Complications of Modern Diagnostic Cerebral Angiography in an Academic Medical Center

doi:10.1016/j.jvir.2009.01.012

Journal of Vascular and Interventional Radiology

Volume 20, Issue 4, April 2009, Pages 442-447

https://doi.org/10.1016/j.jvir.2009.01.012 Get rights and content

Purpose

Catheter cerebral angiography and noninvasive cerebral imaging have steadily improved in the past several decades. Now, catheter angiography is frequently reserved for treatment planning. To remain relevant as a diagnostic modality, catheter angiography must be safe, even in critically ill patients. The present report describes the complication rate of catheter cerebral angiography performed by neurointerventional specialists at an academic medical center.

Materials and Methods

From July 2001 through June 2007, 3,636 diagnostic catheter cerebral angiograms were obtained at a large academic institution. Complication data were prospectively acquired according to institutional policy and New York Patient Occurrence Reporting and Tracking System criteria. Data collected included patient age, sex, indication for the procedure, operator, and nature of adverse event, including need for treatment. Clinical predictors of complications were evaluated with logistic regression.

Results

Among 3,636 diagnostic cerebral angiograms obtained in 6 years, there were 11 clinical complications (0.30%). One patient (0.03%) had magnetic resonance imaging–detected stroke with no apparent clinical deterioration. Iatrogenic dissections were seen in five arteries (0.14%). No patient developed neurologic symptoms. Nonneurologic complications occurred in five patients (0.14%) who had arteriotomy site–related complications: one femoral abscess, two occlusions of the femoral artery with leg ischemia requiring surgical revascularization, one dissection with pseudoaneurysm formation requiring percutaneous thrombin injection, and one retroperitoneal hemorrhage requiring transfusion. Three of these patients were treated with an arterial closure device. Age greater than 65 years was associated with development of complications (P = .03).

Conclusions

Modern catheter cerebral angiography performed by neurointerventionalists is associated with a low complication rate of 0.30%, even in a highly complex patient population.

Section snippets

Materials and Methods

From July 2001 through June 2007, 3,636 consecutive diagnostic catheter cerebral arteriograms were obtained by neurointerventionalists at a large academic institution. Of note, diagnostic procedures done in conjunction with interventional procedures were excluded from this dataset. Data on patients with complications were prospectively acquired over the 72-month period according to institutional policies for quality assurance and the New York Patient Occurrence Reporting and Tracking System

Patients

Over the 72 months of the study period, 3,636 diagnostic angiograms were obtained for indications delineated in Figure 1. The most common indication for angiography was unruptured aneurysm (26.9%), followed by subarachnoid hemorrhage (20.7%). The population was predominately female (62%), with a mean age of 50.5 years ± 17.1 (range, 2 months to 97 years). Most patients (65.4%) were inpatients and 34.6% were outpatients. There were more patients with the diagnoses of subarachnoid hemorrhage and

Discussion

Since the 1970s, several centers have reported their complication rates for cerebral angiography (4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18). Complications are relatively uncommon, and their incidence has decreased in recent decades. Presumably, decreasing complication rates are related in part to technologic improvements in catheters, guide wires, and nonionic contrast agents, and the development of high-resolution digital subtraction imaging with roadmap capabilities. Operator

Acknowledgment

The authors thank Raquel Richard for assistance with data collection and collation.

References (27)

K. Nael et al.
3-T contrast-enhanced MR angiography in evaluation of suspected intracranial aneurysm: comparison with MDCT angiography
AJR Am J Roentgenol
(2008)
E.T. Chappell et al.
Comparison of computed tomographic angiography with digital subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis
Neurosurgery
(2003)
M. Kramer et al.
Vascular mapping of head and neck: computed tomography angiography versus digital subtraction angiography
J Oral Maxillofac Surg
(2008)
J.E. Dion et al.
Clinical events following neuroangiography: a prospective study
Stroke
(1987)
F.T. Earnest et al.
Complications of cerebral angiography: Prospective assessment of risk
AJR Am J Roentgenol
(1984)
M. Komiyama et al.
Prospective analysis of complications of catheter cerebral angiography in the digital subtraction angiography and magnetic resonance era
Neurol Med Chir
(1998)
R.A. Willinsky et al.
Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature
Radiology
(2003)
J.E. Heiserman et al.
Neurologic complications of cerebral angiography
AJNR Am J Neuroradiol
(1994)
T.J. Kaufmann et al.
Complications of diagnostic cerebral angiography: evaluation of 19,826 consecutive patients
Radiology
(2007)
A.A. Dawkins et al.
Complications of cerebral angiography: a prospective analysis of 2,924 consecutive procedures
Neuroradiology
(2007)

D.C. Johnston et al.

Low rate of complications of cerebral angiography in routine clinical practice

Neurology

(2001)

A.M. Leffers et al.

Neurologic complications of cerebral angiography: a retrospective study of complication rate and patient risk factors

Acta Radiol

(2000)

J.C. Pryor et al.

Complications of diagnostic cerebral angiography and tips on avoidance

Neuroimaging Clin N Am

(1996)

Cited by (157)

Predictors of Transfemoral Access Site Complications in Neuroendovascular Procedures: A large Single-Center Cohort Study
2023, Clinical Neurology and Neurosurgery
The transfemoral (TF) route has historically been the preferred access site for endovascular procedures. However, despite its widespread use, TF procedures may confer morbidity as a result of access site complications. The aim of this study is to provide the rate and predictors of TF access site complications for neuroendovascular procedures.
This is a single center retrospective study of TF neuroendovascular procedures performed between 2017 and 2022. The incidence of complications and associated risk factors were analyzed across a large cohort of patients.
The study comprised of 2043 patients undergoing transfemoral neuroendovascular procedures. The composite rate of access site complications was 8.6 % (n = 176). These complications were divided into groin hematoma formation (n = 118, 5.78 %), retroperitoneal hematoma (n = 14, 0.69 %), pseudoaneurysm formation (n = 40, 1.96 %), and femoral artery occlusion (n = 4, 0.19 %). The cross-over to trans radial access rate was 1.1 % (n = 22). On univariate analysis, increasing age (OR=1.0, p = 0.06) coronary artery disease (OR=1.7, p = 0.05) peripheral vascular disease (OR=1.9, p = 0.07), emergent mechanical thrombectomy procedures (OR=2.1, p < 0.001) and increasing sheath size (OR=1.3, p < 0.001) were associated with higher TF access site complications. On multivariate analysis, larger sheath size was an independent risk factor for TF access site complications (OR=1.8, p = 0.02).
Several pertinent factors contribute towards the incidence of TF access site complications. Factors associated with TF access site complications include patient demographics (older age) and clinical risk factors (vascular disease), as well as periprocedural factors (sheath size).
Digital Subtraction Angiography May Reduce the Rate of Radiographic Hemorrhage in Stereoelectroencephalography
2022, World Neurosurgery
Citation Excerpt :
However, the incidence of any complications related to cerebral angiography may be less than 1%.14 More recent studies have even cited complication rates approaching zero.15-17 Common complications, although rare, include stroke, transient ischemic attack, access vessel injury, and kidney failure related to iodinated contrast agents.16
To study the effect of preoperative digital subtractive angiography (DSA) for planning stereoelectroencephalography (sEEG) electrode trajectories on the rate of postoperative radiographic hemorrhage.
A retrospective, single-center observational study was conducted examining every sEEG implantation consisting of 72 implantations of 1028 total electrodes with each patient having received a preoperative planning DSA. Postimplant imaging was analyzed for the presence of hemorrhage. Postoperative computed tomography were then merged and coregistered with preoperative DSA to determine if a collision or near-miss (within 1 mm) occurred between the perihemorrhage electrodes and a vessel. Statistical analysis was then conducted.
Six patients (8.3%) had hemorrhage seen on computed tomography with a bleeding rate of 0.6% per electrode. Five patients were asymptomatic (6.94%) and one symptomatic (1.39%). One patient suffered permanent neurologic deficits, and there have been zero deaths. In the hemorrhage group, there were 3 subdural, 2 subarachnoid, and 2 intraparenchymal. All subdural and subarachnoid hemorrhages had electrodes that were found to collide or near-miss a vessel when compared with preoperative DSA. Half of the intraparenchymal hemorrhages had no obvious vessel in proximity to the electrodes. Our data show that preoperative DSA is a viable screening test and portends a 94.7% sensitivity and 53.6% specificity for predicting post operative radiographic hemorrhage.
Analysis of our sEEG series reveals a substantially lower rate of postimplant hemorrhage when compared with the recent cohort studies. Our data indicate that preoperative DSA may be efficacious in reducing the incidence of sEEG postimplant hemorrhages.
Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature
2022, World Neurosurgery
The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures.
A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures.
Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01).
Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.
Transcranial Doppler findings in a population with clinical probable reversible cerebral vasoconstriction syndrome
2022, Revue Neurologique
Citation Excerpt :
However, these findings are limited by the small sample size of our sample. Conventional angiography remains the gold-standard for detecting brain vasospasm, yet it presents many challenges for practical use in the RCVS diagnosis, especially in mild cases for it is not immediately available, it's expensive, it can’t be used for monitoring and despite having a low complication risk in experienced centers, it is still invasive with inherent potential serious complications [6,11]. MRA and CTA have surpassed some of these limitations.
To describe transcranial Doppler (TCD) findings in a population with clinical probable RCVS. Exploratory objectives included the study of clinical characteristics of probable RCVS patients with and without spasm detected by TCD.
Cross-sectional cohort study of patients with thunderclap headache (TCH) without subarachnoid hemorrhage (SAH) of our neurology and headache center between 2010 and 2019, selecting patients with clinical diagnosis of probable RCVS (negative angiography study) by ICHD-3 criteria and with at least two TCD studies.
From 114 TCH patients, 36/114 had probable RCVS by ICHD-3 criteria and had at least two TCD studies available. The mean age at RCVS onset was 42.9 years (21–72 years); 29/36 (80.6%) were female, 7/28 (25%) had cardiovascular risk factors and 20/36 (55.6%) had history of migraine. Most common triggers were stressful emotion, drugs, valsalva maneuvers and sexual activity. Five/36 (13.9%) had complications and 3/36 (8.3%) had late recurrence. Initial TCD was performed on average of 16 (6–26) days after headache onset. Twenty-nine had vasospasm on TCD, presenting mean flow velocity of MCA (VMCA) of 135.7 ± 17.0 cm/s and mean maximum VMCA of 138.3 ± 17.2. Vasospasm was mild in 21/29 patients (72.4%) and moderate in 8/29 (27.6%). Complete VMCA normalization occurred on average 41 (30–70) days after headache onset and 24 (11–47) days after initial TCD. The group of patients with vasospasm detected by TCD had more female patients (26/29, 89.7% vs. 3/7, 42.8%, P = 0.016), and more TCH attacks (mean of 3.6 vs. 2.14, P = 0.049).
TCD may be a useful tool in the identification of vasospasm in patients with probable RCVS, supporting the diagnosis of RCVS in patients presenting with recurrent TCH without SAH.
Therapeutic Approaches for Cerebrovascular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: An Update and Future Perspectives
2022, World Neurosurgery
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe subtype of stroke occurring at a relatively young age with a significant socioeconomic impact. Treatment of aSAH includes early aneurysm exclusion, intensive care management, and prevention of complications. Once the aneurysm rupture occurs, blood spreading within the subarachnoid space triggers several molecular pathways causing early brain injury and delayed cerebral ischemia. Pathophysiologic mechanisms underlying brain injury after aSAH are not entirely characterized, reflecting the difficulties in identifying effective therapeutic targets for patients with aSAH. Although the improvements of the last decades in perioperative management, early diagnosis, aneurysm exclusion techniques, and medical treatments have increased survival, vasospasm and delayed cerebral infarction are associated with high mortality and morbidity.
Clinical practice can rely on a few specific therapeutic agents, such as nimodipine, a calcium-channel blocker proved to reduce severe neurologic deficits in these patients. Therefore, new pharmacologic approaches are needed to improve the outcome of this life-threatening condition, as well as a tailored rehabilitation plan to maintain the quality of life in aSAH survivors. Several clinical trials are investigating the efficacy and safety of emerging drugs, such as magnesium, clazosentan, cilostazol, interleukin 1 receptor antagonists, deferoxamine, erythropoietin, and nicardipine, and continuous lumbar drainage in the setting of aSAH. This narrative review focuses on the most promising therapeutic interventions after aSAH.
Dual-phase contrast-enhanced CT evaluation of dural arteriovenous fistula in patients with pulsatile tinnitus as an initial symptom
2022, European Journal of Radiology
Intracranial dural arteriovenous fistula (DAVF) can cause pulsatile tinnitus (PT). The purpose of this study was to investigate the diagnostic performance of dual-phase contrast-enhanced CT (DP-CECT) for DAVF in PT patients compared with digital subtraction angiography (DSA).
From February 2015 to April 2021, PT patients undergoing routine DSA examination were prospectively analyzed. Patients with and without DAVF diagnosed by DSA were included. In DP-CECT, the radiological signs related to DAVF were assessed as follows: asymmetric external carotid artery (ECA) branches, asymmetric enhancement of intracranial or extracranial veins, asymmetric venous collaterals in extracranial space, and shaggy tentorium or venous sinus on CTA; asymmetric enhancement of intracranial or extracranial veins on CTV; numerous transcalvarial channels and asymmetric size of foramen spinosum on high-resolution CT (HRCT).
253 PT patients receiving DSA were enrolled, and these patients had previously been screened by DP-CECT. Forty-six patients were diagnosed as DAVF by DSA. Therefore, the prevalence of DAVF was 18% (46/253) in patients with PT as the initial symptom. The sensitivity and specificity of DP-CECT for diagnosis of DAVF were 96% and 100%. The sensitivity of individual CTA signs ranged from 65% to 93%, and specificities ranged from 83% to 100%. The sensitivity of CTV sign was 80%, and specificity was 100%. The sensitivity of individual HRCT signs ranged from 48 to 52% and specificities from 61 to 100%.
DAVF is not rare in patients with PT as the initial symptom. DP-CECT can be used for screening DAVF in patients with PT.

View all citing articles on Scopus

: None of the authors have identified a conflict of interest.

View full text

Clinical studyComplications of Modern Diagnostic Cerebral Angiography in an Academic Medical Center

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Patients

Discussion

Acknowledgment

3-T contrast-enhanced MR angiography in evaluation of suspected intracranial aneurysm: comparison with MDCT angiography

AJR Am J Roentgenol

Comparison of computed tomographic angiography with digital subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis

Neurosurgery

Vascular mapping of head and neck: computed tomography angiography versus digital subtraction angiography

J Oral Maxillofac Surg

Clinical events following neuroangiography: a prospective study

Stroke

Complications of cerebral angiography: Prospective assessment of risk

AJR Am J Roentgenol

Prospective analysis of complications of catheter cerebral angiography in the digital subtraction angiography and magnetic resonance era

Neurol Med Chir

Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature

Radiology

Neurologic complications of cerebral angiography

AJNR Am J Neuroradiol

Complications of diagnostic cerebral angiography: evaluation of 19,826 consecutive patients

Radiology

Complications of cerebral angiography: a prospective analysis of 2,924 consecutive procedures

Neuroradiology

Low rate of complications of cerebral angiography in routine clinical practice

Neurology

Neurologic complications of cerebral angiography: a retrospective study of complication rate and patient risk factors

Acta Radiol

Complications of diagnostic cerebral angiography and tips on avoidance

Neuroimaging Clin N Am

Clinical study
Complications of Modern Diagnostic Cerebral Angiography in an Academic Medical Center