Rupture of posterior inferior cerebellar artery aneurysm into the subarachnoid space during angiography Case report
AMIL JAMES GERLOCK, JR., M . D .
Department of Radiology, The University of Texas Health Science Center at Dallas, Dallas, Texas v' The author reports a case of angiographically-demonstratedaneurysmal rupture, and reviews related reports. KEY WORDS 9 posterior inferior cerebellar artery subarachnoid extravasation 9 angiography
r"r~HE following is a report of a verltebrobasilar system aneurysm that -L leaked into the subarachnoid space during angiography; delayed films show the contrast material filling the posterior aspect of the third ventricle. Case Report
A 56-year-old woman was admitted in a semiconscious state following a severe headache. Examination. Examination showed minimal response to painful stimulation; her neck was stiff, and she was unable to move the right eye past the midline. She had a decreased right corneal reflex, no gag reflex, and bilaterally positive Babinski's reflex. A lumbar puncture was not done. A diagnosis of subarachnoid hemorrhage was made, and J. Neurosurg. / Volume 42 / April, 1975
9 aneurysm
9
carotid and vertebral angiography were immediately performed. Angiographic Examination. Both carotid arterial circulations were studied by selective internal carotid artery catheterization: Conray 60, 10 ml/sec, was injected into each internal carotid artery percutaneously through a Torcon Headhunter Catheter I,* 100 cm long, 6.5 F, lumen 1.09 mm end hole catheter, at 300 psi, via the right femoral artery. No aneurysm was demonstrated. The patient began to show signs of apnea following the internal carotid artery injections. Intubation was immediately performed and her respiration assisted; the blood pressure *Torcon Headhunter Catheter I manufactured by Cook Incorporated, 925 South Curry Pike, P.O. Box 489, Bloomington, Indiana 47401. 469
A. J. Gerlock, Jr. remained stable and the pulse rate rose to 100. Selective catheterization of the left vertebral artery was performed; 7 ml/sec of Conray 60 was injected at 300 psi. Again, no aneurysm was seen, but there was slow flow and poor filling of the vertebrobasilar system (Fig. 1). The left vertebral artery showed an area of narrowing proximal to the origin of the left posterior inferior cerebellar artery (PICA), believed to represent arterial spasm as a result of the subarachnoid hemorrhage. The right vertebral artery was then immediately selectively catheterized and 7 cc of contrast medium injected at 300 psi. This revealed gross subarachnoid extravasation of the contrast medium into the cisterna magna and right cerebellopontine angle cistern; Conray appeared to fill the fourth ventricle and posterior aspect of the third ventricle (Fig. 2). A saccular aneurysm was now seen in the region of the PICA and was believed to represent the site of aneurysmal rupture. The patient died approximately 2 hours following the angiographic examination.
FIG. I. Angiogram, left vertebral artery injection. The arrow points to the area of arterial narrowing proximal to the origin of the left PICA. There is no reflux of contrast media into the right vertebral artery.
FI~. 2. Angiograms, right selective vertebral artery injection. Left: Anteroposterior view shows extravasation of contrast agent into the right cerebellopontine angle cistern (solid arrow) and saccular aneurysm at the site of origin of the right PICA (small open arrow). Large open arrow points to contrast agent extravasated into the cisterna magna. Right." Lateral view. Solid arrow points to contrast medium in posterior aspect of third ventricle, while open arrow points to contrast-filled fourth ventricle. 470
J. Neurosurg. / Volume 42 / April, 1975
Rupture of PICA aneurysm during angiography TABLE 1 Reported cases of extravasation from intracranial aneurysms at angiography
Author, Year
Artery of Extravasation*
Contrast A g e n t and Dosage
Pressure
Gerlock, 1975 Goldstein, 1967 Hoff & Potts, 1969 Jackson, et al., 1960 Jamieson, 1954 Jenkinson, et al., 1954 Lehrer, et al., 1972
rt PICA
300 psi
died
hand inj.
died
hand inj.
died
Murphy & Goldberg, 1967 Triska, 1962 Vines & Davis, 1971
rt supraclin.
Conray 60, 7 ml Renografin 60, 8 ml 50 ~ Hypaque, 6 ml 507o Hypaque, 5 ml Uridone, 15 ml 35 7o Diodrast, 8 ml 50~o Hypaque, 50 ml, brachial inj. 50~o Hypaque, 15 ml 60 ~o Urografin
rt post. comm. basilar rt supraclin. rt mid. cerebral rt supraclin. ant. comm.
mid. cerebral rt post. comm.
Conray 60, 9 ml
Survival
died died died 400 psi
died
hand inj.
died died
200 psi
alive
* PICA = posterior inferior cerebellar artery.
Discussion Extravasation of contrast material during angiography of carotid circulation aneurysms is a rare complication. Fortunately, it is even rarer from the vertebrobasilar circulation. Hoff and Potts a reported leakage of contrast material following vertebra/ angiography in a patient with an arteriosclerotic aneurysm of the basilar artery; the contrast material appeared to pass from the subarachnoid space into the fourth ventricle via the right foramen of Luschka. There have been many case reports of ruptured aneurysms in which the extravasation was demonstrated by angiography. The majority of these aneurysms have been in the carotid circulation (Table 1), which is not surprising if 80% of berry aneurysms occur there? What is surprising is the readiness with which the performance of angiography has been accepted as an etiological factor in causing these aneurysms to rupture. However, all of the patients listed in Table 1 had had clinical signs and symptoms of subarachnoid hemorrhage and were seriously ill prior to the J. Neurosurg. / Volume 42 / April, 1975
performance of angiography. Perhaps then, the extravasated contrast material seen in our case as well as others serves only to diagnose the site of a bleeding aneurysm, rather than to represent rupture of the aneurysm because of the arterial injection. Bakay and Sweet 1 found no increase in internal carotid artery pressure in five patients when a 10 to 12 ml bolus was injected into the common carotid artery in 2 to 3 seconds. One certainly should not ignore the deleterious effects of repeated heparin solution flushings through catheters opening into the internal carotid and vertebral arteries, or the vasodilating effect of the contrast medium itself. Clinical observation of reflux of injected contrast material into the opposite vertebral artery or various portions of the circle of Willis during an arterial injection may also be important. Until these factors have been completely investigated, extravasation from an aneurysm at the time of angiography probably should be regarded only as a bad prognostic sign rather than the result of the procedure. 471
A. J. Gerlock, Jr. References 1. Bakay L, Sweet WH: Cervical and intracranial intra-arterial pressures with and without vascular occlusion. Surg Gynec Obstet 95:67-75, 1952 2. Goldstein SL: Ventricular opacification secondary to rupture of intracranial aneurysm during angiography. Case report. J Neurosurg 27:265-267, 1967 3. Hoff JT, Potts DG: Angiographic demonstration of hemorrhage into the fourth ventricle. Case report. J Neurosurg 30:732-735, 1969 4. Jackson JR, Tindall GT, Nashold BS Jr: Rupture of an intracranial aneurysm during carotid arteriography. A case report. J Neurosurg 17:333-336, 1960 5. Jamieson KG: Rupture of an intracranial aneurysm during cerebral angiography. J Neurosurg 11:625-628, 1954 6. Jenkinson EL, Sugar O, Love H: Rupture of an aneurysm of the internal carotid artery during cerebral angiography. Case report. Am J Roentgenol Rad Ther Nucl Med 71:958-960, 1954 7. Lehrer HZ, Gross LA, Poon TP: Ruptured intracranial aneurysm. Contrast agent ex-
A72
8.
9.
10.
11.
travasation during brachial arteriography. Arch Neurol 27:351-353, 1972 Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section 5, Part 2. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations based on 6368 cases in the cooperative study. J Neurosurg 25:219-239, 1966 Murphy DJ, Goldberg R J: Extravasation from an intracranial aneurysm during carotid angiography. Case report. J Neurosurg 27:459-461, 1967 Triska Von H: Ein Fall yon Kontrastmittelextravasat bei einem ruptierten Aneurysm der Art cerebri media. Zentraibl Neurochir 22:291-295, 1962 Vines FS, Davis DO: Rupture of intracranial aneurysm at angiography. Radiology 99:353-354, 1971
Address reprint requests to: Amil J. Gerlock, M.D., Department of Radiology, The University of Texas Health Science Center at Dallas, Dallas, Texas.
J. Neurosurg. / Volume 42 / April, 1975
AMIL JAMES GERLOCK, JR., M . D .
Department of Radiology, The University of Texas Health Science Center at Dallas, Dallas, Texas v' The author reports a case of angiographically-demonstratedaneurysmal rupture, and reviews related reports. KEY WORDS 9 posterior inferior cerebellar artery subarachnoid extravasation 9 angiography
r"r~HE following is a report of a verltebrobasilar system aneurysm that -L leaked into the subarachnoid space during angiography; delayed films show the contrast material filling the posterior aspect of the third ventricle. Case Report
A 56-year-old woman was admitted in a semiconscious state following a severe headache. Examination. Examination showed minimal response to painful stimulation; her neck was stiff, and she was unable to move the right eye past the midline. She had a decreased right corneal reflex, no gag reflex, and bilaterally positive Babinski's reflex. A lumbar puncture was not done. A diagnosis of subarachnoid hemorrhage was made, and J. Neurosurg. / Volume 42 / April, 1975
9 aneurysm
9
carotid and vertebral angiography were immediately performed. Angiographic Examination. Both carotid arterial circulations were studied by selective internal carotid artery catheterization: Conray 60, 10 ml/sec, was injected into each internal carotid artery percutaneously through a Torcon Headhunter Catheter I,* 100 cm long, 6.5 F, lumen 1.09 mm end hole catheter, at 300 psi, via the right femoral artery. No aneurysm was demonstrated. The patient began to show signs of apnea following the internal carotid artery injections. Intubation was immediately performed and her respiration assisted; the blood pressure *Torcon Headhunter Catheter I manufactured by Cook Incorporated, 925 South Curry Pike, P.O. Box 489, Bloomington, Indiana 47401. 469
A. J. Gerlock, Jr. remained stable and the pulse rate rose to 100. Selective catheterization of the left vertebral artery was performed; 7 ml/sec of Conray 60 was injected at 300 psi. Again, no aneurysm was seen, but there was slow flow and poor filling of the vertebrobasilar system (Fig. 1). The left vertebral artery showed an area of narrowing proximal to the origin of the left posterior inferior cerebellar artery (PICA), believed to represent arterial spasm as a result of the subarachnoid hemorrhage. The right vertebral artery was then immediately selectively catheterized and 7 cc of contrast medium injected at 300 psi. This revealed gross subarachnoid extravasation of the contrast medium into the cisterna magna and right cerebellopontine angle cistern; Conray appeared to fill the fourth ventricle and posterior aspect of the third ventricle (Fig. 2). A saccular aneurysm was now seen in the region of the PICA and was believed to represent the site of aneurysmal rupture. The patient died approximately 2 hours following the angiographic examination.
FIG. I. Angiogram, left vertebral artery injection. The arrow points to the area of arterial narrowing proximal to the origin of the left PICA. There is no reflux of contrast media into the right vertebral artery.
FI~. 2. Angiograms, right selective vertebral artery injection. Left: Anteroposterior view shows extravasation of contrast agent into the right cerebellopontine angle cistern (solid arrow) and saccular aneurysm at the site of origin of the right PICA (small open arrow). Large open arrow points to contrast agent extravasated into the cisterna magna. Right." Lateral view. Solid arrow points to contrast medium in posterior aspect of third ventricle, while open arrow points to contrast-filled fourth ventricle. 470
J. Neurosurg. / Volume 42 / April, 1975
Rupture of PICA aneurysm during angiography TABLE 1 Reported cases of extravasation from intracranial aneurysms at angiography
Author, Year
Artery of Extravasation*
Contrast A g e n t and Dosage
Pressure
Gerlock, 1975 Goldstein, 1967 Hoff & Potts, 1969 Jackson, et al., 1960 Jamieson, 1954 Jenkinson, et al., 1954 Lehrer, et al., 1972
rt PICA
300 psi
died
hand inj.
died
hand inj.
died
Murphy & Goldberg, 1967 Triska, 1962 Vines & Davis, 1971
rt supraclin.
Conray 60, 7 ml Renografin 60, 8 ml 50 ~ Hypaque, 6 ml 507o Hypaque, 5 ml Uridone, 15 ml 35 7o Diodrast, 8 ml 50~o Hypaque, 50 ml, brachial inj. 50~o Hypaque, 15 ml 60 ~o Urografin
rt post. comm. basilar rt supraclin. rt mid. cerebral rt supraclin. ant. comm.
mid. cerebral rt post. comm.
Conray 60, 9 ml
Survival
died died died 400 psi
died
hand inj.
died died
200 psi
alive
* PICA = posterior inferior cerebellar artery.
Discussion Extravasation of contrast material during angiography of carotid circulation aneurysms is a rare complication. Fortunately, it is even rarer from the vertebrobasilar circulation. Hoff and Potts a reported leakage of contrast material following vertebra/ angiography in a patient with an arteriosclerotic aneurysm of the basilar artery; the contrast material appeared to pass from the subarachnoid space into the fourth ventricle via the right foramen of Luschka. There have been many case reports of ruptured aneurysms in which the extravasation was demonstrated by angiography. The majority of these aneurysms have been in the carotid circulation (Table 1), which is not surprising if 80% of berry aneurysms occur there? What is surprising is the readiness with which the performance of angiography has been accepted as an etiological factor in causing these aneurysms to rupture. However, all of the patients listed in Table 1 had had clinical signs and symptoms of subarachnoid hemorrhage and were seriously ill prior to the J. Neurosurg. / Volume 42 / April, 1975
performance of angiography. Perhaps then, the extravasated contrast material seen in our case as well as others serves only to diagnose the site of a bleeding aneurysm, rather than to represent rupture of the aneurysm because of the arterial injection. Bakay and Sweet 1 found no increase in internal carotid artery pressure in five patients when a 10 to 12 ml bolus was injected into the common carotid artery in 2 to 3 seconds. One certainly should not ignore the deleterious effects of repeated heparin solution flushings through catheters opening into the internal carotid and vertebral arteries, or the vasodilating effect of the contrast medium itself. Clinical observation of reflux of injected contrast material into the opposite vertebral artery or various portions of the circle of Willis during an arterial injection may also be important. Until these factors have been completely investigated, extravasation from an aneurysm at the time of angiography probably should be regarded only as a bad prognostic sign rather than the result of the procedure. 471
A. J. Gerlock, Jr. References 1. Bakay L, Sweet WH: Cervical and intracranial intra-arterial pressures with and without vascular occlusion. Surg Gynec Obstet 95:67-75, 1952 2. Goldstein SL: Ventricular opacification secondary to rupture of intracranial aneurysm during angiography. Case report. J Neurosurg 27:265-267, 1967 3. Hoff JT, Potts DG: Angiographic demonstration of hemorrhage into the fourth ventricle. Case report. J Neurosurg 30:732-735, 1969 4. Jackson JR, Tindall GT, Nashold BS Jr: Rupture of an intracranial aneurysm during carotid arteriography. A case report. J Neurosurg 17:333-336, 1960 5. Jamieson KG: Rupture of an intracranial aneurysm during cerebral angiography. J Neurosurg 11:625-628, 1954 6. Jenkinson EL, Sugar O, Love H: Rupture of an aneurysm of the internal carotid artery during cerebral angiography. Case report. Am J Roentgenol Rad Ther Nucl Med 71:958-960, 1954 7. Lehrer HZ, Gross LA, Poon TP: Ruptured intracranial aneurysm. Contrast agent ex-
A72
8.
9.
10.
11.
travasation during brachial arteriography. Arch Neurol 27:351-353, 1972 Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section 5, Part 2. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations based on 6368 cases in the cooperative study. J Neurosurg 25:219-239, 1966 Murphy DJ, Goldberg R J: Extravasation from an intracranial aneurysm during carotid angiography. Case report. J Neurosurg 27:459-461, 1967 Triska Von H: Ein Fall yon Kontrastmittelextravasat bei einem ruptierten Aneurysm der Art cerebri media. Zentraibl Neurochir 22:291-295, 1962 Vines FS, Davis DO: Rupture of intracranial aneurysm at angiography. Radiology 99:353-354, 1971
Address reprint requests to: Amil J. Gerlock, M.D., Department of Radiology, The University of Texas Health Science Center at Dallas, Dallas, Texas.
J. Neurosurg. / Volume 42 / April, 1975
