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To Intracranial Arterial Anastomoses in Therapeutic Embolization: Recognition and Role

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To Intracranial Arterial Anastomoses in Therapeutic Embolization: Recognition and Role 71 Extra- to Intracranial Arterial Anastomoses in Therapeutic Embolization: Recognition and Role Hyo S. Ahn 1 Anastomoses from extra- to intracranial vessels have been shown in normal patients Charles W. Kerber and, more commonly, in patients with arteriosclerotic occlusive disease, arteriovenous Ziad L. Oeeb malformation, and postligation of the carotid artery. These channels may be of clinical importance during therapeutic embolization and probably account for two cases of complication, posterior fossa strokes that occurred after blockage of occipital arteries. By identifying these channels and then monitoring the ever-decreasing vessel accept­ ance of contrast agent and emboli, patient safety may be enhanced. In 1953, Richter [1] angiographically showed anastomoses between the occip­ ital artery and the vertebral artery in two patients with internal carotid artery thrombosis. Subsequent reports by others [2-5] demonstrated frequent exam­ ples of extraintracranial anastomoses in patients with arteriosclerotic occlusive disease and also in patients with arteriovenous malformation. In 1974, Seeger et al. [6] indicated these anastomoses could be seen to varying degrees in patients without known vascular abnormalities. They also reported [6] that visualization of these channels was sometimes entirely technique dependent. Channels may fill by a superselective approach but not by injection into the main arterial trunk. The wide acceptance of therapeutic embolization to obliterate the vascular abnormalities of head and neck makes recognition of these channels important. Our attention was forcefully drawn to this need after we caused two severe posterior fossa strokes after embolization of the occipital artery and its branches. This report reviews these extra- to intracranial anastomoses, indicates th e need for careful preembolization selective angiography, and suggests an embo­ lization technique should those channels be present. Received July 20, 1979; accepted aft er revi ­ Materials and Methods sion August 13 , 1979. Presented at the annual meeting of the Ameri­ In th e past 5 years, 3 7 patients at the University of Oregon Health Sc ience Center and can Society of Neuroradiology, Toronto, Ontario, University of Pittsburgh School of Medicine have undergone therapeutic embolizati on of May 1979. extracranial vascular abnormalities. I All authors: Department of 'Radiology, Neuro­ All patients were evaluated prior to embolization with small catheter (5 French pr small er) radiology Division, University of Pittsburgh School superselective' angiography. Primary magnification and subtraction techniques were rou­ of Medicine, Pittsburgh, PA 15261. Address re­ print requests to H. S. Ahn . tine. Examinations and embolizations were performed under local anesthesia (except in AJNR 1 :71-75, January / February 1980 0195-6108/ 80/ 0011-0071 $00.00 infants and young children) . Diazepam premedication, medical hypnosis, and Fentanyl © Am erican Roentgen Ray Society during th e procedure all ayed the pain and fear. 72 AHN ET AL. AJNR: 1 , January / Febru ary 1980 B c o E Fig. I .-54-year-old woman with larg e glomus jugulare tumor. A- C. Seleclive angiograms (0.5 sec inlerval) of left occipital artery. Vascular mass lesion and main feeder, branch of occipilal arlery. D. Lell common carolid angiogram before embolization. E, Angiogram aller embolizalion. Complete occlu sion of occipital arlery. Inlernal carolid artery remains palenl. AJNR: 1. January / February 1980 ANASTOMOSES AND EMBOLIZATION COMPLICATIONS 73 Fi g. 2. - 68-year-old man wilh extra­ cranial arleriovenous malformation. Lefl comm on carotid angiograms. Early (A) and late (8 ) arteri al phases. Markedly dilaled occipital artery and branches supply malformation. A B Fig. 3.-1 6-year-old boy with occipilal scalp arteri ovenousmalformalion. Fig. 4.-14-year-old boy with nasopharyngeal angiofibroma. Selective Selecti ve left external carolid angiogram. arterial phase. Dilated occipital angiogram of right ascending pharyngeal artery. Vascular lesion in naso­ arlery supplies malformation. Opacification of basil ar artery and lett vertebral pharynx. Right vertebral arte ry fi ll ed via muscular branches (arrow). arlery via muscular branches (arrow). Findings within moments a bradycardia with arrhythmia and a left seventh nerve palsy. After supportive treatment, recovery Two of the first four patients suffered severe posterior was only partial. fossa stroke. A 54-year-old woman had a large left glomus A 68-year-old man had an occipital arteri ovenous malfor­ tumor. Angiography delineated its blood supply (fig . 1). A 3 mation (fig . 2). The left occipital artery was selectively French coaxial mi crocatheter was directed through a 5 catheterized, and gelfoam powder was introduced sus­ Frenc h angiography catheter into the main feeder, a branch pended in a contrast agent. Almost immediately he became of the occipital artery, and tantalum-impregnated isobutyl 2- unresponsive. His blood pressure dropped 30-40 mm , eye cyanoacrylate was infused (Bucrylate, Ethicon, Inc., Somer­ movements were random but conjugate, and he became ville, NJ 08876). An error in mi xing the tantalum made quadriparetic. No follow-up angiography was performed. radiographic control of the infusion difficult; too much was After supportive measures, recovery was incomplete. injected, and the main trunk of the occipital artery was also As a result of these strokes, we began searching for blocked (fig. 1 E). The patient became unresponsive, semi­ extra- to intracranial anastomotic channels. We found these comatose, moved all extremities poorly, and developed six times in the next 33 patients (18% ). Most commonly 74 AHN ET AL. AJNR:1, January/ February 1980 Fig . 5.-58-year-old woman with arteriovenous malformalion of neck. Fig . 6 .-5-year-old girl with angiofibroma of nose. Seleclive left external Seleclive lell deep cervical arlery angiogram, early arterial ph ase. Malfor­ carolid angiogram . Vascular mass lesions of nose and filling of ophthalmic malion and opacificalion of dislal part 0 1 vertebral artery (arrow). artery via ethmoidal arteries (arrow). Fig . 7.-55-year-old woman who presented with atrophic soli ti ssue of frontotemporal scalp. A, Lett common carotid angiogram was normal. Vertebral artery did not opacify. B, Selective left external carotid angiogram . Basilar artery and lett ve rtebral arlery fill via occipitovertebral an­ astomoses (arrow). these communications were between the vertebral artery Discussion and the occipital artery (fig . 3). However, these were also seen between the ascending pharyngeal artery and the Treatment of vascular abnormalities of the head and neck vertebral artery (fig . 4), the deep cervical artery and the by th erapeutic embolization is becoming well accepted [7- vertebral artery (fig . 5), and the middle meningeal and 10). Although the initial wave of enthusiasm has passed, the internal carotid arteries vi a the ophthalmic artery (fig . 6). complications and risks of these procedures, and more These anastomotic channels were predominantly shown by importantly, the factors which increase patient risk, have selective angiography (fig. 7). not yet been stressed in the literature. AJNR: 1 , January/ February 1980 ANASTOMOSES AND EMBOLIZATION COMPLICATIONS 75 Passage of emboli to normal regions of the brain may REFERENCES result in ischemic or toxic damage. To prevent emboli from 1. Richter HR. Collaterals between the external carotid artery and going astray-from refluxing back along the catheter once th e vertebral artery in cases of thrombosis of the intern al the desired occlusion has been accomplished-some have carotid artery. Acta Radiol (Stockh) 1953; 40: 1 08-11 2 advocated blocking the vessel by wedging the catheter in 2. Tatelman M . Pathways of cerebral coll ateral circulation. Ra­ place or more recently by occluding the artery completely diology 1960; 75: 349- 362 with a balloon-tipped catheter [11]. 3 . Schechter MM. The occipital-vertebral anastomosis. J Neuro­ We suggest a more physiologic approach [12, 13]. Emboli surg 1964; 2 1 : 758-762 are first suspended in contrast agent. The appropriate artery 4 . Bosniak MA. Cervical arteri al pathways associated with bra­ is catheterized atraumatically to prevent spasm, then the chiocephali c occlusive disease. AJR 1964; 9 1 : 1232-1 244 emboli are injected. The angiographer watches the infusion 5. Weibel J, Fi elds WS. Atlas of arteriography in occlusive cere­ brovascular disease. Philadelphia: Saunders, 1969: 130, 172, which has become readily visible because of the contrast 185 agent, with fluoroscopy. Monitoring the ever decreasing 6. Seeger JF, Gabrielsen TO, Latchaw RE . Some technique-de­ vessel acceptance of emboli allows slowing of the introduc­ pendent patterns of collateral fl ow during cerebral angiogra­ tion rate before reflux occurs. With this technique the an­ phy. Neuroradiology 1974; 8: 1 49-1 55 giographer maintains precise and instantaneous control of 7. Djindjian R, Cophignon J, Theron J, Merl and JJ, Houdart R. the occlusion process. Emboli zation by selective arteriography from the femoral route We have successfully used this technique in one patient in neuroradiology. Neuroradiology 1973; 6: 20- 26 with patent occipital to vertebral artery anastomosis and in 8. Djindjian R, Cophignon J, Theron J, Rey A, Merland JJ, Hou­ another patient with external carotid-ophthalmic artery pat­ dart R. Superselecti ve arteriographic embolizati on by the fem­ ent anastomosis. oral rou te in neuroradiology.
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