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Neuroradiology |
1 From the Department of Medical Imaging, Toronto Western Hospital, University Health Network, Fell Pavilion 3-210, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8. Received December 19, 2001; revision requested February 27, 2002; final revision received August 7; accepted August 21. Supported by the Canadian Institutes of Health Research Burroughs Wellcome Fund Research Award and the University of Toronto Summer Research Scholarship Program. Address correspondence to R.A.W. (e-mail: robert.willinsky@uhn.on.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSION REFERENCES |
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MATERIALS AND METHODS: A total of 2,899 consecutive cerebral digital subtraction angiograms obtained with nonionic contrast material were prospectively evaluated. Neurologic complications were categorized as transient (<24 hours), reversible (24 hours to 7 days), and permanent (>7 days). The neurologic complication rate was correlated with patient age, type of indication for catheter angiography, medical history, fluoroscopic time, number and size of catheters, type and number of vessels injected, operator experience, and the quartile in which the study was performed. The correlations were statistically analyzed with Fisher exact tests and a multiple logistic regression model.
RESULTS: There were 39 (1.3%) neurologic complications in 2,899 procedures; 20 were transient (0.7%), five (0.2%) were reversible, and 14 (0.5%) were permanent. Neurologic complications were significantly more common in patients 55 years of age or older (25 of 1,361; 1.8%) (P = .035), in patients with cardiovascular disease (CVD) (20 of 862; 2.3%) (P = .004), and when fluoroscopic times were 10 minutes or longer (24 of 1,238; 1.9%) (P = .022). The neurologic complication rate was higher in procedures performed by fellows alone (24 of 1,878; 1.3%) compared with that when staff alone performed the procedures (three of 598; 0.5%), but the difference was not significant (P = .172). Neurologic complications were lower in the fourth quartile of the study (six of 171; 0.9%) compared with the first quartile (16 of 776; 2.1%), which was likely due to fewer patients being examined for carotid stenosis or ischemic stroke and fewer patients with CVD (P = .085).
CONCLUSION: Age-related vascular disease accounted for the failure to lower the neurologic complication rate of cerebral angiography despite technical advances.
© RSNA, 2003
Index terms: Cerebral angiography, complications, 17.124, 17.44 • Cerebral angiography, technology, 17.124
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSION REFERENCES |
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSION REFERENCES |
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Technique
Patients were restricted from having solid foods 6 hours before the procedure but were allowed clear fluids. A questionnaire that included past medical health was filled out for all outpatients. The outpatient procedures were performed in the morning, and the patients were observed for a minimum of 4 hours until discharge. A nurse monitored the vital signs and neurologic status of the outpatients until discharge. A family member or a friend accompanied all outpatients overnight. Outpatients who developed complications within 4 hours of the procedure were admitted.
In all patients, an intravenous catheter was placed prior to angiography. Electrocardiography, pulse oximetry, and vital signs were monitored throughout the procedure. Femoral arterial punctures were performed in all but one procedure, which was performed by using a retrograde brachial approach. A 5-F sheath (Radiofocus Introducer II; Terumo, Tokyo, Japan) was used in all femoral punctures. The sheath was constantly flushed with heparinized saline (6,000 IU of heparin in 1,000 mL of normal saline). A similar heparinized saline solution was used for intermittent flushing of the catheter. In 51 procedures, a bolus of 2,000–2,500 IU of heparin was administered at the beginning of the procedure and was not repeated or reversed. Manual compression at the puncture site for 8–15 minutes was performed at the completion of all procedures.
An angled 0.35-inch radiofocus guide wire (Terumo) was used in 2,704 cases; a 0.35-inch heparin-coated guide wire (Cook, Bloomington, Ind), in 167 cases; and both guide wires, in 28 cases. A one-way stopcock (Cook) was used with the selective catheter. Intermittent flushing techniques were used to prevent clots from developing in the catheter. Special attention was devoted to avoiding any dead-space within the catheter when the guide wire was used. Manipulation with the guide wire was generally less than 60 seconds between catheter flushing.
Nonionic contrast media (Omnipaque 300; Nycomed, Oslo, Norway) were used in all cases. All injections in the angiography suite were performed with a power injector (Mark V; Medrad, Indianola, Pa). The intraoperative procedures were performed with hand injections. Standard injection rates and volumes were as follows: 4–6 mL/sec for 8–12 mL for common carotid artery, 4–5 mL/sec for 8–10 mL for internal carotid artery, 2–3 mL/sec for 5 mL for external carotid artery, 3–4 mL/sec for 7–9 mL for vertebral artery, 6–8 mL/sec for 14 mL for subclavian artery, and 15–20 mL/sec for 30–40 mL for aortic arch. The distribution of the catheterized arteries was as follows: 1,649 (56.9%) right internal carotid arteries, 1,663 (57.3%) left internal carotid arteries, 1,502 (51.8%) left vertebral arteries, 957 (33.0%) right vertebral arteries, 945 (32.6%) right common carotid arteries, 968 (33.4%) left common carotid arteries, 607 (20.9%) right external carotid arteries, 611 (21.1%) left external carotid arteries, 237 (8.2%) right subclavian arteries, and 255 (8.8%) left subclavian arteries. In 220 procedures (7.6%), selective injections of additional vessels, including occipital, ascending pharyngeal, facial, and lingual arteries, were performed.
From January 1996 to December 1998, 1,533 procedures were performed with single-plane digital subtraction angiography (DSA) (LUA; GE Medical Systems, Milwaukee, Wis). Between January 1999 and June 2001, 1,245 cases were performed with biplane DSA (LCN; GE Medical Systems) and 71, with single-plane DSA. Fifty intraoperative angiograms were obtained with a DSA unit (OEC 9800; GE Medical Systems). Neuroradiology fellows and staff performed the procedures. Fellows were allowed to perform the procedures on their own once it was clear that they had reached a safe level of using the technique. A staff neuroradiologist (R.A.W., R.I.F., K.t.B., W.M.) supervised the procedures performed by the fellows alone. Procedures performed by both staff and fellows were performed early during the fellow’s training or when the fellow was having difficulty with a part of the procedure.
Data Collection
At the beginning of the procedure, a technologist prepared the data forms and filled in the patient demographics. At the completion of the procedure, the technologist filled in the contrast material volume and the fluoroscopic time. The angiographer filled out the clinical information. The data forms included the date of the procedure, name of the referring physician, inpatient versus outpatient status, reason for the procedure (hemorrhage, aneurysm, arteriovenous malformation, carotid stenosis, ischemic stroke, sodium amytal test results, tumor, trauma), medical history (not significant, coronary artery disease, peripheral vascular disease, hypertension, renal disease, diabetes mellitus), catheter size and type, type and number of vessels injected, type of anesthesia (local, neuroleptic, general), heparin bolus (dose), complications within 4 hours (none, neurologic, nonneurologic), complications within 24 hours (none, neurologic, nonneurologic), adverse events, and operator experience. Outpatients were contacted by phone on the next working day. Inpatients were evaluated the next day by the attending staff and the next working day by the angiographer.
A neurologic complication was defined as any new neurologic sign or symptom or worsening of a preexisting neurologic deficit that occurred during the procedure or within 24 hours. Neurologic complications were classified as transient if they resolved within 24 hours, reversible if they lasted more than 24 hours and resolved within 7 days, and permanent if they persisted more than 7 days. A nonneurologic complication was defined as any sign or symptom occurring either locally at the puncture site or systemically within 24 hours of the procedure. An adverse event was defined as a procedure-related angiographic finding without neurologic signs or symptoms that may or may not have required treatment (eg, arterial dissection). The exact nature of the complication was clarified on the data form. Hematomas at the puncture site were recorded as small if they were less than 5 cm in diameter and large if they were 5 cm or larger in diameter. Adverse events and their management were documented on the data sheet. A chart review approved by the institutional review board was performed (R.A.W., S.M.T.) for patients with neurologic and nonneurologic complications that persisted more than 24 hours.
Statistical Analysis
For the analysis (R.A.W., S.M.T., G.T.) of preexisting comorbidity, coronary artery disease, hypertension, and peripheral vascular disease were grouped as cardiovascular disease (CVD). All patients with multiple preexisting comorbidities had at least one of the CVDs; the diseases were grouped as cardiovascular. For the analysis of the indication for catheter angiography, carotid stenosis and ischemic stroke were grouped together. The Fisher exact test was used to test associations between the neurologic complication rate and patient age, indication for catheter angiography, medical history, fluoroscopic time, type of vessels injected, number of vessels injected, catheter size, number of catheters, operator experience, and the quartile in which the procedure was performed (R.A.W., S.M.T., G.T.). The relationships between the complication rate and the risk factors that were significant in these bivariate analyses were analyzed (G.T.) with a multiple logistic regression model to determine which factors were independently associated with complications. Interactions between individual cardiovascular risk factors could not be performed with regression models, since we could not adhere to the widely recognized principles of regression analysis that recommend as a guideline a minimum of 10 outcomes per parameter.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSION REFERENCES |
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Neurologic Complications
There were 39 (1.3%) neurologic complications in 2,899 procedures; 20 were transient (0.7%), five (0.2%) were reversible, and 14 (0.5%) were permanent. Seven (0.25%) of 2,899 permanent complications were considered major or disabling strokes. In the outpatient group, all neurologic complications were evident within 4 hours of the procedure. Two of the transient and one of the permanent complications were related to thromboembolism, which was evident on the angiogram during the procedure. All three were treated with intraarterial thrombolysis. Of 20 transient complications, six had the typical findings and course of transient global amnesia.
Neurologic complications were significantly more common in procedures performed in patients who were 55 years of age or older (25 of 1,361; 1.8%) compared with those performed in patients younger than 55 years of age (14 of 1,538, 0.9%) (P = .035) (Table 1). From a logistic regression against age, the estimated odds ratio for neurologic complications was 1.22 per 10 years of age (95% CI: 1.00, 1.52; P = .05). Neurologic complications were significantly more common in patients with CVD (20 of 862; 2.3%) compared with those without these risk factors (19 of 2,037; 0.9%) (P = .004) (Table 2). When the fluoroscopic times were 10 minutes or longer, there were significantly more neurologic complications (24 of 1,238; 1.9%) compared with those when fluoroscopic times were shorter than 10 minutes (15 of 1,661; 0.9%) (P = .004).
Multiple logistic regression was used to analyze which of the factors (age, CVD, and fluoroscopic time) were independently related to the neurologic complication rate. There were eight (2 x 2 x 2) regression models that could be formed by including or excluding each of these three factors. Each of these models was fitted, and the best model was chosen on the basis of likelihood ratio tests. The best model was one that included only fluoroscopic time and CVD. In that model, the estimated relative risk for neurologic complications associated with CVD was 2.32 (95% CI: 1.22, 4.43; P = .010). The estimated relative risk for neurologic complications associated with fluoroscopic times longer than 10 minutes was 1.97 (95% CI: 1.00, 3.87; P = .039). Addition of age to this model did not significantly improve its fit (P = .40).
The fellows alone had a higher neurologic complication rate (24 of 1,878; 1.3%) compared with that of the staff alone (three of 598; 0.5%), but this did not reach significance (P = .172) (Table 4). When the fellow and staff together performed the procedures, there was a significantly higher neurologic complication rate (12 of 423; 2.8%) compared with that when a fellow or staff alone performed the procedures (27 of 2,476; 1.0%) (P = .009).
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Nonneurologic Complications
There were three allergic cutaneous reactions in the 2,899 procedures (0.1%), including urticaria in two procedures and hives in one. These developed within 1 hour of the procedure and resolved without treatment. There were 14 hematomas (0.4%) at the puncture site; seven were small and seven were large. A pseudoaneurysm was associated with one of the large hematomas and was treated with 15 minutes of compression with ultrasonographic (US) guidance. One of the procedures was complicated by a myocardial infarction. The patient remained in the hospital for 19 days and fully recovered. None of the 2,899 patients developed renal failure as a consequence of angiography.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSION REFERENCES |
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Authors of most of the studies who investigated the complication rates of cerebral angiography have included complications that occurred within 24 hours of the procedure. The study of Dion et al (8) is unique in that it included complications that occurred 24–72 hours after the procedure. Factors that significantly correlated with increased neurologic events between 24 and 72 hours included the volume of contrast material, patient age, and diabetes. In patients with frequent transient ischemic attacks and carotid stenosis, it is likely that at least some of these events are part of the natural history of the disease.
Pathophysiology
A number of mechanisms have been proposed to account for the neurologic complications of cerebral angiography. The most common cause implicated is thromboembolism from the catheters or guide wires. These thrombi most likely develop inside the catheter during the manipulation of the guide wire. This is most likely to occur if the guide wire is withdrawn into the catheter, allowing blood to stagnate within this dead-space. In our practice, we stress the importance of avoiding this dead-space and keeping the guide wire manipulations to a minimum time. Continual flushing of the catheter with heparinized saline with use of a three-way stopcock has been advocated to reduce thromboembolic events (8). In our practice, we have used one-way stopcocks, and we keep a full contrast material column in the catheter between manipulations.
Disruption of an atherosclerotic plaque by the catheter or guide wire has been commonly implicated as a mechanism for stroke. Other causes include arterial dissections related to the catheter or guide wire, platelet activation, changes in clotting factors, and neurotoxicity of contrast agents (19–22).
Patient Factors
The neurologic complication rate has been reported to increase with patient age (8,9,12,13,15). In our series, the risk of neurologic complications increases a relative 22% for each 10-year increase in age (Table 1) (P = .05). We found a significantly higher neurologic complication rate in procedures performed in patients 55 years of age or older. Heiserman et al (12), in their prospective series of 1,000 patients, reported no neurologic complications in 363 patients who were younger than 50 years of age. Dion et al (8) reported no neurologic complications in 204 patients who were younger than 30 years of age. In our study, there was only one permanent complication in patients younger than 45 years of age. This complication occurred in a teenager during intraoperative angiography. The high neurologic complication rate (one of 50; 2.0%) in our study with use of intraoperative angiograms may be a reflection of the difficulty with working in the operating room. In previous reports, the permanent neurologic complication rate from intraoperative cerebral angiography was also noted to be higher, ranging from 0.5% to 1.5% (23–25).
Ischemic stroke has been reported to be a risk factor in cerebral angiography (8–14,16,26,27). In a meta-analysis by Cloft et al (28), the neurologic complication rate was lower in patients with a subarachnoid hemorrhage, aneurysm, or arteriovenous malformation compared with that in patients with ischemic stroke. Faught et al (11), in a retrospective study of 147 patients to evaluate stroke, found neurologic complications in 12.2% of the procedures, and 5.2% were permanent. Results of Earnest et al (9) were similar, with transient neurologic complications in 10.8% of patients with frequent transient ischemic attacks and in 9.8% of patients with recent stroke. Earnest et al did not find a significant difference between the reversible (3.6%) and permanent (0.6%) neurologic complication rate in patients with recent ischemic events compared with their overall rates of 2.3% and 0.3%, respectively. In our study, patients with ischemic stroke or carotid stenosis had a higher neurologic complication rate (1.8%), but it was not significant (P = .174). Heiserman et al (12) also found that carotid stenosis correlated with an increased rate of neurologic complications when compared with their entire group but not in the subset that had ischemic stroke. In 297 patients examined with Doppler US of the carotid artery, Earnest et al (9) found no difference in the neurologic complication rate between those with carotid stenosis and those without.
Dion et al (8) found that hypertension was a significant risk factor for neurologic events developing within 24 hours of the procedure. Earnest et al (9) found that elevated levels of creatinine were associated with an increased incidence of neurologic complications. In our study, there was a significantly higher complication rate in patients with CVD (2.3%) (Table 2).
Procedural Factors
Long procedural times have been implicated to be a risk factor in cerebral angiography (15). Heiserman et al (12) found significant correlations between the neurologic complication rate and patient age, length of the procedure, volume of contrast material, carotid stenosis, and ischemic stroke. Within the ischemic stroke group, age was the only significant variable (12). In our series, fluoroscopic times of 10 minutes or longer were associated with a significantly higher neurologic complication rate. The fluoroscopic times were not dependant on whether a staff or fellow performed the procedure (Table 4). A higher neurologic complication rate did correlate with longer fluoroscopic times in procedures performed by both the fellow and staff. Fluoroscopic time was the best measure of the difficulty of the procedure and reflected the time taken to catheterize the blood vessels.
A multiple logistic regression model was used to determine if the significant risk factors (CVD, age older than 55 years, and fluoroscopic times longer than 10 minutes) were independently associated with a higher neurologic complication rate. CVD and fluoroscopic times were found to be independent predictors, whereas age was not a significant predictor once the cardiovascular status and fluoroscopic time were known.
Higher volume of contrast material has been considered a risk factor in cerebral angiography performed with ionic contrast material (8,15). In a prospective evaluation of 230 patients with symptomatic cerebrovascular disease, McIvor et al (16) found a slightly lower neurologic complication rate with use of nonionic contrast material compared with that with ionic contrast material, but it was not statistically significant. In a retrospective study of 1,509 procedures in which ionic contrast material was used and of 1,000 procedures in which nonionic contrast material was used, Skalpe (29) reported a lower neurologic complication rate in procedures performed with nonionic contrast material. The neurologic complication rate in our study with use of nonionic contrast material was similar to that in large prospective studies in which ionic contrast material was used (8,9).
Wishart (30) reported a higher neurologic complication rate when cerebral angiography includes selective injections in the posterior circulation. Later reports did not support this finding (8,9,15). Our study findings did not show a significantly higher neurologic complication rate when the posterior fossa was injected compared with that with only carotid artery injections. We found no difference in the neurologic complication rate when it was correlated with the number of vessels injected, which is similar to the results of Dion et al (8).
The association between the number of catheters used, the catheter size, and fluoroscopic times with the neurologic complication rate is complex owing to the relationship to atherosclerotic disease. Earnest et al (9) found a higher rate of neurologic complications when more than one catheter was required. Dion et al (8) did not find a difference until more than three catheters were used. Heiserman et al (12) found no association with the number of catheters used. Our study findings did not show a significantly higher neurologic complication rate and the number of catheters used. Earnest et al (9) found a lower neurologic complication rate when smaller catheters were used, similar to our study results, but the rate was not significant.
DSA has replaced cut-film changers in most centers. Procedural time has been reduced with DSA compared with cut-film angiography. Grzyska et al (7), in a large series in which cut-film angiography was used, attributed their lower neurologic complication rate (0.4% transient, 0.1% permanent) to the use of DSA and nonionic iso-osmotic contrast material. Later studies in which DSA and nonionic contrast material were used demonstrated similar neurologic complication rates to those of series that were performed with cut-film angiography and ionic contrast material (8,9,12–14). Our study had a similar neurologic complication rate as did these large prospective studies, despite the use of DSA and nonionic contrast material.
During the 5
years of our study, we found that the neurologic complication rate had decreased from the first quartile to the fourth quartile (Table 6). This improvement correlated with the reduction in the percentage of patients who were being treated for carotid stenosis or ischemic stroke and the lower percentage of patients with CVD. The similar neurologic complication rate in the second and third quartiles may reflect the similar percentage of patients with CVD. We believe that the lower neurologic complication rate during the period when biplane DSA was used compared with that when single-plane DSA was used was not related to the technology, since it was not evident when second and third quartiles were compared. As expected, the mean contrast material volume decreased during the period when biplane DSA was used.
Heparinized saline is the standard flush solution used during cerebral angiography. In addition to heparinized saline, Dion et al (8) used a heparin bolus of 2,000 IU in selected cases (32.3% of procedures). Authors of other large prospective studies did not use a heparin bolus (7,9,12). In our study, we used a heparin bolus in 51 (1.7%) of the 2,899 procedures that were considered as high risk. This included some patients with frequent transient ischemic attacks or a recent stroke thought to be due to vasculitis. In comparing our study findings with those in the report by Dion et al, there was a similar overall neurologic complication rate, but their permanent complication rate was lower, which suggests there may be a benefit with the more liberal use of heparin. The disadvantage of heparin is hematomas at the puncture site, 6.9% in the series of Dion et al compared with 0.5% in our series (8). Delayed hemorrhage at the puncture site is more common in patients who underwent systemic heparinization (31).
Operator Experience
The neurologic complication rate of cerebral angiography has been reported to be lower in the hands of more experienced angiographers (3,11,32). Mani et al (15) found a higher rate of neurologic complications in training hospitals (3.9%) compared with that in nontraining hospitals (0.9%). Mani et al also found that general radiologists or angiographers had more than double the neurologic complication rate (1.8%) compared with that of fully trained neuroradiologists (0.7%). Findings of smaller prospective studies (16,32) also demonstrated significantly higher neurologic complication rates in trainees compared with those of consultant radiologists. Heiserman et al (12) found no difference in the neurologic complication rate and the level of training. In our study, the neurologic complication rate in procedures performed by fellows was higher than that in procedures performed by staff (Table 4). The difference can be explained in part by the higher percentage of patients with CVD in procedures performed by fellows. The mean fluoroscopic time and the mean patient age in the procedures performed by staff alone and fellows alone were similar. This finding differs from the report by Grzyska et al (7) who found that trainees use longer fluoroscopic times.
In our study, procedures performed by both fellows and staff together had a significantly higher neurologic complication rate compared with that of staff or fellows alone (Table 4). In the majority of these procedures, the staff participated in the procedure once the fellow was having difficulty. The complexity of these cases is reflected by the longer fluoroscopic times. The procedures performed by fellows and staff together consisted of patients who were slightly older and with a higher percentage of CVD, carotid stenosis, and ischemic stroke.
Technical advances in cerebral angiography have not overcome the patient-related risk factors associated with neurologic complications. The risk of neurologic complications increases with age. CVD and fluoroscopic times longer than 10 minutes were independent predictors of risk. These findings substantiate the argument that patients at a higher risk should undergo noninvasive imaging of the craniocervical vessels and that catheter angiography should be avoided. In patients without these risk factors, neurologic complications still occur and, therefore, the indications for catheter angiography should be limited. Our data support the shift to noninvasive imaging of the craniocervical vessels.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, R.A.W.; study concepts and design, R.A.W.; literature research, R.A.W., S.M.T.; clinical studies, R.A.W., R.I.F., K.t.B., W.M.; data acquisition, R.A.W., K.t.B., R.I.F., W.M.; data analysis/interpretation, R.A.W., S.M.T., G.T.; statistical analysis, G.T.; manuscript preparation, R.A.W., S.M.T.; manuscript editing, R.A.W., S.M.T., K.t.B., R.I.F.; manuscript revision/review, R.A.W., S.M.T., K.t.B., R.I.F., G.T.; manuscript definition of intellectual content and final version approval, R.A.W., K.t.B., R.I.F.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSION REFERENCES |
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 M. J.H. Wermer, H. Koffijberg, I. C. van der Schaaf, and For the ASTRA Study Group Effectiveness and costs of screening for aneurysms every 5 years after subarachnoid hemorrhage Neurology, May 27, 2008; 70(22): 2053 - 2062. [Abstract] [Full Text] [PDF]
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R.S. Saleh, D.G. Lohan, J.P. Villablanca, G. Duckwiler, S.T. Kee, and J.P. Finn Assessment of Craniospinal Arteriovenous Malformations at 3T with Highly Temporally and Highly Spatially Resolved Contrast-Enhanced MR Angiography AJNR Am. J. Neuroradiol., May 1, 2008; 29(5): 1024 - 1031. [Abstract] [Full Text] [PDF]
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A.M. McKinney, C.S. Palmer, C.L. Truwit, A. Karagulle, and M. Teksam Detection of Aneurysms by 64-Section Multidetector CT Angiography in Patients Acutely Suspected of Having an Intracranial Aneurysm and Comparison with Digital Subtraction and 3D Rotational Angiography AJNR Am. J. Neuroradiol., March 1, 2008; 29(3): 594 - 602. [Abstract] [Full Text] [PDF]
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C. A. Taschner, J. Gieseke, V. Le Thuc, H. Rachdi, N. Reyns, J.-Y. Gauvrit, and X. Leclerc Intracranial Arteriovenous Malformation: Time-resolved Contrast-enhanced MR Angiography with Combination of Parallel Imaging, Keyhole Acquisition, and k-Space Sampling Techniques at 1.5 T Radiology, March 1, 2008; 246(3): 871 - 879. [Abstract] [Full Text] [PDF]
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M. Romijn, H.A.F. G. van Andel, M.A. van Walderveen, M.E. Sprengers, J.C. van Rijn, W.J. van Rooij, H.W. Venema, C.A. Grimbergen, G.J. den Heeten, and C.B. Majoie Diagnostic Accuracy of CT Angiography with Matched Mask Bone Elimination for Detection of Intracranial Aneurysms: Comparison with Digital Subtraction Angiography and 3D Rotational Angiography AJNR Am. J. Neuroradiol., January 1, 2008; 29(1): 134 - 139. [Abstract] [Full Text] [PDF]
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 T. Wolff, J. Guirguis-Blake, T. Miller, M. Gillespie, and R. Harris Screening for Carotid Artery Stenosis: An Update of the Evidence for the U.S. Preventive Services Task Force Ann Intern Med, December 18, 2007; 147(12): 860 - 870. [Abstract] [Full Text] [PDF]
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D. R. Hadizadeh, M. von Falkenhausen, J. Gieseke, B. Meyer, H. Urbach, R. Hoogeveen, H. H. Schild, and W. A. Willinek Cerebral Arteriovenous Malformation: Spetzler-Martin Classification at Subsecond-Temporal-Resolution Four-dimensional MR Angiography Compared with That at DSA Radiology, December 1, 2007; 246(1): 205 - 213. [Abstract] [Full Text] [PDF]
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 J. Burrill, Z. Dabbagh, F. Gollub, and M. Hamady Multidetector computed tomographic angiography of the cardiovascular system Postgrad. Med. J., November 1, 2007; 83(985): 698 - 704. [Abstract] [Full Text] [PDF]
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T. J. Kaufmann, J. Huston III, J. N. Mandrekar, C. D. Schleck, K. R. Thielen, and D. F. Kallmes Complications of Diagnostic Cerebral Angiography: Evaluation of 19 826 Consecutive Patients Radiology, June 1, 2007; 243(3): 812 - 819. [Abstract] [Full Text] [PDF]
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M. Lell, C. Fellner, U. Baum, T. Hothorn, R. Steiner, W. Lang, W. Bautz, and F.A. Fellner Evaluation of Carotid Artery Stenosis with Multisection CT and MR Imaging: Influence of Imaging Modality and Postprocessing AJNR Am. J. Neuroradiol., January 1, 2007; 28(1): 104 - 110. [Abstract] [Full Text] [PDF]
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A. F. AbuRahma, J. D. Hayes, J. T. Deel, S. Abu-Halimah, B. B. Mullins, J. H. Habib, C. A. Welch, and Z. AbuRahma Complications of Diagnostic Carotid/Cerebral Arteriography when Performed by a Vascular Surgeon Vascular and Endovascular Surgery, May 1, 2006; 40(3): 189 - 195. [Abstract] [PDF]
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N. Horie, M. Morikawa, N. Kitigawa, K. Tsutsumi, M. Kaminogo, and I. Nagata 2D Thick-Section MR Digital Subtraction Angiography for the Assessment of Dural Arteriovenous Fistulas. AJNR Am. J. Neuroradiol., February 1, 2006; 27(2): 264 - 269. [Abstract] [Full Text] [PDF]
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P. Shannon, J.M. Billbao, T. Marotta, and K. Terbrugge Inadvertent Foreign Body Embolization in Diagnostic and Therapeutic Cerebral Angiography. AJNR Am. J. Neuroradiol., February 1, 2006; 27(2): 278 - 282. [Abstract] [Full Text] [PDF]
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E.S. Bartlett, T.D. Walters, S.P. Symons, and A.J. Fox Quantification of Carotid Stenosis on CT Angiography AJNR Am. J. Neuroradiol., January 1, 2006; 27(1): 13 - 19. [Abstract] [Full Text] [PDF]
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C. W. Yang, J. C. Carr, S. F. Futterer, M. D. Morasch, B. P. Yang, S. M. Shors, and J. P. Finn Contrast-Enhanced MR Angiography of the Carotid and Vertebrobasilar Circulations AJNR Am. J. Neuroradiol., September 1, 2005; 26(8): 2095 - 2101. [Abstract] [Full Text] [PDF]
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J. Krejza, J. Kochanowicz, Z. Mariak, J. Lewko, and E. R. Melhem Middle Cerebral Artery Spasm after Subarachnoid Hemorrhage: Detection with Transcranial Color-coded Duplex US Radiology, August 1, 2005; 236(2): 621 - 629. [Abstract] [Full Text] [PDF]
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C. B. L. M. Majoie, M. E. Sprengers, W. J. J. van Rooij, C. Lavini, M. Sluzewski, J. C. van Rijn, and G. J. den Heeten MR Angiography at 3T versus Digital Subtraction Angiography in the Follow-up of Intracranial Aneurysms Treated with Detachable Coils AJNR Am. J. Neuroradiol., June 1, 2005; 26(6): 1349 - 1356. [Abstract] [Full Text] [PDF]
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M. Berg, Z. Zhang, A. Ikonen, P. Sipola, R. Kalviainen, H. Manninen, and R. Vanninen Multi-Detector Row CT Angiography in the Assessment of Carotid Artery Disease in Symptomatic Patients: Comparison with Rotational Angiography and Digital Subtraction Angiography AJNR Am. J. Neuroradiol., May 1, 2005; 26(5): 1022 - 1034. [Abstract] [Full Text] [PDF]
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C. P. Derdeyn, E. Buskens, P. J. Nederkoorn, Y. van der Graaf, and M. G. M. Hunink Conventional Angiography Remains an Important Tool for Measurement of Carotid Arterial Stenosis * Dr Buskens and colleagues respond: Radiology, May 1, 2005; 235(2): 711 - 713. [Full Text] [PDF]
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D. Sacks and J. J. Connors III Carotid Stent Placement, Stroke Prevention, and Training Radiology, January 1, 2005; 234(1): 49 - 52. [Full Text] [PDF]
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W. A. Willinek, M. von Falkenhausen, M. Born, J. Gieseke, T. Holler, T. Klockgether, H. J. Textor, H. H. Schild, and H. Urbach Noninvasive Detection of Steno-Occlusive Disease of the Supra-Aortic Arteries With Three-Dimensional Contrast-Enhanced Magnetic Resonance Angiography: A Prospective, Intra-Individual Comparative Analysis With Digital Subtraction Angiography Stroke, January 1, 2005; 36(1): 38 - 43. [Abstract] [Full Text] [PDF]
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J. J. Connors III, D. Sacks, A. J. Furlan, W. R. Selman, E. J. Russell, P. E. Stieg, M. N. Hadley, and For the NeuroVascular Coalition Writing Group Training, Competency, and Credentialing Standards for Diagnostic Cervicocerebral Angiography, Carotid Stenting, and Cerebrovascular Intervention: A Joint Statement from the American Academy of Neurology, American Association of Neurological Surgeons, American Society of Interventional and Therapeutic Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, AANS/CNS Cerebrovascular Section, and Society of Interventional Radiology Radiology, January 1, 2005; 234(1): 26 - 34. [Full Text] [PDF]
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 I. K. Moppett and R. P. Mahajan Transcranial Doppler ultrasonography in anaesthesia and intensive care Br. J. Anaesth., November 1, 2004; 93(5): 710 - 724. [Full Text] [PDF]
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M. Bendszus, M. Koltzenburg, A. J. Bartsch, R. Goldbrunner, T. Gunthner-Lengsfeld, F. X. Weilbach, K. Roosen, K. V. Toyka, and L. Solymosi Heparin and Air Filters Reduce Embolic Events Caused by Intra-Arterial Cerebral Angiography: A Prospective, Randomized Trial Circulation, October 12, 2004; 110(15): 2210 - 2215. [Abstract] [Full Text] [PDF]
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M. J.W. Koelemay, P. J. Nederkoorn, J. B. Reitsma, and C. B. Majoie Systematic Review of Computed Tomographic Angiography for Assessment of Carotid Artery Disease Stroke, October 1, 2004; 35(10): 2306 - 2312. [Abstract] [Full Text] [PDF]
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J. M. K.S. U-King-Im, R. A. Trivedi, J. J. Cross, N. J.P. Higgins, W. Hollingworth, M. Graves, I. Joubert, P. J. Kirkpatrick, N. M. Antoun, and J. H. Gillard Measuring Carotid Stenosis on Contrast-Enhanced Magnetic Resonance Angiography: Diagnostic Performance and Reproducibility of 3 Different Methods Stroke, September 1, 2004; 35(9): 2083 - 2088. [Abstract] [Full Text] [PDF]
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T. E. Feasby and J. M. Findlay CT angiography for the assessment of carotid stenosis Neurology, August 10, 2004; 63(3): 412 - 413. [Full Text] [PDF]
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N. Ghosh, D. Tampieri, and D. Melancon Immediate Evaluation of Angioplasty and Stenting Results in Supra-Aortic Arteries by Use of a Doppler-Tipped Guidewire AJNR Am. J. Neuroradiol., August 1, 2004; 25(7): 1172 - 1176. [Abstract] [Full Text] [PDF]
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J. M. U-King-Im, R. A. Trivedi, M. J. Graves, N. J. Higgins, J. J. Cross, B. D. Tom, W. Hollingworth, H. Eales, E. A. Warburton, P. J. Kirkpatrick, et al. Contrast-enhanced MR angiography for carotid disease: Diagnostic and potential clinical impact Neurology, April 27, 2004; 62(8): 1282 - 1290. [Abstract] [Full Text] [PDF]
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M. Nonent, J.-M. Serfaty, N. Nighoghossian, F. Rouhart, L. Derex, C. Rotaru, P. Chirossel, B. Guias, J.-F. Heautot, P. Gouny, et al. Concordance Rate Differences of 3 Noninvasive Imaging Techniques to Measure Carotid Stenosis in Clinical Routine Practice: Results of the CARMEDAS Multicenter Study Stroke, March 1, 2004; 35(3): 682 - 686. [Abstract] [Full Text] [PDF]
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J. D. Barr, J. J. Connors III, D. Sacks, J. C. Wojak, G. J. Becker, J. F. Cardella, B. Chopko, J. E. Dion, A. J. Fox, R. T. Higashida, et al. Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement: Developed by a Collaborative Panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology AJNR Am. J. Neuroradiol., November 1, 2003; 24(10): 2020 - 2034. [Full Text] [PDF]
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