Neurochirurgia 19 (1976) 26-29 © Georg Thieme Verlag Stuttgart
Perangiographic Rupture of a Right Posterior Communicating Artery Aneurysm N. de Tribolet1, R. Oberson2, E. Zander1 Departments of Neurosurgery 1 and Radiology 2 , CHUV Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Contrast material was seen to extravásate twice from a posterior communicating arterial aneurysm during injection of the internal carotid artery under local anesthesia. The patient made full recovery. The aneurysm was then successfully clipped. The authors review related reports. The increase in distal arterial pressure is thought to be the cause of the aneurysmal rupture. Key-Words: Posterior communicating artery aneurysm - subarachnoid extravasation - cerebral angiography - meningeal haemorrhage.
Zusammenfassung Die Autoren berichten über Klinik und Radiologie eines Falls mit einem Aneurysma der arteria communicans posterior, das während der Katheterangiographie der Arteria carotis interna rupturiert. Die Kontrast-Extravasation wird zweimal beobachtet. Die Patientin erholt sich vollständig und das Aneurysma wird später erfolgreich mit einem Clip ausgeschaltet. Die entsprechende Literatur wird besprochen. Als Ursache der Ruptur wird die per-angiographische Erhöhung des peripheren arteriellen Druckes angenommen.
Extravasation of contrast material during cerebral angiography is rare b u t has been described as occuring in intracerebral haem a t o m a (9), t r a u m a t i c vascular r u p t u r e (4), subarachnoid h a e m o r r h a g e (1, 5, 6, 7, 8) and even from t h e anterior spinal artery (2). W e are reporting one case of perangiographic r u p t u r e with massive extravasation of contrast material from a right posterior c o m m u n i c a t ing aneurysm. T h e patient survived a n d her
aneurysm w a s successfully clipped. T h e relationship b e t w e e n injection of c o n t r a s t and r u p t u r e of a n e u r y s m is discussed.
Case report This 27-year-old woman suffered acute severe right orbital headache with vomiting and photophobia on October 27, 1973. On November 1st, she noticed ptosis of her right eyelid and on the 11th she developed a right oculomotor palsy and was admitted to the hospital. Her general physical examination was within normal limits. On neurological examination there was a complete right third netve palsy with a fixed dilated pupil. Ophthalmoscopy was normal on both sides. Laboratory investigations including complete blood count, electrolytes and BUN were normal. A lumbar puncture yielded a xanthochromic fluid with a pressure of 13 cm H 2 0 . Cytology of the fluid revealed the presence of 2,500 erythrocytes and 23 leucocytes per mm 3 (lymphocytes 64 °/o, monocytes 33 %>, reticulum cells 3 °/o, many erythrophages and haemophages were present). On November 13th a right carotid angiogramm was performed under local anaesthesia. The right femoral artery was punctured and a red Formocath B. D. (ID 0.047" and OD 0.086") introduced into the right internal carotid artery at the level of C 2-C 3. Eight ml of contrast material (monoethanolamine ioxithalamate, Vasobrix 32 Guerbet) were injected with a CISAL pneumatic pump with a 0.1 linear rise of pressure (ca. 200 lb per square inch) in 1.5 sec for simultaneous stereoscopic lateral views (Fig. 1). After the injection the patient complained of mild headache. The frontal series was then taken by the same technique (Fig. 2). During the second injection the patient developed extension spasms of the four limbs, deep coma, Cheyness-Stokes respiration, and urine loss. The right pupil was fixed and dilated (as before angiography) and a big retinal haemor-
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Summary
27
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Perangiographic Rupture of a Right Posterior Communicating Artery Aneurysm
Fig. 1: First injection in the internal carotid artery. Lateral view. Note: - 1. a saccular aneurysm at the origin of the posterior communicating artery (—>). 2. opacification of the basilar artery and both vertebral artery ( -{—>). 3. a small extravasation of contrast material (-0—>•). rhage covering the whole temporal half of the right retina was seen. The left pupil reacted normally to light. Immediate reanimation was undertaken and papaverin and Decadron was given i. v. After 15 minutes the patient regained consciousness but showed a left hemiparesis which disappeared within 45 minutes. A cortical
Fig. 2
Fig. 2: Second injection. Frontal views. Note: 1. the catheter in the internal carotid at the level of C 2 (—>-) in a. the arterial phase. 2. the extravasation of contrasted blood into the basal cisterns (white arrows) at b. the arteriolar phase. 3. contrast medium in the cisterna magna (-)—>•) at c. the venous phase. Subtraction was only possible in the venous phase. Before, the patient was restless.
N. de Tribolet, R. Oberson, E. Zander
blindness persisted for about 3 hours. It is noteworthy that after the aneurysmal rupture the right ptosis cleared. The films show an aneurysm located on the right posterior communicating artery at its origin from the internal carotid artery. A slight extravasation of contrast material is seen on the lateral films (Fig. 1) extending into the cisterna ambiens. On the frontal views (Fig. 2), a second extravasation of contrast medium is demonstrated. A larger amount of contrasted blood is seen in the basal cisterns and in the cisterna magna. No vascular spasm can be seen. On November 29th after a right fronto-temporal craniotomy a clip was placed on the neck of the aneurysm (E. Z.). No haematoma was found. The postoperative course was uneventful. A control right carotid angiogram, by direct puncture of the common carotid artery, was done on December 12th, and showed absence of opacification of the aneurysm and a patient right posterior communicating artery (Fig. 3). When the patient was discharged on December 17th, a right third nerve paresis with a fixed dilated pupil persisted. Neurological examination was otherwise normal. When checked 8 months and 18 months later the neurological examination was unchanged. The right retinal haemorrhage had partially cleared. No signs of hydrocephalus were noted. The patient was working full time.
Fig. 3: Right common carotid injection 13 days after operation. See the posterior communicating
Discussion According to the literature this is the 22nd case of perangiographic rupture of an intracranial arterial saccular aneurysm, and is the 5th to survive (1, 5, 7, 8). Triska's case reported by Someda as having survived, did in fact die (6). The question arises of knowing whether the perangiographic bleeding is caused by angiography or simply coincides with it. In our case, there is a clear relationship between injection and haemorrhage. During the first injection a small amount of contrast material leaked into the subarachnoid space and during the second, massive haemorrhage occured. Pressure in the right carotid territory was notably increased as is demonstrated by massive reflux through the posterior communicating artery into the basilar artery and extending down both vertebral arteries to the level of C I . This reflux is also considered by Vines and Davis (7) as being a proof of increased pressure. In addition, Lin (3) reports that rapid injection of contrast material into the brachial artery causes a transient increase in carotid artery pressure.
artery (—>) and the surgical clip ( + —>•) obstructing the neck of the aneurysm which is no longer visible.
Downloaded by: Universite de Sherbrooke. Copyrighted material.
28
29 suggest placing the needle or the tip of the catheter in the common carotid artery. Another interesting feature of our case is the transient cortical blindness which developed after angiography. This is most probably related to the reflux of contrast into both posterior cerebral arteries rather than to subarachnoid extravasation. Transient cortical blindness is a well known complication of vertebral angiography (2).
References 1 Gerlock, A. ].: Rupture of posterior inferior cerebellar artery aneurysm into the subarachnoid space during angiography. Case report. J. Neurosurg. 42 (1975) 469-472 2 Horwitz, N. H, L. Werner: Temporary cortical blindness following angiography. J. Neurosurg. 40 (1974) 583-86 3 Janon, E. A.: Artériographie demonstration of spontaneous spinal subarachnoid hemorrhage. Case report. Radiology 97 (1970) 385-386 4 Lin, J. P., Ï. I. Kricbeff, N. E. Chase: Blood pressure changes during retrograde brachial angiography. Radiology 83 (1964) 640-646 5 Rudikoff, J. C, E. J. Ferris, J. H. Shapiro: Intracerebral vascular rupture. Radiology 90 (1968) 288-291 6 Someda, K., N. Yasni, Y. Moriwaki et al.: Extravasation Roland C
7 8 9 10
of contrast material into subdural space from internal carotid aneurysm during angiography. Case report. J. Neurosurg. 42 (1975) 473-477 Triska, H. von: Ein Fall von Kontrastmittelextravasat bei einem ruptierten Aneurysma der Art. cerebri media. Zbl. Neurochir. 22 (1962) 291-295 Vines, F. S., D. O. Davis: Rupture of intracranial aneurysm at angiography. Radiology 99 (1971) 353-354 Waga, S., A. Hondo, K. Moritake et al.: Rupture of intracranial aneurysm during angiography. Neuroradiology 5 (1973) 169-173 Wolpert, S. M., S. C. Schatzki: Extravasation of contrast material in the intracerebral basal ganglia. Radiology 102 ¡1972) 83-85
•son, Neuroradiology CHUV, CH-1011 Lausanne, Switzerland
Downloaded by: Universite de Sherbrooke. Copyrighted material.
On the other hand, the stress of the angiographic procedure, which may be of some duration, especially when four vessel angiography is needed, may contribute to a rise in the systemic arterial pressure (6). We therefore recommend that in the investigation of a subarachnoid haemorrhage, angiography should be performed under general anaesthesia. The injection should be made gently with a slow rise of pressure or by hand. We also
Perangiographic Rupture of a Right Posterior Communicating Artery Aneurysm N. de Tribolet1, R. Oberson2, E. Zander1 Departments of Neurosurgery 1 and Radiology 2 , CHUV Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Contrast material was seen to extravásate twice from a posterior communicating arterial aneurysm during injection of the internal carotid artery under local anesthesia. The patient made full recovery. The aneurysm was then successfully clipped. The authors review related reports. The increase in distal arterial pressure is thought to be the cause of the aneurysmal rupture. Key-Words: Posterior communicating artery aneurysm - subarachnoid extravasation - cerebral angiography - meningeal haemorrhage.
Zusammenfassung Die Autoren berichten über Klinik und Radiologie eines Falls mit einem Aneurysma der arteria communicans posterior, das während der Katheterangiographie der Arteria carotis interna rupturiert. Die Kontrast-Extravasation wird zweimal beobachtet. Die Patientin erholt sich vollständig und das Aneurysma wird später erfolgreich mit einem Clip ausgeschaltet. Die entsprechende Literatur wird besprochen. Als Ursache der Ruptur wird die per-angiographische Erhöhung des peripheren arteriellen Druckes angenommen.
Extravasation of contrast material during cerebral angiography is rare b u t has been described as occuring in intracerebral haem a t o m a (9), t r a u m a t i c vascular r u p t u r e (4), subarachnoid h a e m o r r h a g e (1, 5, 6, 7, 8) and even from t h e anterior spinal artery (2). W e are reporting one case of perangiographic r u p t u r e with massive extravasation of contrast material from a right posterior c o m m u n i c a t ing aneurysm. T h e patient survived a n d her
aneurysm w a s successfully clipped. T h e relationship b e t w e e n injection of c o n t r a s t and r u p t u r e of a n e u r y s m is discussed.
Case report This 27-year-old woman suffered acute severe right orbital headache with vomiting and photophobia on October 27, 1973. On November 1st, she noticed ptosis of her right eyelid and on the 11th she developed a right oculomotor palsy and was admitted to the hospital. Her general physical examination was within normal limits. On neurological examination there was a complete right third netve palsy with a fixed dilated pupil. Ophthalmoscopy was normal on both sides. Laboratory investigations including complete blood count, electrolytes and BUN were normal. A lumbar puncture yielded a xanthochromic fluid with a pressure of 13 cm H 2 0 . Cytology of the fluid revealed the presence of 2,500 erythrocytes and 23 leucocytes per mm 3 (lymphocytes 64 °/o, monocytes 33 %>, reticulum cells 3 °/o, many erythrophages and haemophages were present). On November 13th a right carotid angiogramm was performed under local anaesthesia. The right femoral artery was punctured and a red Formocath B. D. (ID 0.047" and OD 0.086") introduced into the right internal carotid artery at the level of C 2-C 3. Eight ml of contrast material (monoethanolamine ioxithalamate, Vasobrix 32 Guerbet) were injected with a CISAL pneumatic pump with a 0.1 linear rise of pressure (ca. 200 lb per square inch) in 1.5 sec for simultaneous stereoscopic lateral views (Fig. 1). After the injection the patient complained of mild headache. The frontal series was then taken by the same technique (Fig. 2). During the second injection the patient developed extension spasms of the four limbs, deep coma, Cheyness-Stokes respiration, and urine loss. The right pupil was fixed and dilated (as before angiography) and a big retinal haemor-
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Summary
27
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Perangiographic Rupture of a Right Posterior Communicating Artery Aneurysm
Fig. 1: First injection in the internal carotid artery. Lateral view. Note: - 1. a saccular aneurysm at the origin of the posterior communicating artery (—>). 2. opacification of the basilar artery and both vertebral artery ( -{—>). 3. a small extravasation of contrast material (-0—>•). rhage covering the whole temporal half of the right retina was seen. The left pupil reacted normally to light. Immediate reanimation was undertaken and papaverin and Decadron was given i. v. After 15 minutes the patient regained consciousness but showed a left hemiparesis which disappeared within 45 minutes. A cortical
Fig. 2
Fig. 2: Second injection. Frontal views. Note: 1. the catheter in the internal carotid at the level of C 2 (—>-) in a. the arterial phase. 2. the extravasation of contrasted blood into the basal cisterns (white arrows) at b. the arteriolar phase. 3. contrast medium in the cisterna magna (-)—>•) at c. the venous phase. Subtraction was only possible in the venous phase. Before, the patient was restless.
N. de Tribolet, R. Oberson, E. Zander
blindness persisted for about 3 hours. It is noteworthy that after the aneurysmal rupture the right ptosis cleared. The films show an aneurysm located on the right posterior communicating artery at its origin from the internal carotid artery. A slight extravasation of contrast material is seen on the lateral films (Fig. 1) extending into the cisterna ambiens. On the frontal views (Fig. 2), a second extravasation of contrast medium is demonstrated. A larger amount of contrasted blood is seen in the basal cisterns and in the cisterna magna. No vascular spasm can be seen. On November 29th after a right fronto-temporal craniotomy a clip was placed on the neck of the aneurysm (E. Z.). No haematoma was found. The postoperative course was uneventful. A control right carotid angiogram, by direct puncture of the common carotid artery, was done on December 12th, and showed absence of opacification of the aneurysm and a patient right posterior communicating artery (Fig. 3). When the patient was discharged on December 17th, a right third nerve paresis with a fixed dilated pupil persisted. Neurological examination was otherwise normal. When checked 8 months and 18 months later the neurological examination was unchanged. The right retinal haemorrhage had partially cleared. No signs of hydrocephalus were noted. The patient was working full time.
Fig. 3: Right common carotid injection 13 days after operation. See the posterior communicating
Discussion According to the literature this is the 22nd case of perangiographic rupture of an intracranial arterial saccular aneurysm, and is the 5th to survive (1, 5, 7, 8). Triska's case reported by Someda as having survived, did in fact die (6). The question arises of knowing whether the perangiographic bleeding is caused by angiography or simply coincides with it. In our case, there is a clear relationship between injection and haemorrhage. During the first injection a small amount of contrast material leaked into the subarachnoid space and during the second, massive haemorrhage occured. Pressure in the right carotid territory was notably increased as is demonstrated by massive reflux through the posterior communicating artery into the basilar artery and extending down both vertebral arteries to the level of C I . This reflux is also considered by Vines and Davis (7) as being a proof of increased pressure. In addition, Lin (3) reports that rapid injection of contrast material into the brachial artery causes a transient increase in carotid artery pressure.
artery (—>) and the surgical clip ( + —>•) obstructing the neck of the aneurysm which is no longer visible.
Downloaded by: Universite de Sherbrooke. Copyrighted material.
28
29 suggest placing the needle or the tip of the catheter in the common carotid artery. Another interesting feature of our case is the transient cortical blindness which developed after angiography. This is most probably related to the reflux of contrast into both posterior cerebral arteries rather than to subarachnoid extravasation. Transient cortical blindness is a well known complication of vertebral angiography (2).
References 1 Gerlock, A. ].: Rupture of posterior inferior cerebellar artery aneurysm into the subarachnoid space during angiography. Case report. J. Neurosurg. 42 (1975) 469-472 2 Horwitz, N. H, L. Werner: Temporary cortical blindness following angiography. J. Neurosurg. 40 (1974) 583-86 3 Janon, E. A.: Artériographie demonstration of spontaneous spinal subarachnoid hemorrhage. Case report. Radiology 97 (1970) 385-386 4 Lin, J. P., Ï. I. Kricbeff, N. E. Chase: Blood pressure changes during retrograde brachial angiography. Radiology 83 (1964) 640-646 5 Rudikoff, J. C, E. J. Ferris, J. H. Shapiro: Intracerebral vascular rupture. Radiology 90 (1968) 288-291 6 Someda, K., N. Yasni, Y. Moriwaki et al.: Extravasation Roland C
7 8 9 10
of contrast material into subdural space from internal carotid aneurysm during angiography. Case report. J. Neurosurg. 42 (1975) 473-477 Triska, H. von: Ein Fall von Kontrastmittelextravasat bei einem ruptierten Aneurysma der Art. cerebri media. Zbl. Neurochir. 22 (1962) 291-295 Vines, F. S., D. O. Davis: Rupture of intracranial aneurysm at angiography. Radiology 99 (1971) 353-354 Waga, S., A. Hondo, K. Moritake et al.: Rupture of intracranial aneurysm during angiography. Neuroradiology 5 (1973) 169-173 Wolpert, S. M., S. C. Schatzki: Extravasation of contrast material in the intracerebral basal ganglia. Radiology 102 ¡1972) 83-85
•son, Neuroradiology CHUV, CH-1011 Lausanne, Switzerland
Downloaded by: Universite de Sherbrooke. Copyrighted material.
On the other hand, the stress of the angiographic procedure, which may be of some duration, especially when four vessel angiography is needed, may contribute to a rise in the systemic arterial pressure (6). We therefore recommend that in the investigation of a subarachnoid haemorrhage, angiography should be performed under general anaesthesia. The injection should be made gently with a slow rise of pressure or by hand. We also
