuse dans I'exploration des segments exocraniens des arteres cerebrales. In Bes A, Geraud G. Circulation cere­brale. Toulouse: Imprimerie Fournie, 1980 : 251-253

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12. Kruger RA, Mistretta CA, Houk TL, et al. Computeri zed fluor­oscopy in real time fo r noninvasive visualization of the cardio­vascular system . Preliminary studies . Radiology 1979;13: 49-57

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14. Christenson PC, Ovitt TI '" Fisher HD III , Frost MM , Nudelman S, Roehring H. Intravenous angiog raphy using digital video subtraction : intravenous cervicocerebrovascular angiography. AJNR 1980;1 :379- 386