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Neuroradiology 14, 175-181 (1977)
© by Springer-Verlag 1977
Complications of Cerebral Angiography Hans Olivecrona Department of Ncuroradiology, Karolinska Sjukhuset, Stockholm, Sweden
Summary. All types of complications, both minor and major, are tabulated and analyzed in 5531 consecutive cerebral angiographies performed on 3730 patients during a period of 5 years.
Key words: Cerebral angiography - Complications.
Cerebral angiography, like other angiographic procedures, is associated with a certain degree of risk. Complications can be local, general, or cerebral. Local complications occur at the site of puncture; general adverse reactions are related to a hypersensitivity to the contrast medium used, or depend on a toxic effect of the contrast medium on the organism. Serious neurological complications are represented by new abnormal signs or symptoms or by aggravation of previously existing signs or symptoms. The majority of complications related to cerebral angiography are transient, but complications resulting in permanent neurological deficits do occur, and even deaths have been reported. The present report concerns a study in which all forms of complications were noted in the consecutive records of all angiographic examinations performed during a 5year period in the Department of Neuroradiology at the Karolinska Hospital, Stockholm, Sweden.
Material and Angiographic Technic The subject material for this study includes 5531 consecutive angiographies performed between 1970 and 1974 on 3730 patients, 2030 men (54.4%) and
1700 women (45.6%). In order to be able to conduct a prospective study of the incidence of complications, each patient had a detailed angiographic journal in which all findings concerning the state of the patient before the examination, during the actual performance of the examination and in the subsequent 24 h were registered. The type of examination, the technic of the procedure, the type of catheter and position of the catheter tip, the amount of contrast medium injected and the duration of the procedure were all recorded in detail at the time of the examination, as well as any complications, even slight ones not causing any discomfort to the patient. Angiography was performed under light sedation and local anesthesia with 1% Xylocain in 2922 patients (78.3%). General anesthesia with intubation was used in children and in uncooperative adults - altogether 808 patients (21.7%). The ages and sex distribution of the patients are shown in Table 1. A total of 3978 artery punctures were performed on the 3730 patients (Table 2). Most examinations were performed by the percutaneous femoral route (59.1%). The carotid arteries were used in 37.8% of cases (Table 2), the left somewhat more often than the right. Direct carotid angiography (Table 3) was performed in the vast majority of cases by using some form of catheter technic, either a polythene cannula devised by Westberg [36] consisting of a needle carrying a polythene catheter tightly wrapped around it, or by a catheter set devised by Bergstr6m and R~dberg [3] where the catheter is introduced into the common carotid artery over a guide wire. In a small number of patients, 1.2%, carotid angiography was performed after direct percutaneous puncture of the carotid artery with a needle. Puncture and catheterization of the brachial artery for retrograde vertebral angiography was performed
176
H. Olivecrona: Complications of Cerebral Angiography
Table 1. Age and sex distribution of 3730 patients
Age
Male
Female
Total
Per cent
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
57 99 202 254 366 535 446 70 1
33 51 149 196 331 445 428 63 4
90 150 351 450 697 980 874 133 5
2.4 4.0 9.4 12.1 18.7 26.3 23.4 3.6 0.1
Table 2. Arteries punctured
Number of punctures
Per cent
Femoral Right carotid Left carotid Right brachial Left brachial Vertebral
2352 667 837 69 46 7
59.1 16.8 21.0 1.7 1.2 0.2
Total
3978
in 2.9% of the punctures, while angiography after direct, percutaneous puncture of the vertebral artery with a needle was carried out in 0.2% (Table 2). The distribution of the 5531 angiographic examinations for the different types of investigations is shown in Table 4. Angiography of m o r e t h a n one vessel at the same sitting was p e r f o r m e d on 1283 patients, 34.1% of all. The contrast medium used was Isopaque cerebral (280 mg I/ml), each injection usually consisting of 8 ml of the medium, was made with a pressure injector (Cisal-I). E C G was always registered during t h e cerebral angiography. The catheter was flushed every minute with heparinized saline. After each examination a detailed report was p r e p a r e d and every type of complication arising was scrupulously noted. Each patient was observed for at least 24 h for possible sequelae to the investigation and all reactions of the patient during this period were entered in the record. Thus all types of complications which appeared either at the time of examination, or within the subsequent 24 h were registered in the angiographic record.
Results
Table 3. Technic for cerebral angiography after direct puncture of
the carotid artery Technic
Number of angiographies
Per cent of direct carotid punctures
Short catheter Needle
1473 31
97.9 2.1
Table 4. Type of examination in 5531 consecutive angiographies Type of angiography
Number of examinations
Per cent
Right internal carotid Right common carotid Left internal carotid Left common carotid Right external carotid Left external carotid Right vertebral Left vertebral Aorto-cervical Right subclavian Left subclavian Spinal
1764 225 1524 241 194 186 155 I000 214 5 7 16
31.9 4. i 27.5 4.3 3.5 3.4 2.8 18.1 3.9 0.1 0.1 0.3
No complication whatsoever in 2750 p a t i e n t s (73.7%) occurred. In the remaining 980 patients (26.3%) one or m o r e of the complications set out in Table 5 were noted in the angiographic record. A total of 1220 complications were registered, of which 861 were local, 191 general, and 168 neurological. One patient experienced transient yet rather severe pain in the leg, on the side of the femoral puncture during and after the examination. No study was m a d e of the iliac arteries or the arteries of the leg. One patient developed a purulent infection in the groin at the site of the puncture 2 days after the examination. Myocardial infarction occurred in one patient after puncture of the femoral artery before catheterization had taken place, and the procedure was terminated. One patient studied under general anesthesia suffered a t e m p o r a r y cardiac arrest after extubation. One patient had quickly subsiding bursts of extrasystoles. In three patients a m a r k e d bradycardia was registered in relation to the angiography. Two patients complained of transient retrosternal pain during the study. Most frequent of the general symptoms were nausea and vomiting, which were encountered in 2.4% of the patients. A sensitivity reaction with urticaria was seen in 1.6% while fainting and a condition of shock were noted in 0.5% of the patients.
H. Olivecrona: Complicationsof Cerebral Angiography A deterioration of the patient's general condition occurred in 0.4% of the cases after completion of the study, as compared with the state prior to angiography. H e m a t o m a was the most common local complication, being noted to a varying degree at 752 arterial puncture sites (18.9%). Hematomas occurred with 10.7% of the femoral, 25.3% of the carotid and 15.7% of the axillary or brachial punctures. In seven cases (0.2%), copious bleeding occurred from the site of puncture, in six patients after puncture of the femoral artery and in one after puncture of the carotid artery. The examination of three of these patients had to be postponed to a later date when it was successfully accomplished without complication. Perivascular injection of contrast medium was seen only in association with puncture of the carotid artery in the neck. This occurred in 2.9% of all carotid punctures (43 patients), representing 1.2% of the total number of patients. H e m a t o m a in the cervical region was noted in 55.8% of the perivascular contrast injections. Subintimal or intramural injection of contrast medium in the wall of the carotid artery occurred in 34 patients, 0.9% of all cases. Subintimal tear was more commonly seen after direct puncture of the carotid artery than after transfemoral catheterization, and occurred in 2. l % of all carotid punctures (31 patients). Thus, unsuccessful attempts at direct puncture of the carotid artery which resulted in perivascular or intramural injection of contrast medium occurred in 5% of percutaneous neck punctures. Transfemoral catheterization was only rarely associated with intramural injection of contrast medium in the wall of the carotid artery. This complication was met with in three patients, representing 0.1% of all examinations via the femoral route. Percutaneous femoral catheterization was followed in six patients by an intramural injection of contrast medium outside the carotid artery, namely in one patient in the brachiocephalic trunk, in the lumbar aorta of one patient suffering from Takayasu's disease, and in four patients in the common or external iliac artery. One patient had an intramural injection of contrast medium in the subclavian artery after catheterization from the axillary artery. Thus, intramural injection of contrast medium occurred in 41 patients altogether, i. e. in 1.1% of all patients. Vascular spasm located in relation to the tip of the catheter was noted in 23 patients, or in 0.4% of all angiographies. This complication occurred in 0.5% of carotid angiographies, and in 0.3% of vertebral angiographies. Signs of intracranial embolism with occlusion of arteries and abnormal local circulation with retro-
177 Table 5. Type of complicationin 5531 consecutiveangiographies Number of Per cent patients of patients A. Local complications
Pain in the leg on puncture side 1 Abscess at puncture site in the groin 1 Hematoma at the site of puncture 752 Perivascular injection of contrast medium 43 Intramural injection of contrast medium 34 Intramural injection outside carotid artery 7 Spasm at tip of the catheter 23
0.03 0.03 20.2 1.2 0.9 0.2 0.6
B. General complications
Myocardial infarction Cardiac arrest Retrosternal pain Extrasystoles Marked bradycardia Urticaria Nausea and vomiting Fainting, shock Deterioration of general condition
1 1 2 1 3 59 90 18 16
0.03 0.03 0.05 0.03 0.08 1.6 2.4 0.5 0.4
5 65 11 6 2 44 14 14 6 1
0.1 1.7 0.3 0.2 0.05 1.2 0.4 0.4 0.2 0.03
C. Neurological complications
Increased headache Agitation Vertigo Seizures of Jackson type Grand mal Increased somnolence Diagnosed catheter embolization Neurological deficits with pareses Precoma and coma Death
grade filling of peripheral arterial branches was seen in 15 patients, 0.4% of all carotid angiographies. There was no difference in the incidence of embolism between angiography performed via the transfemoral route or by direct puncture of the carotid artery. Cerebral complications with resulting paresis occurred in 14 patients, 0.4% of all patients (Table 6). Embolism was demonstrated angiographically in five patients, probably resulting from dislodgement of thrombotic material adhering to the surface of the catheter. Cerebral complications developed during vertebral angiography with ensuing permanent neurological deficits in two patients in the form of paresis of both arms, and quadriplegia, respectively. The catheter was placed in the carotid artery in 10 of the remaining 12 patients, and in the brachiocephalic of the other two; of these patients, five had left hemiparesis, six had right hemiparesis and aphasia, and one had right facial palsy and aphasia. The neurological symptoms were transient
178
H. Olivecrona: Complications of Cerebral Angiography
Table 6. Cerebral complications with resulting neurological
Table 7. Distribution of neurological complications according to
deficits
type of cerebral angiography
Case Age Vessel injected 1
55
BCT
2
59
BCT
3
40
RCA
4
44
RCA
Complication
Angiographic diagnosis
Artery injected
Per cent of all angiographies
Per cent of neurological complications
Left hemiparesis and confusion; permanent hemiparesis Left hemiparesis, somnolent 10 h after angiography; death 8 days later Left hemiparesis; complete recovery Left hemiparesis; complete recovery in 24 h Left hemiparesis; complete recovery in 24 h Right hemiparesis and aphasia; permanent sequelae
Attempt at angiography terminated Attempt at angiographyterminated
Right carotid Left carotid Right vertebral Left vertebral
4l 37 3 19
36 50 14 0
Glioma right temporal lobe Right-sided aneurysm and spasm Subarachnoid hemorrhage; no aneurysm found Control study after ligation of left-sided aneurysm Right hemiparesis Aneurysm anand aphasia; perma- terior comnent s e q u e l a e municating artery Right facial palsy and Left-sided aphasia; aphasia aneurysm cleared, but facial palsy remained Right hemiparesis Glioma left and aphasia; during temporal lobe angiography convulsions and then suddenly unresponsive; paresis cleared in 5 days, dysphatic because of temporal tumor Right hemiparesis Atherosclerosis and aphasia; somno- withectatic exlent after angiogtra- and intraraphy; symptoms cranial vessels cleared completely in 3 days Right hemiparesis; Previousknown anaphylactic shock malignantglioafter test injection of ma; attempt at contrast medium, angiography suddenly unresponterminated sive, temporary respiratory arrest; complete recovery in 24 h Right hemiparesis Cerebral contuand aphasia; comsion plete recovery in 7 days Marked weakness of Rightacoustic both arms; permaneuroma nent bilateral paresis of upper limbs Quadriplegiaw i t h Upper brain permanent tetrastem tumor paresis
5
28
RCA
6
53
LCA
7
42
LCA
8
39
LCA
9
53
LCA
10
52
LCA
11
41
LCA
12
20
LCA
13
53
RVA
14
41
RVA
BCT RCA LCA RVA
Brachiocephalic trunk Right carotid artery Left carotid artery Right vertebral artery
Table 8. Duration in hours of the examinations, given as their
percentage distribution Examination time in h 0-1
1-2
2-3
3-4
4-5
5-6
25.2
52.6
17.6
3.8
0.7
0.1
in seven, while four patients suffered p e r m a n e n t neurological sequelae with hemiparesis. One patient developed left hemiparesis during catheterization of the brachiocephalic trunk and died 8 days after the angiographic procedure. Autopsy revealed right cerebral infarction caused by an embolus in the middle cerebral artery. Microscopic examination showed that the embolus contained cholesterol crystals and it was assumed that it represented a dislodged atheromatous plaque from the cervical portion of the internal carotid artery. One patient with a transient cerebral complication reacted with anaphylactic shock after a test injection of 5 ml of the contrast m e d i u m into the carotid artery. It started with itching of the injected half of the face and was followed by violent sneezing and vomiting, and after a few minutes the patient b e c a m e hypotensive and suddenly unresponsive, with t e m p o r a r y respiratory arrest. After regaining consciousness the patient had right hemiparesis, which cleared completely within 24 h. Right carotid angiography was associated with some type of neurological complication in 0.25% of the cases, and left carotid angiography in 0.4%. By contrast right vertebral angiography was followed by neurological complication in 1.3% of the selective angiographies of this artery, while selective angiography of the left vertebral artery in this material did not give rise to any cerebral complications at all. A comparison between the percentage of various cerebral angiographies p e r f o r m e d and the percentage of neurological complications (Table 7) shows that right carotid angiography accounted for 4 1 % of all angiographies and 36% of the neurological complications, whereas the corresponding figures for left carotid angiography were 37 and 50% respectively. Right vertebral angiography constituted only 3% of all angiographies, but accounted for 14% of the
H. Olivecrona: Complications of Cerebral Angiography
neurological complications, while left vertebral angiography, comprising 19% of all cerebral angiographies, was entirely without cerebral complication. Agitation was registered in 65 cases, constituting 1.7% of the patients. Increased somnolence after completion of the examination was noted in 44 patients, or 1.2% of all patients. Six patients (0.2%) became comatose during angiography, though no deaths occurred among these patients in connection with or following the examination. Epileptic seizures of Jacksonian type were seen in six patients with intracranial tumors, and generalized seizures occurred in two patients, representing 0.2 and 0.05% of the patients, respectively (Table 5). Other neurological manifestations related to the angiographic procedure were transient disorders causing little discomfort to the patient. Five patients complained of increased headache after the examination, and 11 patients experienced varying degrees of vertigo, corresponding to 0.1 and 0.3% of the patients respectively. Thus, neurological symptoms arose in 168 cases (4.6% of all patients). Serious neurological complications with paresis occurred in 8.3% of all patients who showed some form of neurological dysfunction during or after angiography, and attributable to the procedure. Duration of the examination time is considered in Table 8, from which it can be seen that more than 75% of the investigations were performed in less than 2 h, and that less than 5% of the studies required more than 3 h to complete. The duration of the examination did not seem to bear any relation to the number of complications. It has been reckoned for the whole series that about 80% of the examinations were performed by the less experienced investigators and about 20% by the more qualified neuroradiologists with greater experience in the performance of cerebral angiography. In two cases of complications with paresis the investigator had less than one month of experience with neuroradiology, and in nine cases the examiner had between 2 and 6 months of training. In the remaining 3 cases of complications with motor deficits, corresponding to about 20% of such complications, the study was performed by thoroughly experienced neuroradiologists. Thus, in this material no definite difference in the incidence of serious neurological complications could be discerned between the less experienced and the more experienced investigators.
Discussion
The incidence of complications associated with cerebral angiography varies greatly in different reports, probably because of variations in the definition of complications and the manner of their evaluation.
179
Thus the incidence of complications reported varies between nil [27, 35, 37] and 15-20% [4, 5, 20, 34]. Generally speaking the complication rate is reported to vary between 1 and 10% [8, 11, 16, 19, 22, 23, 26, 28, 31, 32]. The incidence of angiographic complications with a fatal outcome is difficult to assess but is considered to vary within rather narrow limits, from nil to 1.6% [5, 16, 22, 23, 26, 29]. In the present series all types of complications were carefully registered in the angiographic report, whether they occurred during the course of study or within the succeeding 24 h. Even slight symptoms such as mild headache, slight nausea and occasional allergic skin reaction causing no distress to the patient were noted. The overall incidence of complications related to the angiographic procedure was about 22% of all angiographies, which might appear to be rather high, but if slight and trifling symptoms were excluded the percentage of complications would be only 4%, which is of about the same order as in several other reports. Hematoma of varying degree was the most common local complication. It was more frequently seen after direct puncture of the carotid artery than after puncture of the femoral artery, the incidence rates being 25 and 11% respectively. Amundsen et al. [2] reported a frequency of 13% for cervical hematoma after carotid puncture. Neither in the neck nor in the groin did any hematoma become so big as to necessitate surgical intervention with evacuation of blood, and none of the patients required tracheostomy. Nausea and vomiting were, as was also noted by T6rmfi and Fogelholm [34], the most common general symptoms, and appeared during angiography in 2.4% of all patients. These symptoms were usually of short duration, disappeared spontaneously before the investigation was completed, and did not interfere with its course. The incidence of sensitivity reaction with urticaria did not reach significant proportions. It was seen in 1.6% of patients, was usually slight with only a scanty rash, and in no case did the examination have to be terminated because of this. That sensitivity reactions such as nausea, vomiting, sneezing and urticaria constitute only a small minority of angiographic complications has also been pointed out by Decker [7], Eiken and Gormsen [10], and others. Local trauma to the carotid artery with consequent intramural injection of contrast medium is a fairly common cause of angiographic complication. Allen et al. [1] reported an incidence of 7.1% of subintimal or extraluminal contrast medium injection, and they further found that 62% of patients with a complication from needle carotid angiography had a subintimal injection of contrast medium.
180
In an earlier publication Saltzman [25] found the frequency of extravascular injection of contrast medium in connection with direct needle carotid angiography to be about 10%. In the present series the vast majority of the carotid studies were performed after transcarotid or transfemoral catheterization. Intramural or perivascular injection of contrast medium was seen in 2.1% of patients. The catheter technic used probably limits the occurrence of these complications, which were not followed by any other adverse events. The most serious complications of cerebral angiography concern the central nervous system, with the appearance of new abnormal neurological signs and symptoms, or with aggravation of previously existing signs or symptoms. These complications may be either temporary or permanent, immediate or delayed. Abnormal neurological signs may be paresis, dysphasia, visual impairment with field defects or blindness, or sensory symptoms with numbness and paresthesia. Such neurological complications may result from an embolus of thrombotic material outside or inside the catheter [38] and angiographically the embolism with ensuing local circulatory disturbance may be very inconspicuous and thus easily overlooked [6]. Catheter embolism was diagnosed in 15 patients, and this complication resulted in neurological deficits in five cases. Restoration of function occurred within 7 days in four patients, while in one patient it remained permanent. The overall incidence of neurological complications, including agitation, drowsiness, confusion, vertigo, seizures, pareses, stupor and coma, was 4.6%, affecting 168 patients in all. Fourteen patients developing pareses with or without aphasia represented 8.3% of the total number of neurological complications and 0.4% of all patients. The neurological deficit became permanent in six patients (0.2%). Neurological complications with pareses following cerebral angiography performed either by a direct puncture method or by transfemoral catheterization have been reported to vary between 0.2 and 2.4%, with permanent neurological sequelae in up to 0.7%, the mortality rate directly related to angiography reaching 0.8% [1, 2, 10, 11, 16, 19, 21-24, 26, 32-34]. In the present material there was one death, giving a mortality rate of 0.03 per cent. This patient died one week after angiography of extensive cerebral infarction caused by embolism of cholesterol material from an atheromatous plaque in the cervical portion of the internal carotid artery. The incidence of neurological complications with resulting motor deficiencies varied with the type of examination. Angiography of the right carotid artery
H. Olivecrona: Complications of Cerebral Angiography
had a complication rate of 0.25%, while the corresponding figures for left carotid angiography and right vertebral angiography were 0.4 and 1.3% respectively. Selective angiography of the left vertebral artery did not give rise to any serious neurological complications. The total frequency of such complications was 0.32% for carotid angiography and 0.17% for vertebral angiography. Thus, in the present material, the complication rate for vertebral angiography was lower than that for carotid angiography, a finding also noted by Perret and Nishioka [22]. Two patients developed signs of an anterior spinal artery syndrome with cervical myelopathy following catheter vertebral angiography. A direct neurotoxic effect of the contrast medium on the cervical spinal cord appears to be the most likely explanation [14, 15, 18]. Fried et al. [12] demonstrated how blood enters the cervical spinal cord in the low cervical area, and that most of this blood flows cephalad to the upper cervical segments. Spinal cord injury following vertebral angiography with the development of paralysis of both arms or quadriplegia is fortunately uncommon [9, 13, 17, 32, 33]. The cervical spinal cord might in such cases be more than ordinarily vulnerable to the contrast agent. The patient who developed quadriplegia had signs of dysfunction of the cervical spinal cord prior to the examination, and in such cases it is especially important to take certain precautions during the anglographic procedure in order to minimize the risk of spinal cord injury. Repeated injections should be avoided, particularly if transient spinal cord symptoms appear during the investigation. It is reasonable to assume that the risk of serious neurological complication becomes greater with increasing difficulty with selective catheterization of a vessel. The following vessels are listed in increasing order of difficulty with transfemoral catheterization of the aortocranial vessels: left vertebral artery, right carotid artery, left carotid artery, and right vertebral artery. Consequently, as was found in the present series, left vertebral angiography can be expected to cause the fewest complications, whereas, according to such an assumption, right vertebral angiography is the most dangerous of the various types of cerebral angiography, which was also true in this study. T6rmfi and Fogelholm [34] also found more complications with right vertebral than with left vertebral angiography. Furthermore, and in agreement with this hypothesis, somewhat fewer complications were encountered with right carotid than with left carotid angiography. All examinations were carried out under the supervision of experienced neuroradiologists. With
H. Olivecrona: Complications of Cerebral Angiography
regard to the incidence of serious cerebral complications, no definite difference could be established between the experienced and the less experienced operators, a finding also reported by Lester and Klee [16] and Takahashi and Kawanami [32]. However, it might well be, as pointed out by Lester and Klee [16], that the less experienced examiners are more apt to occasion a greater number of local complications than the more experienced.
References 1. Allen, J.H., Parera, C., Potts, D.G.: The relation of arterial trauma to complications of cerebral angiography. Amer. J. Roentgenol. 95, 845-851 (1965) 2. Amundsen, P., Dietrichson, P., Enge, I., Williamson, R.: Cerebral angiography by catheterization - complications and side effects. Acta radiol. Diagn. 1, 164--172 (1963) 3. Bergstrrm, K., Jorulf, H.: Disposable equipment for percutaneous angiography in infancy and childhood. Pediat. Radiol. 1, 241-243 (1973) 4. Blain, J. G., Resch, J. A.: Complications of angiography in the stroke patient. Geriatrics 21, 149-154 (1966) 5. Coddon, D.R., Krieger, H.P.: Circumstances surrounding complications of cerebral angiography: analysis of 546 consecutive cerebral angiograms. Amer. J. Med. 25, 580-589 (1958) 6. Cronqvist, S., Efsing, H.O., Palacios, E.: Embolic complications in cerebral angiography with the catheter technique. Acta radiol. Diagn. 10, 97-107 (1970) 7. Decker, K.: Klinische Neuroradiologie. Stuttgart: Thieme 1960 8. Dunsmore, R., Scoville, W.B., Whitcomb, B.B.: Complications of angiography. J. Neurosurg. 8, 110-118 (1951) 9. Ederli, A., Sassaroli, S., Spaccarelli, G.: Vertebral angiography as a cause of necrosis of the cervical spinal cord. Brit. J. Radiol. 35, 261-264 (1962) 10. Eiken, M., Gormsen, J.: Complications of carotid angiography in acute cerebrovascular conditions. Acta reed. scand. 172, 151-161 (1962) 11. Feild, J.R., Robertson, J.T., DeSaussure, R.L., Jr.: Complications of cerebral angiography in 2000 consecutive cases. J. Neurosurg. 19, 775-781 (1962) 12. Fried, L. C., Doppman, J. L., Di Chiro, G.: Direction of blood flow in the primate cervical spinal cord. J. Neurosurg. 33, 325-330 (1970) 13. Howieson, J., Megison, L.C.: Complications of vertebral artery catheterization. Radiology 91, 1109-1111 (1968) 14. Killen, D.A., Foster, J.H.: Spinal cord injury as a complication of aortography. Ann. Surg. 152, 211-230 (1960) 15. Killen, D.A., Foster, J.H.: Spinal cord injury as a complication of contrast angiography. Surgery 59, 969-981 (1966) 16. Lester, J., Klee, A.: Complications of 337 pereutaneous vertebral angiographies. Acta neurol, scand. 41, 301-314 (1965) 17. Lyon, L.W.: Transfemoral vertebral angiography as a cause of an anterior spinal artery syndrome. J. Neurosurg. 35, 328-330 (1971) 18. Margolis, G., Tarazi, A.K., Grimson, K. S.: Contrast medium injury to the spinal cord produced by aortography. J. Neurosurg. 13, 349-365 (1956)
181 19. Patterson, R.H., Goodell, H., Dunning, H.S.: Complications of carotid arteriography. Arch. Neurol. 10, 513-520 (1964) 20. Perese, D.M., Kite, W.C., Bedell, A.J., Campbell, E.: Complications following cerebral angiography. Arch. Neurol. Psychiat. 71, 105-115 (1954) 21. Perret, G.: Diagnostic value and complications of carotid and vertebral angiography. Acta radiol. Diagn. 5, 453-457 (1966) 22. Perret, G., Nishioka, H.: Cerebral angiography. An analysis of the diagnostic value and complications of carotid and vertebral angiography in 5484 patients. J. Neurosurg. 25, 98-114 (1966) 23. Pribram, H.F.W.: Complications of angiography in cerebrovascular disease. Radiology 85, 33-37 (1965) 24. Ruggiero, G., Thibaut, A., Bories, J.: L'art6riographie vertrbrale dans le diagnostic neuro-chirurgical. Acta radiol. 50, 365-380 (1958) 25. Saltzman, G.-F.: Angiographic demonstration of the posterior communicating and posterior cerebral arteries. I. Normal angiography. Acta radiol. 52, 1-20 (1959) 26. Scheinberg, P., Zunker, E.: Complications in direct percutaneous carotid arteriography. Arch. Neurol. 8, 676-684 (1963) 27. Sedzimir, C.B.: Towards safer angiography. J. Neurosurg. 12, 460-467 (1955) 28. Silverstein, A., Krieger, H.P.: Complications of cerebral angiography: a supplementary report. J. Sinai Hosp. 27, 1-4 (1960) 29. Silverstein, A.: Arteriography of stroke. III. Complications. Arch. Neurol. 15, 206-210 (1966) 30. Takahashi, M., Wilson, G., Hanafee, W.: Catheter vertebral angiography: A review of 300 examinations. J. Neurosurg. 30, 722-731 (1969) 31. Takahashi, M., Wilson, G., Hanafee, W.: Diagnostic value of catheter vertebral angiography. Review of 250 examinations. Acta radiol. Diagn. 9, 494-502 (1969) 32. Takahashi, M., Kawanami, H.: Femoral catheter techniques in cerebral angiography - an analysis of 422 examinations. Brit. J. Radiol. 43, 771-775 (1970) 33. Takahashi, M., Kawanami, H.: Complications of catheter cerebral angiography. An analysis of 500 examinations. Acta radiol. Diagn. 13, 248-258 (1972) 34. T6rm~i, T., Fogelholm, R.: Complications of cerebral angiography with Urografin. Acta neurol, scand. 43, 616-629 (1967) 35. Verbrugghen, A.: Complications of iodopyracet (Diodrast) arteriography. Arch. Neurol. Psychiat. 71, 518-519 (1954) 36. Westberg, G.: Cannula for injection of contrast medium in cerebral angiography. Acta radiol. Diagn. 10, 553-556 (1970) 37. Whiteleather, J.E., DeSaussure, R.L.: Experience with new contrast medium (Hypaque) for cerebral angiography. Radiology 67, 537-543 (1956) 38. Zatz, L.M., Iannone, A.M.: Cerebral emboli complicating cerebral angiography. Acta radiol. Diagn. 5, 621-630 (1966) Received: September 23, 1977 Dr. Hans Olivecrona Department of Neuroradiology Karolinska sjukhuset S-104 01 Stockholm Sweden
Neuroradiology 14, 175-181 (1977)
© by Springer-Verlag 1977
Complications of Cerebral Angiography Hans Olivecrona Department of Ncuroradiology, Karolinska Sjukhuset, Stockholm, Sweden
Summary. All types of complications, both minor and major, are tabulated and analyzed in 5531 consecutive cerebral angiographies performed on 3730 patients during a period of 5 years.
Key words: Cerebral angiography - Complications.
Cerebral angiography, like other angiographic procedures, is associated with a certain degree of risk. Complications can be local, general, or cerebral. Local complications occur at the site of puncture; general adverse reactions are related to a hypersensitivity to the contrast medium used, or depend on a toxic effect of the contrast medium on the organism. Serious neurological complications are represented by new abnormal signs or symptoms or by aggravation of previously existing signs or symptoms. The majority of complications related to cerebral angiography are transient, but complications resulting in permanent neurological deficits do occur, and even deaths have been reported. The present report concerns a study in which all forms of complications were noted in the consecutive records of all angiographic examinations performed during a 5year period in the Department of Neuroradiology at the Karolinska Hospital, Stockholm, Sweden.
Material and Angiographic Technic The subject material for this study includes 5531 consecutive angiographies performed between 1970 and 1974 on 3730 patients, 2030 men (54.4%) and
1700 women (45.6%). In order to be able to conduct a prospective study of the incidence of complications, each patient had a detailed angiographic journal in which all findings concerning the state of the patient before the examination, during the actual performance of the examination and in the subsequent 24 h were registered. The type of examination, the technic of the procedure, the type of catheter and position of the catheter tip, the amount of contrast medium injected and the duration of the procedure were all recorded in detail at the time of the examination, as well as any complications, even slight ones not causing any discomfort to the patient. Angiography was performed under light sedation and local anesthesia with 1% Xylocain in 2922 patients (78.3%). General anesthesia with intubation was used in children and in uncooperative adults - altogether 808 patients (21.7%). The ages and sex distribution of the patients are shown in Table 1. A total of 3978 artery punctures were performed on the 3730 patients (Table 2). Most examinations were performed by the percutaneous femoral route (59.1%). The carotid arteries were used in 37.8% of cases (Table 2), the left somewhat more often than the right. Direct carotid angiography (Table 3) was performed in the vast majority of cases by using some form of catheter technic, either a polythene cannula devised by Westberg [36] consisting of a needle carrying a polythene catheter tightly wrapped around it, or by a catheter set devised by Bergstr6m and R~dberg [3] where the catheter is introduced into the common carotid artery over a guide wire. In a small number of patients, 1.2%, carotid angiography was performed after direct percutaneous puncture of the carotid artery with a needle. Puncture and catheterization of the brachial artery for retrograde vertebral angiography was performed
176
H. Olivecrona: Complications of Cerebral Angiography
Table 1. Age and sex distribution of 3730 patients
Age
Male
Female
Total
Per cent
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
57 99 202 254 366 535 446 70 1
33 51 149 196 331 445 428 63 4
90 150 351 450 697 980 874 133 5
2.4 4.0 9.4 12.1 18.7 26.3 23.4 3.6 0.1
Table 2. Arteries punctured
Number of punctures
Per cent
Femoral Right carotid Left carotid Right brachial Left brachial Vertebral
2352 667 837 69 46 7
59.1 16.8 21.0 1.7 1.2 0.2
Total
3978
in 2.9% of the punctures, while angiography after direct, percutaneous puncture of the vertebral artery with a needle was carried out in 0.2% (Table 2). The distribution of the 5531 angiographic examinations for the different types of investigations is shown in Table 4. Angiography of m o r e t h a n one vessel at the same sitting was p e r f o r m e d on 1283 patients, 34.1% of all. The contrast medium used was Isopaque cerebral (280 mg I/ml), each injection usually consisting of 8 ml of the medium, was made with a pressure injector (Cisal-I). E C G was always registered during t h e cerebral angiography. The catheter was flushed every minute with heparinized saline. After each examination a detailed report was p r e p a r e d and every type of complication arising was scrupulously noted. Each patient was observed for at least 24 h for possible sequelae to the investigation and all reactions of the patient during this period were entered in the record. Thus all types of complications which appeared either at the time of examination, or within the subsequent 24 h were registered in the angiographic record.
Results
Table 3. Technic for cerebral angiography after direct puncture of
the carotid artery Technic
Number of angiographies
Per cent of direct carotid punctures
Short catheter Needle
1473 31
97.9 2.1
Table 4. Type of examination in 5531 consecutive angiographies Type of angiography
Number of examinations
Per cent
Right internal carotid Right common carotid Left internal carotid Left common carotid Right external carotid Left external carotid Right vertebral Left vertebral Aorto-cervical Right subclavian Left subclavian Spinal
1764 225 1524 241 194 186 155 I000 214 5 7 16
31.9 4. i 27.5 4.3 3.5 3.4 2.8 18.1 3.9 0.1 0.1 0.3
No complication whatsoever in 2750 p a t i e n t s (73.7%) occurred. In the remaining 980 patients (26.3%) one or m o r e of the complications set out in Table 5 were noted in the angiographic record. A total of 1220 complications were registered, of which 861 were local, 191 general, and 168 neurological. One patient experienced transient yet rather severe pain in the leg, on the side of the femoral puncture during and after the examination. No study was m a d e of the iliac arteries or the arteries of the leg. One patient developed a purulent infection in the groin at the site of the puncture 2 days after the examination. Myocardial infarction occurred in one patient after puncture of the femoral artery before catheterization had taken place, and the procedure was terminated. One patient studied under general anesthesia suffered a t e m p o r a r y cardiac arrest after extubation. One patient had quickly subsiding bursts of extrasystoles. In three patients a m a r k e d bradycardia was registered in relation to the angiography. Two patients complained of transient retrosternal pain during the study. Most frequent of the general symptoms were nausea and vomiting, which were encountered in 2.4% of the patients. A sensitivity reaction with urticaria was seen in 1.6% while fainting and a condition of shock were noted in 0.5% of the patients.
H. Olivecrona: Complicationsof Cerebral Angiography A deterioration of the patient's general condition occurred in 0.4% of the cases after completion of the study, as compared with the state prior to angiography. H e m a t o m a was the most common local complication, being noted to a varying degree at 752 arterial puncture sites (18.9%). Hematomas occurred with 10.7% of the femoral, 25.3% of the carotid and 15.7% of the axillary or brachial punctures. In seven cases (0.2%), copious bleeding occurred from the site of puncture, in six patients after puncture of the femoral artery and in one after puncture of the carotid artery. The examination of three of these patients had to be postponed to a later date when it was successfully accomplished without complication. Perivascular injection of contrast medium was seen only in association with puncture of the carotid artery in the neck. This occurred in 2.9% of all carotid punctures (43 patients), representing 1.2% of the total number of patients. H e m a t o m a in the cervical region was noted in 55.8% of the perivascular contrast injections. Subintimal or intramural injection of contrast medium in the wall of the carotid artery occurred in 34 patients, 0.9% of all cases. Subintimal tear was more commonly seen after direct puncture of the carotid artery than after transfemoral catheterization, and occurred in 2. l % of all carotid punctures (31 patients). Thus, unsuccessful attempts at direct puncture of the carotid artery which resulted in perivascular or intramural injection of contrast medium occurred in 5% of percutaneous neck punctures. Transfemoral catheterization was only rarely associated with intramural injection of contrast medium in the wall of the carotid artery. This complication was met with in three patients, representing 0.1% of all examinations via the femoral route. Percutaneous femoral catheterization was followed in six patients by an intramural injection of contrast medium outside the carotid artery, namely in one patient in the brachiocephalic trunk, in the lumbar aorta of one patient suffering from Takayasu's disease, and in four patients in the common or external iliac artery. One patient had an intramural injection of contrast medium in the subclavian artery after catheterization from the axillary artery. Thus, intramural injection of contrast medium occurred in 41 patients altogether, i. e. in 1.1% of all patients. Vascular spasm located in relation to the tip of the catheter was noted in 23 patients, or in 0.4% of all angiographies. This complication occurred in 0.5% of carotid angiographies, and in 0.3% of vertebral angiographies. Signs of intracranial embolism with occlusion of arteries and abnormal local circulation with retro-
177 Table 5. Type of complicationin 5531 consecutiveangiographies Number of Per cent patients of patients A. Local complications
Pain in the leg on puncture side 1 Abscess at puncture site in the groin 1 Hematoma at the site of puncture 752 Perivascular injection of contrast medium 43 Intramural injection of contrast medium 34 Intramural injection outside carotid artery 7 Spasm at tip of the catheter 23
0.03 0.03 20.2 1.2 0.9 0.2 0.6
B. General complications
Myocardial infarction Cardiac arrest Retrosternal pain Extrasystoles Marked bradycardia Urticaria Nausea and vomiting Fainting, shock Deterioration of general condition
1 1 2 1 3 59 90 18 16
0.03 0.03 0.05 0.03 0.08 1.6 2.4 0.5 0.4
5 65 11 6 2 44 14 14 6 1
0.1 1.7 0.3 0.2 0.05 1.2 0.4 0.4 0.2 0.03
C. Neurological complications
Increased headache Agitation Vertigo Seizures of Jackson type Grand mal Increased somnolence Diagnosed catheter embolization Neurological deficits with pareses Precoma and coma Death
grade filling of peripheral arterial branches was seen in 15 patients, 0.4% of all carotid angiographies. There was no difference in the incidence of embolism between angiography performed via the transfemoral route or by direct puncture of the carotid artery. Cerebral complications with resulting paresis occurred in 14 patients, 0.4% of all patients (Table 6). Embolism was demonstrated angiographically in five patients, probably resulting from dislodgement of thrombotic material adhering to the surface of the catheter. Cerebral complications developed during vertebral angiography with ensuing permanent neurological deficits in two patients in the form of paresis of both arms, and quadriplegia, respectively. The catheter was placed in the carotid artery in 10 of the remaining 12 patients, and in the brachiocephalic of the other two; of these patients, five had left hemiparesis, six had right hemiparesis and aphasia, and one had right facial palsy and aphasia. The neurological symptoms were transient
178
H. Olivecrona: Complications of Cerebral Angiography
Table 6. Cerebral complications with resulting neurological
Table 7. Distribution of neurological complications according to
deficits
type of cerebral angiography
Case Age Vessel injected 1
55
BCT
2
59
BCT
3
40
RCA
4
44
RCA
Complication
Angiographic diagnosis
Artery injected
Per cent of all angiographies
Per cent of neurological complications
Left hemiparesis and confusion; permanent hemiparesis Left hemiparesis, somnolent 10 h after angiography; death 8 days later Left hemiparesis; complete recovery Left hemiparesis; complete recovery in 24 h Left hemiparesis; complete recovery in 24 h Right hemiparesis and aphasia; permanent sequelae
Attempt at angiography terminated Attempt at angiographyterminated
Right carotid Left carotid Right vertebral Left vertebral
4l 37 3 19
36 50 14 0
Glioma right temporal lobe Right-sided aneurysm and spasm Subarachnoid hemorrhage; no aneurysm found Control study after ligation of left-sided aneurysm Right hemiparesis Aneurysm anand aphasia; perma- terior comnent s e q u e l a e municating artery Right facial palsy and Left-sided aphasia; aphasia aneurysm cleared, but facial palsy remained Right hemiparesis Glioma left and aphasia; during temporal lobe angiography convulsions and then suddenly unresponsive; paresis cleared in 5 days, dysphatic because of temporal tumor Right hemiparesis Atherosclerosis and aphasia; somno- withectatic exlent after angiogtra- and intraraphy; symptoms cranial vessels cleared completely in 3 days Right hemiparesis; Previousknown anaphylactic shock malignantglioafter test injection of ma; attempt at contrast medium, angiography suddenly unresponterminated sive, temporary respiratory arrest; complete recovery in 24 h Right hemiparesis Cerebral contuand aphasia; comsion plete recovery in 7 days Marked weakness of Rightacoustic both arms; permaneuroma nent bilateral paresis of upper limbs Quadriplegiaw i t h Upper brain permanent tetrastem tumor paresis
5
28
RCA
6
53
LCA
7
42
LCA
8
39
LCA
9
53
LCA
10
52
LCA
11
41
LCA
12
20
LCA
13
53
RVA
14
41
RVA
BCT RCA LCA RVA
Brachiocephalic trunk Right carotid artery Left carotid artery Right vertebral artery
Table 8. Duration in hours of the examinations, given as their
percentage distribution Examination time in h 0-1
1-2
2-3
3-4
4-5
5-6
25.2
52.6
17.6
3.8
0.7
0.1
in seven, while four patients suffered p e r m a n e n t neurological sequelae with hemiparesis. One patient developed left hemiparesis during catheterization of the brachiocephalic trunk and died 8 days after the angiographic procedure. Autopsy revealed right cerebral infarction caused by an embolus in the middle cerebral artery. Microscopic examination showed that the embolus contained cholesterol crystals and it was assumed that it represented a dislodged atheromatous plaque from the cervical portion of the internal carotid artery. One patient with a transient cerebral complication reacted with anaphylactic shock after a test injection of 5 ml of the contrast m e d i u m into the carotid artery. It started with itching of the injected half of the face and was followed by violent sneezing and vomiting, and after a few minutes the patient b e c a m e hypotensive and suddenly unresponsive, with t e m p o r a r y respiratory arrest. After regaining consciousness the patient had right hemiparesis, which cleared completely within 24 h. Right carotid angiography was associated with some type of neurological complication in 0.25% of the cases, and left carotid angiography in 0.4%. By contrast right vertebral angiography was followed by neurological complication in 1.3% of the selective angiographies of this artery, while selective angiography of the left vertebral artery in this material did not give rise to any cerebral complications at all. A comparison between the percentage of various cerebral angiographies p e r f o r m e d and the percentage of neurological complications (Table 7) shows that right carotid angiography accounted for 4 1 % of all angiographies and 36% of the neurological complications, whereas the corresponding figures for left carotid angiography were 37 and 50% respectively. Right vertebral angiography constituted only 3% of all angiographies, but accounted for 14% of the
H. Olivecrona: Complications of Cerebral Angiography
neurological complications, while left vertebral angiography, comprising 19% of all cerebral angiographies, was entirely without cerebral complication. Agitation was registered in 65 cases, constituting 1.7% of the patients. Increased somnolence after completion of the examination was noted in 44 patients, or 1.2% of all patients. Six patients (0.2%) became comatose during angiography, though no deaths occurred among these patients in connection with or following the examination. Epileptic seizures of Jacksonian type were seen in six patients with intracranial tumors, and generalized seizures occurred in two patients, representing 0.2 and 0.05% of the patients, respectively (Table 5). Other neurological manifestations related to the angiographic procedure were transient disorders causing little discomfort to the patient. Five patients complained of increased headache after the examination, and 11 patients experienced varying degrees of vertigo, corresponding to 0.1 and 0.3% of the patients respectively. Thus, neurological symptoms arose in 168 cases (4.6% of all patients). Serious neurological complications with paresis occurred in 8.3% of all patients who showed some form of neurological dysfunction during or after angiography, and attributable to the procedure. Duration of the examination time is considered in Table 8, from which it can be seen that more than 75% of the investigations were performed in less than 2 h, and that less than 5% of the studies required more than 3 h to complete. The duration of the examination did not seem to bear any relation to the number of complications. It has been reckoned for the whole series that about 80% of the examinations were performed by the less experienced investigators and about 20% by the more qualified neuroradiologists with greater experience in the performance of cerebral angiography. In two cases of complications with paresis the investigator had less than one month of experience with neuroradiology, and in nine cases the examiner had between 2 and 6 months of training. In the remaining 3 cases of complications with motor deficits, corresponding to about 20% of such complications, the study was performed by thoroughly experienced neuroradiologists. Thus, in this material no definite difference in the incidence of serious neurological complications could be discerned between the less experienced and the more experienced investigators.
Discussion
The incidence of complications associated with cerebral angiography varies greatly in different reports, probably because of variations in the definition of complications and the manner of their evaluation.
179
Thus the incidence of complications reported varies between nil [27, 35, 37] and 15-20% [4, 5, 20, 34]. Generally speaking the complication rate is reported to vary between 1 and 10% [8, 11, 16, 19, 22, 23, 26, 28, 31, 32]. The incidence of angiographic complications with a fatal outcome is difficult to assess but is considered to vary within rather narrow limits, from nil to 1.6% [5, 16, 22, 23, 26, 29]. In the present series all types of complications were carefully registered in the angiographic report, whether they occurred during the course of study or within the succeeding 24 h. Even slight symptoms such as mild headache, slight nausea and occasional allergic skin reaction causing no distress to the patient were noted. The overall incidence of complications related to the angiographic procedure was about 22% of all angiographies, which might appear to be rather high, but if slight and trifling symptoms were excluded the percentage of complications would be only 4%, which is of about the same order as in several other reports. Hematoma of varying degree was the most common local complication. It was more frequently seen after direct puncture of the carotid artery than after puncture of the femoral artery, the incidence rates being 25 and 11% respectively. Amundsen et al. [2] reported a frequency of 13% for cervical hematoma after carotid puncture. Neither in the neck nor in the groin did any hematoma become so big as to necessitate surgical intervention with evacuation of blood, and none of the patients required tracheostomy. Nausea and vomiting were, as was also noted by T6rmfi and Fogelholm [34], the most common general symptoms, and appeared during angiography in 2.4% of all patients. These symptoms were usually of short duration, disappeared spontaneously before the investigation was completed, and did not interfere with its course. The incidence of sensitivity reaction with urticaria did not reach significant proportions. It was seen in 1.6% of patients, was usually slight with only a scanty rash, and in no case did the examination have to be terminated because of this. That sensitivity reactions such as nausea, vomiting, sneezing and urticaria constitute only a small minority of angiographic complications has also been pointed out by Decker [7], Eiken and Gormsen [10], and others. Local trauma to the carotid artery with consequent intramural injection of contrast medium is a fairly common cause of angiographic complication. Allen et al. [1] reported an incidence of 7.1% of subintimal or extraluminal contrast medium injection, and they further found that 62% of patients with a complication from needle carotid angiography had a subintimal injection of contrast medium.
180
In an earlier publication Saltzman [25] found the frequency of extravascular injection of contrast medium in connection with direct needle carotid angiography to be about 10%. In the present series the vast majority of the carotid studies were performed after transcarotid or transfemoral catheterization. Intramural or perivascular injection of contrast medium was seen in 2.1% of patients. The catheter technic used probably limits the occurrence of these complications, which were not followed by any other adverse events. The most serious complications of cerebral angiography concern the central nervous system, with the appearance of new abnormal neurological signs and symptoms, or with aggravation of previously existing signs or symptoms. These complications may be either temporary or permanent, immediate or delayed. Abnormal neurological signs may be paresis, dysphasia, visual impairment with field defects or blindness, or sensory symptoms with numbness and paresthesia. Such neurological complications may result from an embolus of thrombotic material outside or inside the catheter [38] and angiographically the embolism with ensuing local circulatory disturbance may be very inconspicuous and thus easily overlooked [6]. Catheter embolism was diagnosed in 15 patients, and this complication resulted in neurological deficits in five cases. Restoration of function occurred within 7 days in four patients, while in one patient it remained permanent. The overall incidence of neurological complications, including agitation, drowsiness, confusion, vertigo, seizures, pareses, stupor and coma, was 4.6%, affecting 168 patients in all. Fourteen patients developing pareses with or without aphasia represented 8.3% of the total number of neurological complications and 0.4% of all patients. The neurological deficit became permanent in six patients (0.2%). Neurological complications with pareses following cerebral angiography performed either by a direct puncture method or by transfemoral catheterization have been reported to vary between 0.2 and 2.4%, with permanent neurological sequelae in up to 0.7%, the mortality rate directly related to angiography reaching 0.8% [1, 2, 10, 11, 16, 19, 21-24, 26, 32-34]. In the present material there was one death, giving a mortality rate of 0.03 per cent. This patient died one week after angiography of extensive cerebral infarction caused by embolism of cholesterol material from an atheromatous plaque in the cervical portion of the internal carotid artery. The incidence of neurological complications with resulting motor deficiencies varied with the type of examination. Angiography of the right carotid artery
H. Olivecrona: Complications of Cerebral Angiography
had a complication rate of 0.25%, while the corresponding figures for left carotid angiography and right vertebral angiography were 0.4 and 1.3% respectively. Selective angiography of the left vertebral artery did not give rise to any serious neurological complications. The total frequency of such complications was 0.32% for carotid angiography and 0.17% for vertebral angiography. Thus, in the present material, the complication rate for vertebral angiography was lower than that for carotid angiography, a finding also noted by Perret and Nishioka [22]. Two patients developed signs of an anterior spinal artery syndrome with cervical myelopathy following catheter vertebral angiography. A direct neurotoxic effect of the contrast medium on the cervical spinal cord appears to be the most likely explanation [14, 15, 18]. Fried et al. [12] demonstrated how blood enters the cervical spinal cord in the low cervical area, and that most of this blood flows cephalad to the upper cervical segments. Spinal cord injury following vertebral angiography with the development of paralysis of both arms or quadriplegia is fortunately uncommon [9, 13, 17, 32, 33]. The cervical spinal cord might in such cases be more than ordinarily vulnerable to the contrast agent. The patient who developed quadriplegia had signs of dysfunction of the cervical spinal cord prior to the examination, and in such cases it is especially important to take certain precautions during the anglographic procedure in order to minimize the risk of spinal cord injury. Repeated injections should be avoided, particularly if transient spinal cord symptoms appear during the investigation. It is reasonable to assume that the risk of serious neurological complication becomes greater with increasing difficulty with selective catheterization of a vessel. The following vessels are listed in increasing order of difficulty with transfemoral catheterization of the aortocranial vessels: left vertebral artery, right carotid artery, left carotid artery, and right vertebral artery. Consequently, as was found in the present series, left vertebral angiography can be expected to cause the fewest complications, whereas, according to such an assumption, right vertebral angiography is the most dangerous of the various types of cerebral angiography, which was also true in this study. T6rmfi and Fogelholm [34] also found more complications with right vertebral than with left vertebral angiography. Furthermore, and in agreement with this hypothesis, somewhat fewer complications were encountered with right carotid than with left carotid angiography. All examinations were carried out under the supervision of experienced neuroradiologists. With
H. Olivecrona: Complications of Cerebral Angiography
regard to the incidence of serious cerebral complications, no definite difference could be established between the experienced and the less experienced operators, a finding also reported by Lester and Klee [16] and Takahashi and Kawanami [32]. However, it might well be, as pointed out by Lester and Klee [16], that the less experienced examiners are more apt to occasion a greater number of local complications than the more experienced.
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181 19. Patterson, R.H., Goodell, H., Dunning, H.S.: Complications of carotid arteriography. Arch. Neurol. 10, 513-520 (1964) 20. Perese, D.M., Kite, W.C., Bedell, A.J., Campbell, E.: Complications following cerebral angiography. Arch. Neurol. Psychiat. 71, 105-115 (1954) 21. Perret, G.: Diagnostic value and complications of carotid and vertebral angiography. Acta radiol. Diagn. 5, 453-457 (1966) 22. Perret, G., Nishioka, H.: Cerebral angiography. An analysis of the diagnostic value and complications of carotid and vertebral angiography in 5484 patients. J. Neurosurg. 25, 98-114 (1966) 23. Pribram, H.F.W.: Complications of angiography in cerebrovascular disease. Radiology 85, 33-37 (1965) 24. Ruggiero, G., Thibaut, A., Bories, J.: L'art6riographie vertrbrale dans le diagnostic neuro-chirurgical. Acta radiol. 50, 365-380 (1958) 25. Saltzman, G.-F.: Angiographic demonstration of the posterior communicating and posterior cerebral arteries. I. Normal angiography. Acta radiol. 52, 1-20 (1959) 26. Scheinberg, P., Zunker, E.: Complications in direct percutaneous carotid arteriography. Arch. Neurol. 8, 676-684 (1963) 27. Sedzimir, C.B.: Towards safer angiography. J. Neurosurg. 12, 460-467 (1955) 28. Silverstein, A., Krieger, H.P.: Complications of cerebral angiography: a supplementary report. J. Sinai Hosp. 27, 1-4 (1960) 29. Silverstein, A.: Arteriography of stroke. III. Complications. Arch. Neurol. 15, 206-210 (1966) 30. Takahashi, M., Wilson, G., Hanafee, W.: Catheter vertebral angiography: A review of 300 examinations. J. Neurosurg. 30, 722-731 (1969) 31. Takahashi, M., Wilson, G., Hanafee, W.: Diagnostic value of catheter vertebral angiography. Review of 250 examinations. Acta radiol. Diagn. 9, 494-502 (1969) 32. Takahashi, M., Kawanami, H.: Femoral catheter techniques in cerebral angiography - an analysis of 422 examinations. Brit. J. Radiol. 43, 771-775 (1970) 33. Takahashi, M., Kawanami, H.: Complications of catheter cerebral angiography. An analysis of 500 examinations. Acta radiol. Diagn. 13, 248-258 (1972) 34. T6rm~i, T., Fogelholm, R.: Complications of cerebral angiography with Urografin. Acta neurol, scand. 43, 616-629 (1967) 35. Verbrugghen, A.: Complications of iodopyracet (Diodrast) arteriography. Arch. Neurol. Psychiat. 71, 518-519 (1954) 36. Westberg, G.: Cannula for injection of contrast medium in cerebral angiography. Acta radiol. Diagn. 10, 553-556 (1970) 37. Whiteleather, J.E., DeSaussure, R.L.: Experience with new contrast medium (Hypaque) for cerebral angiography. Radiology 67, 537-543 (1956) 38. Zatz, L.M., Iannone, A.M.: Cerebral emboli complicating cerebral angiography. Acta radiol. Diagn. 5, 621-630 (1966) Received: September 23, 1977 Dr. Hans Olivecrona Department of Neuroradiology Karolinska sjukhuset S-104 01 Stockholm Sweden
