Cerebral Angiography

Cerebral angiography means angiography of brain and neck vessels. The procedure in Liv Hospital Neuroradiology Clinic is performed in angiography unit. Under local anesthesia, the groin artery is entered with a thin catheter and the images of the brain and neck vessels are obtained by administering contrast medium (a special medical dye) into these vessels. The presence of stenosis, aneurysm (bubble), arteriovenous malformation or fistula (tangle of vessels and short circuit between the artery and vein) or other problems in the brain and neck arteries is investigated. The patient is sent home after resting for 4-5 hours in the hospital after angiography (if there is no any other situation requiring hospitalization). It is a comfortable, short lasting and safe procedure in experienced and well-equipped centers.

Myelography

It is an examination performed by injecting contrast agent (a special medical dye) into the spinal canal. After obtaining images in the X-ray machine in this way, the examination can be extended by taking the patient to the tomography unit. This examination is often requested due to problems developing after kyphosis, curvature of the spine, back operations and problems such as sliding back.

Intrathecal Contrast Cisternography

It is an examination performed in case of CSF rhinorrhea (accidents, cerebrospinal fluid coming from the nose or ears after some of the surgery or intervention). The aim to detect the region that the fluid leaked clearly and lead to rapid repair. A special medical dye called contrast medium is injected into the spinal canal. This dye is directed to the head and neck region by giving position to the patient and the region of leakage is determined with the guidance of MRI or CT.

Petrosal and Cavernous Sinus Sampling

It is an examination performed in Cushing’s disease is characterized by excessive secretion of hormones by the pituitary gland. It used to determine where the hormones are secreted exactly in cases that MRI examination is not giving clear information. Pituitary gland vein is accessed by entering from both groin veins under local anesthesia in the angiography unit; blood samples are obtained from here and hormone tests are performed. Thus, hormone secretion region is determined in order to perform surgery in the most successful way.

Carotid and Vertebral Artery Occlusion Tests

The main arteries in the neck are injured in cases such as accidents, tumor spread in head and neck region or injury during the operation; and permanent closure of them may be necessary. In such cases, there is a risk of neurological sequelae (stroke) occurrence in the patient. A balloon is inflated in the vessel planned to be closed with the guidance of angiography and the patient is angiographically and clinically tested before the closure procedure in order to eliminate this risk.

Discography

It is an examination for detecting the source of pain in spine pain depending on disc degeneration, which is performed by injecting medical dye into the intervertebral discs (acting as a cushion between the vertebrae and cushions forming back or neck hernia in their slipping).

Cerebral Angiography

Cerebral angiography can be performed to the baby of all ages from newborns. The procedure is performed under general anesthesia in Liv Hospital Neuroradiology Clinic, so the patient does not feel pain and will be under the control of the anesthesiologist during the procedure. The inguinal artery is entered via a very thin catheter and brain and neck vessels are examined with the contrast agent (medical paint) in appropriate dose to the child’s age.

It is very important to get the procedure performed in an experienced and equipped center by a neuroradiologist working in the field of children’s interventions. This procedure may be needed in congenital (present at birth) brain vascular diseases, with accidents, injuries and cerebral hemorrhage in the children.

Endovascular Treatment in Vein of Galen aneurysmal malformation

Vein of Galen aneurysmal malformation is a disease usually diagnosed in the womb or immediately after birth. One or more fistula (direct access of the arteries to a large median line vein) with very high flow that threatens the life of the baby is present in the brain of the baby. These short-circuits must be closed under general anesthesia by entering from the groin artery with angiographic procedure in emergency conditions by applying several sessions if necessary. This procedure is performed in Liv Hospital Neuroradiology Clinic by equipped and experienced team of experts.

Treatment in Pediatric Cerebral Aneurysm, Arteriovenous Malformation and Fistulas

Vascular bubble, tangles of vessels or short circuit (fistula) of arteries, veins can be found in the brain of also babies and children. These events are often threatening the child’s life or potentially to become disabled. Closed surgery (treatment by going through the vessels) is preferred in Liv Hospital Neuroradiology Clinic, because open surgery may be very risky in certain cases. The procedure is performed in the angiography unit under general anesthesia. The treatment is performed by reaching related artery region in the brain from the groin artery with filler, drying agent, etc. appropriate for the disease. Such interventions can only be performed in fully equipped and experienced centers in terms of children interventions by experienced teams.

Intra-arterial chemotherapy in Retinoblastoma

Retinoblastoma is an eye tumor found in infants and young children. Until very recently, removing the ill eyes of these children, systemic chemotherapy, radiotherapy and local treatments were applied; administration of chemotherapy agents directly into the eye vessels (intra-arterial chemotherapy) method was developed.

The groin is entered via cerebral angiography method under general anesthesia in Liv Hospital Neuroradiology Clinic. Thin and featured catheters are first placed into the associated side and then into the associated eye vessel. From here, the appropriate dose of the chemotherapy agent is administered into the vessel of the eye. Then, the child will be sent home after a day of observation. The number of teams who have experience in this area is extremely small, it needs knowledge and experience

What is brain aneurysm?

Aneurysm is expansion and ballooning of a weak point of artery.

What is the incidence of aneurysm? 

It is a disease that is developed and to be developed in the rate of 1.5 to 5% of the general population. Based on this calculation, 1.200.000 – 4.000.000 people have or will have aneurysm in our country.  A lot of these aneurysm patients has no complaint about aneurysm. Cerebral hemorrhage (brain bleeding) may develop in 1 to 3% of patients with cerebral vascular aneurysm. Approximately half of the patients underwent cerebral hemorrhage associated with aneurysm is lost

How aneurysm occurs? Is it exist during birth?

Usually, aneurysms are not congenital.  They are mostly occur after the age of 40. However, they can be observed in 20s. Also in people whose first degree relative has more than 2 aneurysms, probability of having aneurysm is 5 times higher than the normal society.

Aneurysms may occur in the vascular bifurcation regions and it is considered that they develop secondary to continuous over-pressurization of these regions.  They grow up slowly and their walls are getting weakened as long as they growing up.  Incidence is more frequent in some vascular diseases (i.e. fibromuscular dysplasia, cerebral arteritis, and arterial dissection). Infection, use of drug (such as amphetamines) or drugs like cocaine has a role in development of some aneurysms.

Is all of the cerebral aneurysms the same?

No. Aneurysms demonstrate difference depending on their size, shape and localization.
Depending on the size:
Small-sized aneurysms: Smaller than 5 mm
Medium-sized aneurysms: In 6 – 15 mm
Large-sized aneurysms: In 16 – 25 mm
Giant-sized aneurysms: Larger than 25 mm
Depending on the shape:
Saccular:  In the shape of balloon with narrow neck depending on the size
With large neck: In the shape of balloon with large neck depending on the size
Fusiform: Expansion of a segment of artery in all walls
Depending on the localization:

Aneurysms are usually observed in the common arteries in close proximity of the cerebral tissue. In case of it occurs in a side wall of a flat artery, they are called “sidewall aneurysm”, and in case of it occurs in the vascular bifurcation region, they are called “bifurcation aneurysm”. Aneurysms occurred in the anterior arteries of the brain are called “anterior circulation aneurysms” and aneurysms occurred in the posterior arteries of the brain are called “posterior circulation aneurysms”.

How aneurysm is diagnosed?

Aneurysm can be diagnosed using some special imaging techniques:
Computerized Tomographic Angiography (CTA)
Magnetic Resonance Angiography (MRA)
In these methods, images of computerized tomography or magnetic resonance obtained by means of infusing an agent through the arm vein are obtained by converting them into a vascular image using a special program. It is usually possible to visualize and diagnose the aneurysms larger than 3 mm using these methods.

Angiography: 

The most advanced method providing information in detail used in vascular visualization is the catheter angiography.  In this method called Digital Subtraction Angiography (DSA) in today’s technology, a thin tube is inserted into the groin artery to reach the common arteries leading to the brain, and image of the artery is obtained after infusing a kind of stain agent.  On these images obtained in different positions and which can even be converted into 3-dimensional vascular image, all characteristics of the cerebral arteries can be examined in detail.

Vascular issues should be examined with all details by performing a diagnostic cerebral angiography prior to planning a vascular treatment.

Is another aneurysm possible in a patient with an aneurysm?

Possibility of another aneurysm in a patient with an aneurysm is around 15-20%.

Which symptoms reveals the non-hemorrhagic cerebral aneurysm?

Non-hemorrhagic aneurysms may usually not lead to any symptom.  They are mostly identified by chance on a cerebral visualization performed for another purpose.  Some aneurysms can be diagnosed since they grow up silently, compress on the surrounding nerves or other formations and cause to their malfunctioning. Rarely, they can be diagnosed since they cause to some symptoms at the result of partial clot formation in large or giant aneurysms and of occlusion of an artery due to part of this broken clot.

Why aneurysm bleeds?

We cannot know exactly what effect plays a role in bleeding of an aneurysm or when an aneurysm will bleed. However, reasons that increase the probability of hemorrhage (bleeding) are known:

High blood pressure level raises the risk of hemorrhage. Heavy lifting or straining raises the pressure on the cerebral artery and may cause to aneurysm to bleed.
Severe emotional storms (i.e. sadness, anger) which lead the blood pressure to raise increase the risk of hemorrhage.
Use of some drugs (Ephedrine, amphetamines, diet drugs) and substances like cocaine raise the risk of hemorrhage of the aneurysm.
Smoking increases the risk of hemorrhage.

What is the probability of hemorrhage of a non-ruptured aneurysm?

There is no any clear answer.
This issue shows a great similarity to an actual issue in our country: earthquake.  If we make an analogy, having an aneurysm in our brain is like sitting on a fault line. Just as it could not be known exactly when and how severe a fault line would cause to an earthquake, it is impossible to know when and how severe an aneurysm would explode.
Some characteristics of the aneurysm can give us an idea about the risk level of hemorrhage.  We can get a rough idea about the risk of hemorrhage of the aneurysm looking at the characteristics such as the size, shape and localization, but it is not definitive. In case of an aneurysm bleeds, the possibility of re-bleeding is too high in a short term. Thus, it must be treated as soon as possible.

What causes hemorrhage of the aneurysm?

Our brain and vessels feeding it in the scull are inside a fluid (cerebrospinal fluid) and there is a cortex surrounding this fluid. Aneurysm-related cerebral hemorrhage is mixing of blood with the fluid at the result of explosion of the artery in this fluid (subarachnoid hemorrhage). In case of hemorrhage of the cerebrospinal fluid, response of our brain to this may be in different ways:
Sudden death occurs in approximately 20% of the patients with hemorrhagic aneurysm  (A significant portion of the events described as ‘he/she died suddenly or found dead’ are the patients who lost at the result of the cerebral hemorrhage).
Very severe headache emerges that lasts several hours or days . Patients usually define that headache as “most severe headache of my life”.
Nausea and vomiting may be occurred.
Cervical movements and nape are associated with severe pain and movements are limited.
Tendency to sleep or coma may emerge.
In case the hemorrhage occurs partially in the brain tissue, loss of strength of arm and/or leg, deterioration in speech and understanding, vision loss or seizure may be observed.

Which damages may occur in the brain after hemorrhage of the aneurysm?

The risk of death due to hemorrhagic aneurysm is approximately 50%.

The possibility of becoming moderate or severe disabled varies around 20-35%.
15-30% of the patients are either completely healed or survive the situation with mild disability.

“Vasospasm” may emerge in 15-20% of the patients underwent aneurysm-related cerebral hemorrhage (shrinkage of the blood vessels secondary to mixing of blood to the cerebrospinal fluid). Depending on this shrinkage of the vessels, feeding of the brain may be distorted and brain damage may develop.
Other adverse events that may occur in the aneurysm-related cerebral hemorrhage are “hydrocephaly” (expansion of the fluid-filled spaces in the brain) and respiration problem. Cardiac and pulmonary (heart and lungs) problems that may emerge secondary to the brain damage may cause to damages of other organs.

Is the brain damage reversible at the result of treatment of the hemorrhagic aneurysm?

No.  If a brain damage occurred secondary to hemorrhage of the aneurysm, treatment of the aneurysm would not help to remedy this damage.  The purpose of the treatment of the hemorrhagic aneurysm is to prevent the occurrence of hemorrhage again and the brain damage or death that may emerge secondary to hemorrhage.  In case of a brain damage secondary to hemorrhage, the method to be recommended to recover the lost functions is rehabilitation.

How is the aneurysm treated?

The aneurysm cannot be treated with drugs. An intervention must absolutely be performed.  There are mainly two methods: clipping with open surgery or treatment with endovascular way (treatment from inside the artery without opening the scull).
How clipping of the aneurysm is performed by open surgery?
The operation is performed under general anesthesia naturally. A portion of the scull is removed at a place where the aneurysm is localized and in a width found appropriate by  the surgeon. Under microscopic examination, the artery with the aneurysm on it is accessed by advancing through the spaces and folds around the brain, and the portion of the artery containing the aneurysm is reached. A clips (one or more) is placed on the aneurysm’s neck where the aneurysm is joining with the artery using various surgical techniques.  In the meantime, it may be required to close the common artery using a temporary clips to prevent the possible aneurysm hemorrhage. After checking the localization and position of the clips, by turning from the distance back, the cerebral cortex is re-sutured, opening on the scull is closed and the operation is terminated. The patient who transferred to the intensive care unit after operation is transferred to the inpatient clinic when the stable condition is ensured.

How the aneurysm is treated by the closed method (endovascular method)?

The procedure must be carried out under general anesthesia. The purpose of general anesthesia is not to relieve the possible pain. The purpose is to ensure that the patient and head must not be moved even 1 mm during the treatment that will last one or a few hours. A the same time, controlling the vital functions of the patients such as heart and lungs during a brain treatment by the anesthesiologist increases the patient’s safety.

During staining of the patient’s inguinal regions to contaminate from microbes, sterile covering is made on the patient and small openings are left in the inguinal regions. The groin artery is inserted into using a needle and a short entry passage called “introducer” is inserted into this segment of the artery. Usually a valve is present on the external tip of this tube in diameter of 2 mm and it prevents external hemorrhage during the procedure.  Under guidance of imaging, the long and thin tube called catheter is advanced and so it is possible to access the artery with the aneurysm on it in a short while. A second tube (a “micro-catheter in diameter of average 0.5 mm) more thinner than the one we call “guide-catheter” is advanced.  Inside the aneurysm is accessed via this micro-catheter (under guidance of imaging), and inside of the aneurysm is filled with a bucket of very soft wire spirals called “coil”.  The purpose here is to prevent the blood from entering into the aneurysm.  Through the stain injections infused via the common artery intermittently during the procedure, examinations are done such as how much the aneurysm is filled, whether blood in entered into it, and how the conditions of the neighboring arteries. During the procedure, a balloon can be used in order to check the blood flow in the artery or to proper wrap the coils inserted into the aneurysm. Using a very tiny balloon fixed on the tip of another catheter (in maximum diameter of 4 mm), the close proximity of the aneurysm can be accessed by advancing through the guide-catheter. Temporary inflation of this balloon shows the effect of the temporary clips in the open surgery technique.
In case of the aneurysm neck is large, a special stent can be placed on this part of the artery to prevent the coils inside the aneurysm from overflow to the common artery.

In case of the size of the aneurysm is very big and its neck is very large, it may be required to place a special stent with very tight meshwork called “flow-routing stent” on this part of the artery with aneurysm on it.

How proceeds the healing process after the treatment of aneurysm?

In non-hemorrhagic aneurysms:
The patients with open surgery are usually discharged within one week. It takes several weeks or months for them to fully heal.
The patients with endovascular surgery are usually discharged within 1 to 2 days.  They would return to their normal life within maximum one week.
In hemorrhagic aneurysms:
No matter which method was used for treatment, the risky period continues for a while even in case of the treatment was very successful. Complications that may emerge depending on the effect created by the hemorrhage may be effective for about 3 weeks following hemorrhage and pose risk for the life.  Even in the case of overcoming this period without any damage, it takes months for the patient to heal fully.

What complications may emerge in the hemorrhagic aneurysms?

Two main problems may be experienced in case of hemorrhage of the aneurysm:
Vasospasm:  It is an artery shrinkage in case of mixing of blood with the cerebrospinal fluid where the brain and vessels are localized.  Because the stenosis secondary to the shrinkage of the artery makes the blood flow inside it difficult, the brain tissue fed by the shrunken artery cannot obtain sufficient amount of blood, and edema and/or damage may emerge secondary to malnutrition. Treatment of vasospasm results better if it is diagnosed in early stage. Besides some drug treatments and treatments such as lowering the pressure by partially emptying the cerebrospinal fluid using a needle or catheter, applications can be performed that require advanced techniques such as application of balloon or drug to expand the artery by accessing this region through inside the artery using the angiography.

Hydrocephaly:  It is the expansion of circulation of the fluid-filled spaced which are normally exist in the brain, secondary to their deterioration with the blood effect. This may cause to jam of the brain in the scull and to malnutrition. In case of development of hydrocephaly, a tube called shunt is placed inside these spaces with a relatively easy operation, and the excess fluid collected is transferred into a cavity (thoracic or abdominal cavity) other than the scull.

Which method is more suitable for the aneurysm treatment?

Both methods including the open clipping operation and the closed method called endovascular treatment (from inside the artery) are the methods with proven efficacy and reliable long-term results.  What is important here as a choice is to properly determine for which method the patient and the aneurysm are suitable.  It should be decided based on the localization, size relationship with the arteries, relationship with the neighboring brain tissues of the aneurysm, the flow characteristics at that portion of the artery, the patient’s overall condition and the patient’s other comorbidities. A common belief developed today is to choose the endovascular treatment (closed treatment), if possible, in the treatment of the aneurysm.  Usually, open clipping surgery is performed for the situations where possibility for the endovascular treatment could not found.  At the result of this development, attempts to treat using the closed method have been started recently also in the neurosurgery community.  Treatment of the cerebral aneurysms using the endovascular method (closed method) are carried out by neuroradiology specialists for years.

How should the method be chosen in the treatment of aneurysm?

Decision on how the aneurysm will be treated is of great importance. The most modern and proper method in making this decision is that the common decision of the surgeon who will perform the open operation, the neuroradiology specialist who will perform the closed operation together with the patient and patient’s relatives.  Depending on the characteristics mentioned above, decision on which treatment method is more suitable for your patient’s aneurysm should be made by such a team altogether.

What is the probability of experiencing complication in the treatment of aneurysm? 

Probability of experiencing a complication during the treatment of a non-hemorrhagic aneurysm is very low.  The complication rate of a treatment to prevent the problems that may be experienced should already be low  even in the case of hemorrhage of the present aneurysm.  The probability of experiencing complication in the treatment of such a patient is around 1%.

How should the follow-up be done after an aneurysm treatment?

A diagnostic angiography is performed after the surgical clipping and it is checked that the aneurysm is closed completely and the blood flow inside the arteries. A short-term control is not necessary since it is already done during the endovascular treatment. In both situations, the patient should be under control in certain periods and the stability of the treatment should be checked by control evaluations when needed. Another benefit of control is to take precaution against development of any new aneurysm in the patient with aneurysm that was occurred on a weak point in the artery.

Carotid artery occlusion which means common atherosclerosis is particularly seen after the age of 40s. Sometimes, a vascular damage may occur following a trauma at the result of an impact to the vessel.

Carotid artery occlusion may cause to loss such as vision loss, speech disorder, inability of understanding what is said, inability to move limbs, and facial paralysis may occur due to occlusion. All of these occurs with symptoms such as dizziness, nausea, and vomiting.

In case of carotid artery occlusion, two types of symptoms may occur:

• The disruption of activities of that region since sufficient blood cannot enter into the occluded area of the brain.
• Formation of a small clot where blood cannot pass due to stenosis or stroke of the area at the result of an occlusion of a vessel in the brain due to a piece broken off from the fat accumulation that leads to stenosis.

How is it diagnosed?

Imaging methods are used for diagnosis-purpose after clinical examination. Doppler examination, MRI angiography and CT angiography can be done but the most accurate result can be achieved by angiography performed via catheter.

How is stenting applied in carotid artery stenosis?

Stenting is performed by entering the groin. The carotid artery is entered into by catheter and the closed umbrella on the tip of the catheter will be opened after passing the stenosis, and blood flow is ensured.

What are the advantages of stent application?

Return to everyday life is possible with a 1 day-hospitalization in the hospital without the need of anesthesia.

The interventional neuroradiology helps to solve the vascular problems of head, neck and brain, and even spinal cord. Angiography method is used in this process mostly. Access is made via entering from groin, vessels at the farthest points of the brain are reached, and treatment of problems here can mostly be possible by the interventional neuroradiology method. The interventional neuroradiology can be considered under two topics as diagnostic and therapeutic interventions.

• Diagnostic interventions include procedures such as biopsy under guidance of imaging methods; performing hormonal examination by obtaining blood sample from the point where venous blood of hypophysis is discharged bilaterally accessing via the inguinal veins in some hypophysis tumors; and definitive diagnosis and examination in detail by angiography in the vascular diseases in the area of interest, etc.
• Therapeutic interventions include procedures such as treatment of aneurysms -the name of bubbles which must be not available in the brain vessels- from inside the vessel via catheter (embolization); treatment of A-V malformations of brain vessels; treatment of fistula (short-circuits) between the brain veins and arteries; occlusion of vessels for the purpose of preparation to treatment/operation of some head-neck region and brain tumors; treatment of diseases with vascular origin observed in head-neck region and even in other regions of the body and called hemangioma, by administering drug both via inside the vessel and needle under fluoroscopic guidance; removal of stenosis of common cervical and intracranial vessels by applying balloon and stent; treatment by catheter of vascular constrictions that occur in the brain vessels particularly in cerebral hemorrhages in the form of SAK and threat the life; and elimination of the risk of stroke or death of patient by removing the vascular occlusions under emergency conditions that occur suddenly in acute stroke cases. In addition, some interventions for vertebroplasty in spine fractures and for pain therapy are performed intensively in some neuroradiology clinics.

The most frequently applied procedures in the daily practice are cerebral aneurysm, A-V malformation, A-V fistula and embolization in tumor cases. Treatment of stenosis of the carotid, vertebral artery, cerebral arteries by stent.

Which clinical branches are cooperated with in patients with neuroradiological procedures applied?

•             Neurosurgery

•             Neurology

•             Cardiology

•             Vascular Surgery

•             Plastic Surgery

•             Orthopedics (before spine surgery and in tumors)

•             Otorhinolaryngology

•             Ophthalmology

The rate of incidence of major diseases in the community that have possibility of treatment by neuroradiologic methods:

• Intracranial aneurysm: Incidence in the regular community varies between 2% and 6% according to various studies. (it can be thought that there are 300.000 to 900.000 aneurysm patients in Istanbul). When we apply the US statistics, 1500 patients undergo cerebral hemorrhage secondary to aneurysm every year in Istanbul and about 20% of them are lost without reaching the hospital. 50% of them are died within a year following hemorrhage.
• Carotid artery stenosis: Based on the NIH (USA) data, advanced asymptomatic carotid artery stenosis is reported as 0.2% in males under 50 years of age, as 7.5% in 80 years of age and above, and 3% in general population (450,000 patients in Istanbul).

Advanced carotid stenosis is reported in 11-26% of coronary artery patients and 25-49% of peripheral artery patients (these statistical results may vary based on the population studied). )

• Intracranial vascular stenosis: Based on the studies in the USA, intracranial stenosis was found in 23% of population with the age of 60s.