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Evaluation of Prototype Equipment for Digital Subtraction Angiography in Diagnosing Intracranial Lesions

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Evaluation of Prototype Equipment for Digital Subtraction Angiography in Diagnosing Intracranial Lesions 259 I I i ~ Evaluation of Prototype Equipment for Digital Subtraction Angiography in Diagnosing Intracranial Lesions Mutsumasa Taka~ashi , 1 :oshihisa Hirota,1 Hiromasa Bussaka,1 Tadatoshi Tsuchigame ,1 Masayuki Miyawaki,1 Sukeyoshl Ueno, Yasuhlko Matsukado,2 and Yoshibumi Hirata2 Two prototype units for digital subtraction angiography have Subjects and Methods been developed by Japanese manufacturers. Their performance in demonstrating various intracranial lesions in 121 patients was DSA was perform ed on 121 patients with known or suspected evaluated. Comparison with conventional selective catheter an­ intracran ial lesions. In 77 cases conve ntional cerebral angiography giography was possible in 77 patients. Digital subtraction an­ was performed within 2 weeks of DSA. Most cerebral angiograms giography proved useful in preoperative evaluation of pituitary were obtain ed usin g transfemoral catheter techniques with biplane tumors when transsphenoidal surgery was being considered; stereoscopi c magnifi cati on. demonstration of faint tumor stains which might be missed on Patients were denied food and water before the procedure. In conventional angiography; demonstration of larger aneurysms, most cases, a 16 gauge, 15-cm-long Tefl on needle was inserted in arteriovenous malformations, and tumors as a screening tech­ the antecubital ve in . Wh en the thoracic artery and its branches nique; demonstration of abnormalities involving the dural si­ were examined together or when placement of the needle in the nuses; and follow-up of patients after surgery or embolization. antecubital vein was un successful, an angiographic catheter (5.5 Fren ch) was in serted in th e femoral ve in using the Seldinger tech­ nique and advanced under flu oroscopy into the inferior ve na cava The usefulness of digital subtraction angiography (DSA) has been near the ri ght atrium . Forty ml of 76% meglumine and sodiu m established for evaluation of the aorta and its primary branches, diatrizoate solution was injected mechani call y at a fl ow rate of 12- especially for delineation of the extracranial carotid and vertebral 15 ml /sec, usin g a pressure injector. A 20- 25 ml solution of 5% arteries [1-6]. Several recent reports have demonstrated the value glucose or saline was layered over the contrast medium. At 5-8 of DSA in the intracranial vascular system [7 -10]. Japanese man­ sec after initial injection , seri al im ages were obtain ed at a rate of ufacturers have developed two prototype units for DSA . We have one/sec for 20 sec or two/ sec for 5 sec, foll owed by one / sec for evaluated their clinical usefulness in diagnosing intracranial dis­ 10 sec. The beginning of the exposure varied according to heart eases. rate. Filming of the first seri es of images in each patient generall y began sli ghtly earli er than filmings of later seri es, which were ad justed after review of the first se ri es. Equipment and Technique Straight anteroposterior and lateral projecti ons were obtained routinely. Caldwell projections were frequently useful for delineati on Two DSA imaging systems (Hitachi and Shimadzu, respectively) of the horizontal portion of th e anterior and middle cerebral arteries. were used in this study [11]. The major components and capabilities Towne projections were used for posterior fossa lesions. Sli ghtly of each unit are outlined in table 1 . Both units have U-arm assem­ oblique lateral projecti ons were obtained to avoid overl apping or blies th at can position the x-ray tube and im age intensifier for any superposition of th e carotid siphon. The patient with normal renal desired projection while maintaining the patient in a comfortable function can withstand three or four injecti ons. position on a floating table top. The results of DS A were graded as: (1) excell ent, when findings The output signal of the image intensifier-television camera sys­ were comparable or superi or to th ose obtained by conventional tem is digitized by an analog-digital converter in which digital angiog raphy; (2) good, when useful informati on was obtained, but information is formed on 512 x 512 pi xels, 8-9 bits deep. Digital with sign ificant chance of error; (3) fair, when no diagnostic infor­ information is fed into the im age processing assembly after loga­ mati on was obtained, although intracranial vessels were visualized ; rithmic amplification, where two to eight frames are combined and and (4) poor, when the study was un successful or uninterpretable. su btracted from the mask images to form the final digital im ages. Up to 32 serial digital images can be stored in real time in the frame memories, while additional images are transferred to other record­ ing units as necessary (Hitachi) or recorded on a video disk record er Results (Shimadzu). Using the host computer, image manipulations such as remasking, edge enhancement, image smoothing, image mag nifi­ In 18 (14.9%) of 121 patients, DSA was judged excell ent or as cation, r-adjustment, and changing of window level and width can diagnosti c as conventional angiog raphy for evaluati on of intracra­ be carri ed out. ni al lesions. In 17 cases (14%), studies were technicall y un suc- , Departm ent of Radiology, Kumamoto University Sc hool of Medicine, Hon jo 1-1-1 , Kumamoto, Japan 860. Address reprint requ ests to M. Takahashi . 2 Departm ent of Neurosurg ery, Kumamoto Unive rsity School of Medicine, Kumamoto, Japan 860. AJNR 4:259-262, May / June 1983 0195- 6108/ 83 / 0403- 0259 $00.00 © American Roentgen Ray Society 260 DIGITAL RADIOGRAPHY AND DSA AJNR:4, May/ June 1983 cessful or uninterpretable. In th e great majority (70.8%) of cases, Cerebral Aneurysms r es ult ~ of DSA fell between th ese two extremes (table 2). Most Larger cerebral aneu rysms and their necks were clearly dem­ " poor" examinations were secondary to misregistration artifacts onstrated by DSA, which was as diagnostic as conventional angiog­ from pati ent motion and technical difficulties encountered during raphy (fig. 3). Th ere was considerable difficulty in diagnosing th e early phase of clinical trials. smaller aneurysms, particularly when the diameter of the aneurysm was less th an twice th e diameter of th e parent artery. Arteri al spasm second ary to subarachnoid hemorrhage was ob­ Brain Tumors served with some difficulty, although th eoretically such physiologic Larg er tumors and vascular tumors were diagnosed easily by activity should be more readily demonstrated by DSA. DSA could DSA, whereas smaller tumors (diameter <3 cm) and avascular be repeated easily to monitor such conditions. tumors were difficult to diagnose. Tum or stains were clearly demonstrated by DSA. Meningiomas in th e suprasellar area, olfactory groove, and planum sphenoidale Arteriovenous Malformations were better delineated by DSA th an by conventional angiography Arteriovenous malformations were demonstrated to good advan­ (fig. 1). This was due partly to higher contrast sensitivity and partly tage. The feeding arteri es and draining veins were visualized with to bilateral blood supply to th e tumors, both sides being opacified DSA as well as by conventional angiography (fig. 4). Eve n a 1 cm during DSA. arteriovenous malformation was clearly shown. The superior sagittal sinus was clearly visualized with DSA and in vasion of th e superi or sagittal sinus was demonstrated in two convexity meningiomas (fig. 2). Arterial Occlusive Diseases In patients with intrasell ar tumors, DSA provided enough infor­ mation to recommend transsphenoidal hypophysectomy. Arterial occlusions and stenoses of more than 50% were dem­ onstrated in larger vessels such as the internal carotid arteries, horizontal parts of the anterior and middle cerebral arteries, and basilar and proximal posterior cerebral a rt e ri e~ (fig. 5). Occlusions TABLE 1: DSA Prototype System Components and Capabilities in small er vessels and stenoses of less than 50% were not demon­ strated with certainty. Coll ateral vessels were often difficult to M anufacturer Component observe and only th e recanalized parts of th e arteries were visual­ Hitachi Shimadzu ized. Generator 150 kVp, 1,300 mA 150 kVp, 1,000 mA X-ray tu be 450 kH, 0 .8 / 1.3 400 kH , 1.0 mm fo- mm focus cus Other Intracranial Lesions Image intensifier 22.9 cm, 17.8 cm 22.9 cm Csi Csi A case of carotid-cavernous sinus fistula was clearly demon­ Gri d 8:1 , 28 line pairs/ 10:1, 32 line pairs/ strated with visualization of th e site of th e fistula and enlarged cm, wood cm, glass fiber superior ophthalmic vein. Vascular anomalies such as azygous TV camera Plumbicon, 525 Plumbicon, 525 anterior cerebral artery, persistent primitive arteries, and ven ous lines, 5 MHz, lines, 5 MHz, sin us anomali es were also demonstrated. A large hypertensive SNR 650:1 SNR 450:1 intracerebral hemorrhage was diagnosed. Amplification Logarithmic or lin- Logarithmic or lin- ear ear A/ D converter 9 bit, 20 MHz 8 bit, 10 MHz Postoperative Evaluation Di gital memory 512 x 512 x 16 512 x 512 x 13 bits ( x2) bits ( X2) Patients with brain tumors, arteriovenous malformations, and 512x512x10 cerebral aneurysm were evaluated by postoperative DSA. TI e bits (18-30) procedure was also used to evaluate anastomosis between the Nole.-Csi = cesium iodide: SNR = signal-Io-noise ralio: AI D = analog-la-digital. superficial temporal artery and middle cerebral artery. Patency or TABLE 2: Diagnostic Usefulness of DSA in Demonstrating Intracranial Disease No. (% ) Pathotogy Excellent Good Fair Poor Totat;; Brain tumor 10 16 7 9 42 Cerebral aneurysm 4 2 7 Arteriovenous malformation 2 1 3 Arterial occlu sive disease 2 15 11 3 3 1 Cerebrovascular anomaly 1 4 5 Hypertensive intracerebral 3 2 5 hemorrhage STA-MCA anastomosis 1 1 3 Other intracranial lesions 15 6 4 25 Totals .
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