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      Incidence, Clinical Significance, and Longitudinal Signal Characteristics of Ischemic Lesions Related to Diagnostic Cerebral Catheter Angiography

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          Abstract

          Purpose

          Cerebral DSA is a routine procedure with few complications. However, it is associated with presumably clinically inapparent lesions detectable on diffusion-weighted MRI imaging (DWI lesions). However, there are insufficient data regarding incidence, etiology, clinical relevance, and longitudinal development of these lesions. This study prospectively evaluated subjects undergoing elective diagnostic cerebral DSA for the occurrence of DWI lesions, potentially associated clinical symptoms and risk factors, and longitudinally monitored the lesions using state-of-the-art MRI.

          Materials and Methods

          Eighty-two subjects were examined by high-resolution MRI within 24 h after elective diagnostic DSA and lesion occurrence was qualitatively and quantitatively evaluated. Subjects’ neurological status was assessed before and after DSA by clinical neurological examination and a perceived deficit questionnaire. Patient-related risk factors and procedural DSA data were documented. Subjects with lesions received a follow-up MRI and were questioned for neurological deficits after a median of 5.1 months.

          Results

          After DSA, 23(28%) subjects had a total of 54 DWI lesions. Significantly associated risk factors were number of vessels probed, intervention time, age, arterial hypertension, visible calcified plaques, and less examiner experience. Twenty percent of baseline lesions converted to persistent FLAIR lesions at follow-up. After DSA, none of the subjects had a clinically apparent neurological deficit. Self-perceived deficits were nonsignificantly higher at follow-up.

          Conclusion

          Cerebral DSA is associated with a considerable number of postinterventional lesions, some persisting as scars in brain tissue. Presumably because of the small lesion size and inconsistent location, no clinically apparent neurological deficits have been observed. However, subtle self-perceived changes may occur. Therefore, special attention is needed to minimize avoidable risk factors.

          Supplementary Information

          The online version contains supplementary material available at 10.1007/s00270-023-03415-z.

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          Most cited references21

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          Silent cerebral ischaemia: hidden fingerprints of invasive medical procedures.

          Martin Bendszus, Guido Stoll (2006)
          Cardiovascular and cerebrovascular disorders are the main cause of death and permanent disability worldwide. Improved diagnostic and therapeutic options for these diseases have led to increasing numbers of invasive procedures such as angiography, stent placement, and operations exceeding 4 million each year in the USA. Although clinical examinations suggest a relatively low risk for ischaemic complications affecting the brain, new magnetic resonance techniques have led to the awareness of much higher numbers of clinically silent ischaemic brain lesions. Diffusion-weighted MRI (DWI) has shown new ischaemic lesions in a substantial number of patients undergoing cardiac or carotid-artery surgery, and coronary or cerebral-angiographic interventions. The clinical impact of these "silent" ischaemic lesions within brain areas without primary motor, sensory, or linguistic function ("non-eloquent" brain areas) is debated. There is increasing evidence, however, that cumulative burden of ischaemic brain injury causes neuropsychological deficits or aggravates vascular dementia. Thus, DWI emerges as a valuable diagnostic method for the monitoring of periprocedural ischaemic events in the brain, and could be a surrogate parameter for optimising diagnostic and therapeutic vascular procedures in the future.
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            Neurologic complications of cerebral angiography.

            Joseph Heiserman, Nigel C. Bird, R Flom … (1994)
            To examine the incidence of neurologic complications associated with modern cerebral angiography and to assess patient characteristics associated with an increased risk of complications. One thousand consecutive cerebral angiographic procedures were evaluated prospectively. Examinations were performed using transfemoral catheterization and film-screen methods. For purposes of this trial, a neurologic complication was defined as any new focal neurologic deficit or change in mental status occurring during the angiogram or within the following 24 hours. Patients were evaluated during and at the completion of angiography. Follow-up evaluations were performed on the day of and the day after angiography. There were a total of 10 neurologic complications within 24 hours of angiography, 5 of which were persistent. Onset of 5 of the deficits occurred during angiography, the other 5 (3 persistent) were delayed. All complications occurred in patients being evaluated for stroke/transient ischemic attack or (in one case) asymptomatic bruit. A higher average age, longer average procedure time, and greater volume of radiographic contrast was noted in these patients than in the study population. Cerebral angiography was associated with a 1% overall incidence of neurologic deficit and a 0.5% incidence of persistent deficit. All complications occurred in patients presenting with a history of stroke/transient ischemic accident or carotid bruit, which may reflect the difficulty of performing angiography in this population at risk for atherosclerotic changes.
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              Complications of cerebral angiography: a prospective analysis of 2,924 consecutive procedures.

              Benjamin Evans, A T Dawkins, Simon T Hodgson … (2007)
              Cerebral angiography is an invasive procedure associated with a small, but definite risk of neurological morbidity. In this study we sought to establish the nature and rate of complications at our institution among a large prospective cohort of consecutive patients. Also, the data were analysed in an attempt to identify risk factors for complications associated with catheter angiography. Data were prospectively collected for a consecutive cohort of patients undergoing diagnostic cerebral angiography between January 2001 and May 2006. A total of 2,924 diagnostic cerebral angiography procedures were performed during this period. The following data were recorded for each procedure: date of procedure, patient age and sex, clinical indication, referring specialty, referral status (routine/emergency), operator, angiographic findings, and the nature of any clinical complication or asymptomatic adverse event (arterial dissection). Clinical complications occurred in 23 (0.79%) of the angiographic procedures: 12 (0.41%) significant puncture-site haematomas, 10 (0.34%) transient neurological events, and 1 nonfatal reaction to contrast agent. There were no permanent neurological complications. Asymptomatic technical complications occurred in 13 (0.44%) of the angiographic procedures: 3 groin dissections and 10 dissections of the cervical vessels. No patient with a neck dissection suffered an immediate or delayed stroke. Emergency procedures (P = 0.0004) and angiography procedures performed for intracerebral haemorrhage (P = 0.02) and subarachnoid haemorrhage (P = 0.04) were associated with an increased risk of complications. Neurological complications following cerebral angiography are rare (0.34%), but must be minimized by careful case selection and the prudent use of alternative noninvasive angiographic techniques, particularly in the acute setting. The low complication rate in this series was largely due to the favourable case mix.
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                Author and article information

                Contributors
                David Schinz:
                ORCID: http://orcid.org/0000-0003-3734-1135
                david.schinz@tum.de
                Thomas Zimmermann: thomas-zimmermann1996@web.de
                Jens Göttler: jens.goettler@tum.de
                Dominik Sepp: dominik.sepp@tum.de
                Claus Zimmer: claus.zimmer@tum.de
                Tobias Boeckh-Behrens: boeckh-behrens@tum.de
                Jan S. Kirschke: jan.kirschke@tum.de
                Kornelia Kreiser: kornelia.kreiser@rku.de
                Hans Liebl: hans.liebl@bgu-murnau.de
                Journal
                Journal ID (nlm-ta): Cardiovasc Intervent Radiol
                Journal ID (iso-abbrev): Cardiovasc Intervent Radiol
                Title: Cardiovascular and Interventional Radiology
                Publisher: Springer US (New York )
                ISSN (Print): 0174-1551
                ISSN (Electronic): 1432-086X
                Publication date (Electronic): 29 March 2023
                Publication date PMC-release: 29 March 2023
                Publication date (Print): 2023
                Volume: 46
                Issue: 7
                Pages: 921-928
                Affiliations
                [1 ]GRID grid.6936.a, ISNI 0000000123222966, Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, , Technical University of Munich, ; Ismaninger Street 22, 81675 Munich, Germany
                [2 ]GRID grid.488560.7, ISNI 0000 0000 9188 2870, Department of Radiology/Neuroradiology, , RKU, Universitäts- und Rehabilitationskliniken Ulm, gGmbH, ; Oberer Eselsberg 45, 89081 Ulm, Germany
                [3 ]GRID grid.469896.c, ISNI 0000 0000 9109 6845, Department of Radiology/Neuroradiology, , BGU, Berufsgenossenschaftliche Unfallklinik, Murnau, ; Professor-Kuentscher-Straße 8, 82418 Murnau Am Staffelsee, Germany
                Author information
                http://orcid.org/0000-0003-3734-1135
                Article
                Publisher ID: 3415
                DOI: 10.1007/s00270-023-03415-z
                PMC ID: 10322964
                PubMed ID: 36991095
                SO-VID: f4f973ff-9733-4aba-9760-be5158de0170
                Copyright © © The Author(s) 2023
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 5 December 2022
                Date accepted : 6 March 2023
                Funding
                Funded by: Technische Universität München (1025)
                Open Access :

                Open Access funding enabled and organized by Projekt DEAL.

                Categories
                Subject: Clinical Investigation
                Custom metadata
                issue-copyright-statement © Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2023

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: silent ischemia,ischemia,stroke,neuroangiography
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: silent ischemia, ischemia, stroke, neuroangiography

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