Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography

BACKGROUND AND PURPOSE

Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography.

METHODS

We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size: .466 mm³ ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.0 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0 = reduction, 1 = no change, 2 = increase) and total rCBV change scores were summated.

RESULTS

Twenty-five patients with internal carotid artery stenosis (n = 18; 0-90% in severity) or extracranial vertebral artery stenosis (n = 7; 0-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score: 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with an assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; P = .68).

CONCLUSION

Selective vasodilatory response to intra-arterial nicardipine in the affected arterial distribution during catheter-based cerebral angiography may provide new data for risk stratification.

Prolonged Microcatheter-Based Local Thrombolytic Infusion as a Salvage Treatment After Failed Endovascular Treatment for Cerebral Venous Thrombosis: A Multicenter Experience

BACKGROUND AND PURPOSE

To determine the effectiveness of prolonged microcatheter-based local thrombolytic infusion in treatment of patients with cerebral venous thrombosis who achieved no or suboptimal recanalization with transvenous endovascular treatment.

METHODS

Data collection: Prospectively registries supplemented by retrospective review.

SETTINGS

Three hospitals with tertiary referral base.

PATIENTS

Patients who underwent transvenous endovascular treatment for cerebral venous thrombosis.

INTERVENTION

Prolonged microcatheter-based local thrombolytic infusion of alteplase at the rate of 0.5-1 mg/h in patients in whom initial angiographic outcome was deemed suboptimal, either due to incomplete or no recanalization.

RESULTS

Serial angiograms were performed to assess treatment response as follows: grade I, partial recanalization of one or more occluded dural sinuses with improved flow or visualization of branches; grade II, complete recanalization of one sinus but persistent occlusion of the other sinuses (A-no residual flow, B-nonocclusive flow); grade III, complete recanalization. Clinical outcome was determined at 1-3 months using modified Rankin scale. A total of 14 patients underwent 15 transvenous endovascular treatments. Initial treatment was considered suboptimal in 12/15 procedures due to no recanalization in five (grade 0), partial recanalization (grade I) in four, complete recanalization of one sinus but persistent occlusion of the other sinuses (grade 2A in two and 2B in one). A prolonged microcatheter-based local recombinant tissue plasminogen activator infusion was used following ten of the 15 procedures for a median duration of 18 h (range 13-22 h). Follow-up angiography demonstrated complete recanalization in four procedures and improvement in grades of partial recanalization in six procedures (final grades 2A in three and 2B in three procedures). None of the patients developed new symptomatic intracranial hemorrhage associated with local thrombolytic infusion. At follow-up, patients in five of ten procedures had achieved a modified Rankin scale of 0 and one patient had achieved a score of 1 (no neurological deficits but had residual headaches).

CONCLUSION

Prolonged microcatheter-based local thrombolytic infusion appeared to be effective treatment in patients who have suboptimal response to acute transvenous endovascular treatment without any additional adverse events.

Abstract WP22: A New Technique for the Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography

Background: Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography.

Methods: We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size 0.466 mm 3 ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.5 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0=reduction, 1=no change, 2=increase) and total rCBV change scores were summated. The rCBV score values were averaged between the two observers for each patient. Mean arterial pressure was monitored at baseline and at 1 minute intervals post nicardipine administration for 5 minutes.

Results: Twenty-five patients with internal carotid artery stenosis (n=18; 0%-90% in severity) or extracranial vertebral artery stenosis (n=7; 0%-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; p=0.68 by ANOVA). There was an average (±SD) reduction of mean arterial pressure of 14mmHg ± 7.5 after intra-arterial nicardipine. There was no correlation between the magnitude of mean arterial pressure reduction post nicardipine (regression coefficient -0.13; p=0.38) or between the severity of stenosis (regression coefficient -0.04; p=0.29) and rCBV change scores.

Conclusions: We describe a new technique for selective assessment of cerebral vasodilatory response in the affected arterial distribution during catheter-based cerebral angiography.

Abstract WP379: Femoral Neuropathy Following Transfemoral Neuroendovascular Procedures. An Analysis of a Prospective Registry

Background: Although femoral neuropathy is recognized as an adverse consequence following trans-femoral neuro-endovascular procedures, no reliable estimates are available. We analyzed data from a prospective registry to ascertain the frequency and characteristics of femoral neuropathy following trans-femoral neuro-endovascular procedures.

Methods: Consecutive patients who underwent neuro-endovascular procedures through the trans-femoral route were included. Detailed assessment was performed if any patient reported occurrence of sensory or motor symptoms in the femoral or lower extremity region including neurological examination (sensory/motor deficits) and femoral region ultrasound.

Results: Femoral neuropathy was diagnosed following 4 of 270 neurovascular procedures with an occurrence rate of 1.5% (95% confidence intervals 0.4% - 3.7%). The symptoms were exclusively sensory without any motor involvement. The femoral neuropathy appeared to involve anterior femoral cutaneous nerves in all and medial cutaneous branches in 2 patients, and more than one nerve distribution in one patient in whom lateral cutaneous nerve appeared to be involved. All patients reported resolution of symptoms within a period ranging from 1 week to 2 months. No local hematoma or arterial pseudo-aneurysm was identified at femoral region ultrasound.

Conclusions: Femoral neuropathy is a rare occurrence following trans-femoral neuro-endovascular procedures and usually occurs with pure sensory manifestations with complete resolution.

Effectiveness of premedication protocol using intravenous fentanyl to reduce pain associated with femoral artery closure device placement

AIM

To test the effectiveness of a premedication protocol using intravenous bolus of 100 μg fentanyl to reduce pain associated with femoral artery closure device placement for neuro-endovascular procedures.

MATERIALS AND METHODS

The severity of pain associated with femoral artery closure device placement was analysed using a numerical rating scale score ranging from 0 (no pain) to 10 (most severe pain) in two cohorts of consecutive adult patients (n=118), those who were (n=64) or were not (n=54) treated with premedication protocol. The primary endpoints were the proportion of patients with excellent (score ≤1) and failed pain control (score ≥8). Stepwise logistic regression analysis was performed to identify the effect of premedication on pain control after adjustment for potential confounders.

RESULTS

The median numerical pain rating score at femoral artery closure device placement was significantly lower in patients treated with premedication protocol compared with those who underwent closure without premedication (1 versus 5, p<0.001). There was a significantly higher rate of excellent (56.2% versus 14.8%, p<0.001) and good (68.7% versus 31.2%, p<0.001) pain control at closure device placement among patients treated with premedication protocol. None of the patients treated with premedication protocol reported failed pain control compared with 33.4% of those who underwent closure device placement without premedication. In the multivariate analysis, treatment with the premedication protocol was significantly associated with an increased rate of excellent pain control (odds ratio 2.3; 95% confidence interval 1.9-3.1).

CONCLUSION

Premedication with intravenous fentanyl injection prior to femoral artery closure device placement can reduce the intensity of pain associated with closure.

Migraine and Non-Migraine Headaches Following Diagnostic Catheter-Based Cerebral Angiography

BACKGROUND AND OBJECTIVE

No reliable estimates of headaches following catheter-based cerebral angiography are available. We performed an observational cohort study to ascertain the frequency and type of headaches following catheter-based cerebral angiography.

MATERIALS AND METHODS

Consecutive patients who underwent cerebral angiography through the transfemoral (or infrequently radial) route were included. Each patient underwent a brief neurological assessment after the procedure and more detailed assessment was performed if any patient reported occurrence of a headache. The headaches were classified as migraine if the diagnostic criteria specified by International Headache Society were met. The headache severity was classified using a visual numeric rating scale and time to reach pain free status for 2 consecutive hours was ascertained.

RESULTS

Migraine headaches occurred in 5 (3.1%, 95% confidence interval [CI] 1.0-7.2%) of 158 patients who underwent cerebral angiography. The median severity of migraine headaches was 10/10 and time to resolution of headaches was 120 minutes (range 60-360 minutes). Migraine headaches occurred in 4 (18.1%, 95% CI 5.2-40.3%) of 22 patients with a history of migraine and 4 (23.5%, 95% CI 6.8-50%) of 17 patients with regular migraine headaches (≥1 episodes per month). Headaches occurred in 6 (3.8%, 95% CI 1.8-8.0%) patients who did not meet the criteria for migraine headaches.

CONCLUSIONS

We provide occurrence rates of migraine headaches, an under-recognized adverse event, in patients undergoing catheter-based cerebral angiography.

Chest Pain as a Manifestation of Intracranial Hypotension: Report of Four Cases

BACKGROUND

Chest pain has not been recognized as a manifestation of intracranial hypotension secondary to cerebrospinal fluid leakage.

CASE REPORT

We report on 4 patients with intracranial hypotension diagnosed by the pattern of headaches, temporal proximity to dural puncture, magnetic resonance imaging findings, and resolution of symptoms after epidural blood patch who presented with chest pain. The chest pain was episodic, located in the sternal and interscapular region for the first 3 patients, with no radiation to any other region and no clear relationship to exertion. The fourth patient had episodic chest pain located in the subclavicular and suprascapular region. Two patients reported dyspnea with chest pain. Underlying coronary artery ischemia was excluded using a combination of the electrocardiogram and cardiac enzyme assays. The pain resolved after epidural blood patch treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of chest pain that can be seen with intracranial hypotension and cerebrospinal leakage to ensure appropriate diagnostic tests and treatment.

Effect of epidural blood injection on upright posture intolerance in patients with headaches due to intracranial hypotension: A prospective study

BACKGROUND

We performed a prospective study to quantify changes in various aspects of upright posture intolerance in patients with intracranial hypotension.

METHODS

Six patients were provided a standard questionnaire before, immediately after epidural blood patch injection and at follow-up visit within 1 month after epidural blood injection inquiring: (a) How long can they stand straight without any support? (b) Do they feel any sense of sickness when they sit or lie down after standing? (c) How long do they have to wait before they are comfortable standing again after they have stood straight? (d) How effectively and fast can they get up from sitting or lying position to stand straight? and (e) Rate their activities in upright posture without support on a standard vertical visual analogue scale between 100 (can do everything) and 0 (cannot do anything).

RESULTS

All patients responded that they could not stand straight for ≥30 min (four responding <5 min) on pretreatment evaluation. All patients reported improvement in this measure immediately postprocedure with two reporting ≥30 min. At follow-up, three patients reported further improvement and one patient reported worsening in this measure. The magnitude of improvement ranged from 10 to 80 points increase immediately postprocedure in their ability to perform activities, while they are standing without any support on visual analogue scale. At follow-up, four patient reported additional improvement in their ability to perform activities, while they are standing without any support (ranged from 10 to 20 points increase compared with immediately postprocedure rating).

CONCLUSIONS

We present semiquantitative data on various aspects of upright posture intolerance in patients with intracranial hypotension before and after epidural blood injection.

Effectiveness of Topical Lidocaine-Prilocaine Cream for Pain Control During Femoral Artery Catheterization in Adult Patients: A Prospective Study

OBJECTIVE

To test the effectiveness of topical EMLA cream (lidocaine 2.5% and prilocaine 2.5%) for pain control during femoral artery catheterization for neuro-endovascular procedures in adult patients.

METHODS

The body habitus overlying the femoral arterial pulsation was graded as: (1) pubic symphysis and iliac crest bone protuberances visualized; (2) Pubic Symphysis and Iliac Crest bone protuberances not seen but easily palpable; (3) Pubic Symphysis and Iliac Crest bone protuberances palpable with considerable difficulty; and (4) abdominal layers fold over the femoral region. The severity of pain at femoral artery catheterization was classified using a numeric rating scale score ranging from 0 (no pain) to 10 (worst pain). The primary endpoints were the proportion of patients with excellent (score of ≤1) and failed pain control (score of ≥8).

RESULTS

The mean (±SD) and median numeric rating scale scores were 2.4 ± 2.7 and 1, respectively, in 186 patients included. The proportion of patients with excellent pain control was 49.4% [95% confidence interval (CI) 42.1%-56.7%] and failed pain control was 6.9% (95% CI 4.1%-11.6%). The body habitus was graded as 1 (n = 31), 2 (n = 61), 3 (n = 48), and 4 (n = 46). In multivariate analysis, grade 4 body habitus [odds ratio (OR) 1.8; 95% CI 1.3-2.9], grade 4 ease of cannulation (OR 2.1; 95% CI 1.2-2.7), and previous femoral artery catheterization (OR 2.5; 95% CI 1.8-4.2) were independent predictors of failed pain control. Grade 1 ease of cannulation (OR 1.6; 95% CI 1.2-3.1) independently predicted excellent pain control.

CONCLUSION

Topical EMLA cream as an adjunct to local lidocaine infiltration was associated with very low rates of failed pain control during femoral artery catheterization despite a relatively high rate of unfavorable body habitus.

Effect of Endovascular Treatment on Quality of Life in Patients with Recurrent Symptoms Associated with Vertebral, Subclavian, or Innominate Arterial Stenosis

BACKGROUND

Patients with vertebral, subclavian, or innominate arterial stenosis can present with recurrent symptoms that can adversely affect the quality of life (QOL). We aimed at determining the short-term effects of endovascular treatment (ET) on QOL in these patients.

METHODS

European Quality of Life Five Dimension Scale (EQ-5D) utility index and visual analog scale (VAS) were ascertained before and within one month of ET in patients with vertebral, subclavian, or innominate arterial stenosis with recurrent episodes of vertigo, near syncope, and/or ataxia. The EQ-5D utility scores were derived from responses to five questions on EQ-5D questionnaire (-0.109 for the least to 1 for most favorable). The EQ-5D VAS score was obtained by subject's indication of his/her health state on a scale of 0 (worst) to 100 (best).

RESULTS

Angioplasty and/or stent placement was performed in 10 patients for stenosis in extracranial vertebral (n = 6), intracranial vertebral (n = 1), subclavian (n = 2), or innominate artery (n = 1). There was a significant reduction in preprocedure severity [mean ± standard deviation (SD)] of stenosis compared with postprocedure severity (79.9 ± 14.05% vs. 26.4 ± 37.7%, p < 0.001). There was a significant improvement in mean values of EQ-5D VAS postprocedure compared with preprocedure values (72 vs. 57.5, p = 0.018). Minimal important difference (improvement of at least 0.074) on EQ-5D utility index and on VAS (improvement ≥ 10 points) was reported by five and six of 10 patients, respectively.

CONCLUSIONS

Improvement in QOL appears to be an important measure of effectiveness of ET in patients with vertebral, subclavian, or innominate arterial stenosis with recurrent episodes of vertigo, near syncope, and/or ataxia.

A New Technique for the Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography

BACKGROUND

Previous studies have demonstrated the value of cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography.

METHODS

We assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection through a diagnostic catheter placed in the common carotid or the subclavian artery. rCBV maps were created using predefined algorithm based on contrast distribution in the venous phase (voxel size 0.466 mm³) into high, intermediate, low, and no detectable rCBV regions. rCBV maps were acquired again after the administration of intra-arterial nicardipine (1.5-2.5 mg), and percentage increases of the area of various grades of rCBV were calculated.

RESULTS

Three patients with internal carotid artery stenosis (32% - 64% in severity) and 1 patient with extracranial vertebral artery stenosis (46% in severity) were assessed. There was a variable but consistent increase in the area of high rCBV in the ipsilateral hemisphere in 3 patients with internal carotid artery flow (5.5%-24.5%) and the cerebellum (9.6%) in 1 patient with vertebral artery flow assessments. The increase in high rCBV was most prominent in the patient who received 2.5 mg (24.5%) and least prominent in a patient who received 1.5 mg (5.5%) of intra-arterial nicardipine. There was a concurrent reduction in areas of intermediate and low rCBV (shift) in 3 patients, and there was an increase in all areas of rCBV grades (addition) in 1 patient.

CONCLUSIONS

Selective assessment of cerebral vasodilatory response in the affected arterial distribution is feasible during catheter-based cerebral angiography.

Abstract TP149: A Prospective Study of Use of a Topical Anesthetic Cream (EMLA) to Reduce Pain During Femoral Artery Catheterization for Diagnostic and Interventional Neurovascular Procedures in Awake Patients

Objectives: To test the effectiveness of EMLA cream (lidocaine 2.5% and prilocaine 2.5%) for pain control during femoral artery catheterization for diagnostic and interventional neurovascular procedures in awake patients.

Methods: Topical EMLA cream was applied in the femoral region under occlusive dressing prior to lidocaine infiltration and femoral artery catheterization. The body habitus overflying the femoral arterial pulsation was graded as: (1) Pubic symphysis and iliac crest bone protuberance visualized; (2) Pubic symphysis and iliac crest bone protuberances not seen but easily palpable; (3) Pubic symphysis and iliac crest bone protuberance palpable with considerable difficulty; (4) Abdominal layers fold over the femoral region. The severity of pain at femoral artery catheterization was classified using a visual analog scale (VAS) rating from 0-10. Ease of cannulation was scored using a four-point scale, ranging from insertion at first attempt (1), a number of minor adjustments needed (2), a second attempt required (3), or failure of 2 or more attempts (4). The primary endpoints were the proportion of patients with good (VAS score of <3) and excellent (VAS score of ≤1) pain control, and failed pain control (VAS score of ≥8).

Results: A total of 164 patients (mean age ±SD, 60.8±16.1) were included in the registry. The mean (±SD) and median VAS scores were 2.2±2.6 and 1, respectively. The ease of cannulation was rated as 1 (n=49), 2 (n=82), 3 (n=20, and 4 (n=13). The proportions of patients with good, excellent, and failed pain control were 69.4%, 51.5%, and 4.4%, respectively. The primary endpoints were significantly different according to strata defined by body habitus as follows (Table 1):

Conclusions: Topical EMLA cream as an adjunct to local lidocaine infiltration was associated with high rates of good and excellent pain control during femoral artery catheterization in this cohort of patients despite a relatively high rate of unfavorable body habitus.

Abstract WMP65: Left Atrial Enlargement Without Atrial Fibrillation: A Risk Factor for Ischemic Stroke?

Background: Left atrial enlargement without atrial fibrillation can be seen during evaluation of patients with cerebral ischemic events. However, it remains unclear whether such patients should be considered high risk for further cerebral ischemic events and may benefit from long term anticoagulation may be considered.

Methods: We analyzed data from the Cardiovascular Health Study participants aged ≥65 years who underwent echocardiogram (included M-mode, 2-D, spectral, and color Doppler studies) and electrocardiogram (EKG) at baseline evaluation. All recordings were interpreted by central reader and left atrial diameter dimensions were recorded. We classified atrial dilation into four grades: 2.7-3.8 cm (ref), 3.9-4.2 cm (mild), 4.3-4.6 cm (moderate), and ≥4.7 cm (severe). We excluded patients with atrial fibrillation on EKG. Incident stroke was identified during annual follow-up examinations and at 6-month telephone contact and adjudicated by a central committee. Hazards ratio for all strokes, ischemic stroke, and hemorrhagic stroke during follow up were estimated using Cox proportional Hazards analysis.

Results: Severe atrial dilation was observed in 298 (6.8%) of 4,384 study participants without atrial fibrillation (35.6% women, 2.3% African American; mean baseline age, 72.9 ± 5.2 years). The rate of ischemic stroke and any stroke was similar among patients with and without severe atrial dilation over a mean follow up period (mean ±SD) of 7.2 ±1 years. The risk of ischemic stroke (HR 1.3, 95% confidence interval [CI] 0.8-2.0) and all strokes (HR 1.2, 95% CI 0.8-1.8) was not different among patients with severe atrial dilation(compared with those without) after adjusting for age, race, gender, body mass index, heart disease, systolic blood pressure and cigarette smoking. The risk of hemorrhagic stroke (HR 1.1, 95% CI 0.3-3.6) was not significantly different among patients with and without severe atrial dilation.

Conclusions: There was no increase in risk of any stroke or ischemic stroke in patients with severe atrial dilation without atrial fibrillation.

Abstract TP156: Migraine and Non-migraine Headaches Following Diagnostic Catheter Based Cerebral Angiography: A Prospective Study

Background: No reliable estimates of headaches following catheter based cerebral angiography are available. We performed a prospective study to ascertain the frequency and type of headaches following cerebral angiography including time to resolution.

Methods: Consecutive patients who underwent diagnostic catheter based cerebral angiography through the transfemoral (or infrequently radial) route using iodixanol (270 mg/ml) injection were included. Each patient underwent a brief neurological assessment after the procedure by a board-certified neurologist and more detailed assessment was performed if any patient reported occurrence of any headache. The headaches were classified as migraine if the diagnostic criteria specified by International Headache Society were met. The severity of headache was classified using a visual analog scale rating from 0-10. Another endpoint was the time to reach pain free status for two consecutive hours.

Results: A total of 168 patients (mean age 60.5 ±SD 16.2 years; 90 were men) underwent diagnostic cerebral angiography. Of the 168 patients, 5 (3.0%, 95% confidence interval [CI]1.1%-6.6%) reported occurrence of migraine headaches and14 (8.3%, 95% CI 4.7%-13.7%) reported occurrence of non-migraine headaches. The median severity of migraine headaches was 10/10 and time (in minutes) to resolution of headaches was 140 minutes (range 60-360); two patient did not have complete resolution within 48 hrs of procedure. Of the patients with history of migraine, 3 (1.8%, 95% CI 0.5%-4.9%) reported occurrence of migraine headaches and 5 (3.0% 95% CI 1.0%-6.6%) reported occurrence of non-migraine headaches. Occurrence rates for migraine headaches in men and women were 1.1% (95% CI 0.1%-5.5%) and 3.9% (95% CI 1.0%-10.7%), respectively. Occurrence rates for migraine headaches was very high among patients with arterial dissections: 22.2 %, (95% CI 3.7% - 73.4%), although numbers were small.

Conclusions: We provide occurrence rates of migraine and non-migraine headaches, an under recognized adverse event, in patients undergoing catheter based cerebral angiography.

Upright Catheter-Based Cerebral Angiography

BACKGROUND

Several studies using Doppler ultrasound have suggested cerebral venous drainage is through paravertebral venous plexus due to the collapse of internal jugular veins in an upright position.

METHODS

We present a technique of acquiring venographic images during an upright position as part of catheter-based angiography to provide additional information regarding cerebral venous diseases. Angiographic images in anteroposterior projection were acquired in lying position and after patients were placed at 60° using radiolucent supporting wedges on angiographic table.

RESULTS

In the first patient, there was activation of the paravertebral venous plexus as supplemental venous drainage to right internal jugular vein and stenosis of left internal jugular vein in high cervical segment in the upright position. There was relative collapse of both internal jugular veins in the mid-cervical region. In the second patient, there was attenuation of contrast opacification of right posterior cervical veins and complete occlusion of right internal jugular vein proximal extracranial segment (high-grade stenosis in lying position). There was activation of additional supplemental drainage to left internal jugular vein including paravertebral venous plexus. In the third patient, there was exacerbation of stenoses of the left and right internal jugular veins proximal extracranial segment in the upright position (moderate stenoses in lying position). There was activation of additional supplemental drainage via paravertebral venous plexus to both internal jugular veins.

CONCLUSION

Our results demonstrate prominent changes in venous drainage patterns during upright angiographic images. Further studies would have to identify the patients in whom additional information in the upright angiography may provide clinically relevant information.

Long Acting Liposomal Bupivacaine for Percutaneous Sympathetic Stellate Ganglion Blockade: A Technical Note

INTRODUCTION

We describe the use of long acting liposomal bupivacaine for percutaneous stellate ganglion blockade to treat severe headaches following internal carotid artery dissection.

METHODS

A 43-year old woman developed right-sided refractory headache after right internal carotid artery dissection. Patient underwent percutaneous stellate ganglion block using bupivacaine hydrochloride (0.25%-20 ml) in the past with short acting relief. Liposomal bupivacaine (EXPAREL) 13.3 mg/mL (1.3%) solution diluted with preservative-free normal saline: a total solution of 20 ml (52 mg of bupivacaine) was injected at the level of the lower portion of body of the sixth cervical vertebra, medial to the right internal carotid artery. The response to sympathetic block was assessed by a neurologist not involved in the procedure.

RESULTS

After the stellate ganglion block with bupivacaine hydrochloride, patient was headache free immediately after the block but with recurrence of pain on Day 3 with return to peak intensity by Day 4. After the stellate ganglion blockade with liposomal bupivacaine hydrochloride, patient reported recurrence of pain on Day 15 post injection with return to peak intensity by Day 17. The patient reported an episode of aura which consisted of visual scintillations on Day 2 which lasted for five days and resolved spontaneously.

CONCLUSION

Liposomal bupivacaine injection for stellate ganglion blockade can result in a more prolonged effect compared with bupivacaine hydrochloride.

Assessment of Skeletal Muscle Perfusion using Contrast-Enhanced Ultrasonography: Technical Note

BACKGROUND

Intravenous contrast-enhanced ultrasonography is a recently developed technique for assessment of tissue perfusion, but has not been used for assessment of skeletal muscle perfusion.

METHODS

We studied a 42-year-old woman in whom myonecrosis was suspected due to systemic vasculitis and ischemia. The biceps brachii (right) and quadriceps femoris (vastus medialis) on right-hand side and subsequently left-hand side were imaged. Intravenous bolus of activated perflutren lipid microspheres was injected and B-Flow color mode (brown color) was used within a selected region of interest to image the passage of contrast through muscle parenchyma throughout three cardiac cycles.

RESULTS

Visual interpretation of muscle perfusion was performed based on the maximal intensity of contrast in the muscle, and the speed of contrast replenishment. No deficits were noted in the perfusion pattern. The arterial phase demonstrated stellate vascularity, centrifugal filling, and homogeneous hypervascularity at peak enhancement.

CONCLUSIONS

The bolus of contrast resulted in good signal persistence and satisfactory imaging for multiple muscle groups.