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BackgroundThe transradial approach for cardiac catheterization is associated with improved patient safety and satisfaction in comparison with the transfemoral approach. Prospective data for the transradial approach for cerebral arteriography are lacking.ObjectiveTo carry out a prospective study of consecutive patients undergoing transradial cerebral arteriography at our institution to evaluate the safety, feasibility, and limitations of this approach.MethodsConsecutive patients referred for diagnostic cerebral arteriography at an institution with minimal transradial experience were enrolled until 50 right transradial diagnostic cerebral arteriograms were obtained. A procedural staging system was developed and goals of angiography were defined before each procedure. The primary outcome was the ability to achieve the predefined goals using the transradial approach. Secondary outcomes included the technical ability to access and inject each supra-aortic artery of interest and the incidence of complications.ResultsA total of 65 patients were screened; 15 were excluded owing to contraindications and 50 underwent attempted right transradial cerebral arteriography. The primary outcome was achieved in 44 patients (88%). Failures occurred at stage 1 (n=3, 6%), stage 2 (n=1, 2%), stage 3a (n=1, 2%), and stage 3b (n=1, 2%). Crossover to the transfemoral approach occurred in four patients (8%) and the procedure was terminated in two patients (4%). All supra-aortic arteries of interest were accessed and injected, with success rates between 89% and 100% with the exception of the left vertebral artery (successful in 59%). There were no major complications and five minor complications.ConclusionNeurointerventionalists attempting the transradial approach can expect to achieve moderate early success and a low complication rate.

A 56-year-old woman presented with visual loss in the right eye with best-corrected visual acuity of 20/40. Funduscopic examination revealed neovascularization of the disc with peripapillary preretinal hemorrhages and leakage on fluorescein angiography. Cerebral arteriography demonstrated stenosis of the major cerebral vessels with classic collaterals configuring as “puff of smoke”. A diagnosis of moyamoya-related ocular ischemic syndrome manifesting with optic disc neovascularization was made.

BackgroundDespite growing interest in the transradial approach for neurovascular procedures, prospective data about the learning curve for neurointerventionalists adopting this approach are limited.MethodsA subsequent prospective series of 50 consecutive right transradial diagnostic cerebral arteriograms was compared with our initial institutional experience using a procedural staging system. The primary outcome was the ability to achieve the predefined procedural goals using the radial approach. Secondary outcomes included the technical ability to access and inject each supraaortic artery of interest and the incidence of complications.ResultsThe primary outcome was achieved in 49 patients (98%) compared with 88% in the initial series (p=0.05). One stage 2 failure (2%) occurred. Crossover to the transfemoral approach occurred in one patient (2%) compared with 8% in the initial series (p=0.16). All supraaortic arteries of interest were accessed and injected with success rates between 93% and 100%. There were no major complications and two minor complications.ConclusionNeurointerventionalists can overcome the right transradial learning curve and achieve high success rates and low crossover rates after performing 30–50 cases.

Objetivo: Analisar o processo diagnóstico de morte encefálica, além de caracterizar o perfil dos doadores de órgãos e tecidos. Métodos: Análise de registros médicos de 203 pacientes com suspeita de morte encefálica acompanhados pela Central de notificação, captação e distribuição de órgãos do norte de Minas Gerais, entre 2013 e 2016. Resultados: Os indivíduos do sexo masculino foram os mais prevalentes (62%), com idade média de 40,4 anos (±16,6), sendo a principal causa de morte encefálica o traumatismo crânio-encefálico (44,5%), seguido pelo acidente vascular cerebral (43,6%). Quanto aos exames complementares, o doppler transcraniano e a arteriografia cerebral foram utilizados na confirmação de morte encefálica em 82,3% e 16,2% dos casos, respectivamente. O percentual de doadores efetivos na população estudada foi de 41% e a taxa média de doadores efetivos por milhão de população entre 2013 e 2016 no norte de Minas Gerais foi de 12,5. Conclusão: O doppler transcraniano apresentou tempo de execução e resolutividade semelhantes ao padrão-ouro. A taxa de efetivação de doações no norte de Minas Gerais foi superior à média estadual e nacional, enquanto a taxa estimada de identificação de potenciais doadores de órgãos foi inferior à média nacional e da maioria dos países desenvolvidos.

Primary angiitis of the central nervous system (PACNS) is a vasculitis of small arteries and veins of unknown cause restricted to the central nervous system (CNS), and controversy and disagreement exist over the means to establish the diagnosis. Cerebral arteriography, cerebrospinal fluid examination, and MRI singly or in combination do not have sufficiently demonstrated positive predictive value to establish the diagnosis. An alternative diagnosis is established at biopsy in 35% of cases. Histologic confirmation is required for the diagnosis of PACNS. Patients without histologic confirmation should not be included in case reports, case series, or reviews.

Cerebral angiography was introduced and expanded by the Portuguese neurologist Egas Moniz close to a century ago. Significant morbidity and mortality lead to a transition to iodinated solution as contrast media, leading to satisfactory technical results. Despite the original “distrust” and controversy regarding this method and its future, cerebral angiography not only remains the gold standard for the diagnosis of vascular conditions affecting the craniocervical and cerebral vessels, but has also developed itself into a very sophisticated interventional field. This chapter discusses indications, risks, periprocedural care, as well as recent advancements in the field of cerebral angiography.

Il s’agit d’une jeune femme de 33 ans, suivie pour HTA sous monotherapie depuis un an, admise aux urgences pour des cephalees d’installation brutale. L’examen clinique trouve une patiente consciente, TA=13/7, avec presence d’un syndrome meninge franc sans fievre. La TDM cerebrale a montre une hemorragie meningee au niveau de la vallee sylvienne droite. L’arteriographie a objective trois dilatations anevrismales au niveau de l’artere communicante posterieure droite de 8,3mm, au niveau du segment M2 de la sylvienne droite de 4 mm (A) et enfin au niveau de la bifurcation sylvienne gauche de 4mm (B). La patiente a beneficie d’un traitement endovasculaire des deux anevrismes a droite avec un rendez-vous de 3 mois pour securiser l’anevrisme gauche. La prevalence des anevrismes intracrâniens dans la population generale est evaluee de 1 a 5%. Seulement 15% de ces patients ont des anevrismes multiples, et 7% de ces patients ont plus de quatre anevrismes. La strategie therapeutique vise a securiser d’abord l’anevrisme qui a saigne et de traiter ulterieurement les autres anevrismes en fonction de leur taille et du risque hemorragique.

The aim of this study is to evaluate dose values in patients and staff involved in some interventional radiology procedures. Doses have been measured using thermoluminescent dosemeters for single procedures (such as renal and cerebral arteriography, transjungular intrahepatic portasystemic shunt (TIPS) and chemoembolization). The magnitude of doses through the hands of interventional radiologists has been studied. Dose levels were evaluated in three points for patients (eye, thyroid and gonads). The dose–area product (DAP) was also investigated using a Diamentor (PTW-M2). The dose in extremities was estimated for a professional who generally performed one TIPS, two chemoembolizations, two cerebral arteriographies and two renal arteriographies in a week. The estimated annual radiation dose was converted to effective dose as suggested by the 453-MS/Brazil norm The annual dose values were 137.25 mSv for doctors, 40.27 mSv for nurses and 51.95 mSv for auxiliary doctors, and all these annual dose values are below the limit established. The maximum values of the dose obtained for patients were 6.91, 10.92 and 15.34 mGy close to eye, thyroid and gonads, respectively. The DAP values were evaluated for patients in the same interventional radiology procedures. The dose and DAP values obtained are in agreement with values encountered in the literature.

La fístula carótido-cavernosa postraumática (FCCt) es una complicación poco frecuente tras un traumatismo craneoencefálico (TCE). Se diagnostica mediante la arteriografía cerebral habitualmente cuando ya ha aparecido la sintomatología clínica. El dúplex transcraneal codificado en color (DTCC) es una técnica no invasiva que en la cabecera del paciente permite la visualización del polígono de Willis (PW) y del segmento intracavernoso de la arteria carótida interna (ACIi). Los patrones sonográficos iniciales que sugieren la presencia de una FCCt mediante DTCC son una imagen en mosaico en el modo color, la presencia de flujos arteriales y venosos mezclados con elevadas velocidades y bajas resistencias. Exponemos nuestra experiencia en el diagnóstico precoz y no invasivo de la FCCt en una Unidad de Cuidados Intensivos.

Brain death diagnosis is based upon several clinical and paraclinical criteria that have been legally defined. There is a medico-legal protocol when brain death diagnosis is made in order to allow organ removal for a possible transplantation. In France, EEG or cerebral arteriography must legally be used to confirm a clinical brain death suspicion. There is a specific procedure to perform an EEG to confirm the diagnosis of brain death. However all the criteria have been made using conventional paper EEG, while numerized is now used. The comparison of EEG recording using both analogical and numerised acquisition allow us to report several recommendations to use EEG for brain death diagnosis.

A 23-year-old man was brought to the emergency department by paramedics after a high-impact motor vehicle accident. He was a restrained driver of a car that ran into the back of a truck. The car was thrown sideways and the driver-side door hit a stationary pole. The injured man had to be extricated from the massively damaged vehicle. At the scene he had a Glasgow coma score of 3. In the emergency department his score improved to 7, he was mildly combative, and he did not respond to commands. He was intubated and underwent urgent noncontrast head computed tomography (CT; Fig 1). Because of the intracranial CT findings, cerebral arteriography was performed (Fig 2).

Recurrence of intracranial aneurysms in autosomal-dominant polycystic kidney disease. Background The natural history of intracranial aneurysms (ICAs) in individuals with autosomal-dominant polycystic kidney disease (ADPKD) is poorly defined. Methods We followed twenty ADPKD subjects, eleven with ruptured and nine with intact ICA, for 15.2 ± 8.1 years (range, 6.0 to 33.2 years). Initial diagnosis was by four-vessel cerebral angiography in eighteen subjects. Follow-up examinations were four-vessel cerebral angiography in fourteen and magnetic resonance angiography (MRA) in six subjects. We examined the occurrence of new ICAs, an increase in size of existing ICAs, recurrent rupture or surgical intervention, and death. Results Age at initial diagnosis of ICA was 37.7 ± 10.4 years (range, 20.2 to 53.1 years). Seventeen subjects (85%) had an anterior and three (15%) had a posterior ICA at initial diagnosis. On restudy, five subjects (25%) had a significant change, consisting of new ICAs in a different location in all five and an increase in size of an existing ICA in two of the five. All subjects with ruptured ICA and one subject with intact ICA had undergone surgery at the time of initial diagnosis. Ten subjects (50%) underwent further surgery 8.1 ± 6.1 years later (1.3 to 17 years). No subject died during follow-up and one subject experienced a recurrent RICA (RICA). We were unable to identify risk factors associated with development of a new ICA or increase in size of an existing ICA. Conclusion Individuals with ADPKD and ICA appear to be at moderate risk for new ICAs and increase in size of existing ICAs; mortality and risk of recurrent rupture, however, appear to be low.

INTRODUCTION The transradial approach has been well described for arteriography of the coronary vessels. To assess the safety and success rate of the transradial approach for three-vessel or four-vessel diagnostic cerebral arteriography, we reviewed the experience at our institution and compared our

Resume Introduction. – Frequentes dans la maladie de Behcet, les atteintes vasculaires (23 a 64 % des cas selon les series) sont le plus souvent veineuses (95 % des atteintes vasculaires) et plus rarement arterielles (2 a 7 % des cas). Les atteintes arterielles consistent en stenoses, occlusions et anevrismes particulierement graves du fait de leur risque imprevisible de rupture. Les anevrismes intracrâniens associes a la maladie de Behcet sont exceptionnels. Seuls dix cas ont ete publies jusqu’a present. Exegese. – Nous rapportons le cas d’un homme de 36 ans, d’origine armenienne, chez qui le diagnostic de maladie de Behcet a ete porte lors d’une hemorragie meningee liee a la rupture d’un anevrisme de l’artere cerebelleuse superieure gauche. Le traitement endovasculaire de l’anevrisme a ete associe a un traitement immunosuppresseur par cyclophosphamide, corticoides et de la colchicine. L’evolution a ete favorable avec un recul de six mois. Il s’agit du premier cas publie d’anevrisme de la circulation posterieure et du premier traite par voie endovasculaire. Une revue de la litterature est faite. Conclusion. – Les anevrismes intracrâniens constituent une localisation exceptionnelle mais grave d’atteinte vasculaire dans la maladie de Behcet. Comme dans les autres atteintes arterielles, les recidives sont frequentes. Le traitement est neurochirurgical, mais doit associer un traitement par immunosuppresseurs et corticoides. La colchicine a sa place dans la prevention des rechutes.

To formulate management guidelines for blunt vertebral arterial injury (BVI).Compared with carotid arterial injuries, BVIs have been considered innocuous. Although screening for BVI has been advocated, particularly in patients with cervical spine injuries, the appropriate therapy of lesions is controversial.In 1996 an aggressive arteriographic screening protocol for blunt cerebrovascular injuries was initiated. A prospective database of all screened patients has been maintained. Analysis of injury mechanisms and patterns, BVI grades, treatment, and outcomes was performed.Thirty-eight patients (0.53% of blunt trauma admissions) were diagnosed with 47 BVIs during a 3.5-year period. Motor vehicle crash was the most common mechanism, and associated injuries were common. Cervical spine injuries were present in 71% of patients, but there was no predilection for cervical vertebral level or fracture pattern. The incidence of posterior circulation stroke was 24%, and the BVI-attributable death rate was 8%. Stroke incidence and neurologic outcome were independent of BVI injury grade. In patients treated with systemic heparin, fewer overall had a poor neurologic outcome, and fewer had a poor outcome after stroke. Trends associated with heparin therapy included fewer injuries progressing to a higher injury grade, fewer patients in whom stroke developed, and fewer patients deteriorating neurologically from diagnosis to discharge.Blunt vertebral arterial injuries are more common than previously reported. Screening patients based on injury mechanisms and patterns will diagnose asymptomatic injuries, allowing the institution of therapy before stroke. Systemic anticoagulation appears to be effective therapy: it is associated with improved neurologic outcome in patients with and without stroke, and it appears to prevent progression to a higher injury grade, stroke, and deterioration in neurologic status.

Catheter angiography is still considered the gold standard for imaging cerebral vasculature, and is the topic of this chapter. Diagnostic angiography is also typically done as the first step during neurointerventional procedures. Mastery of diagnostic angiography is a prerequisite for neurointerventional training. Training standards formulated by the American Society of Interventional and Therapeutic Neuroradiology (ASITN), the Joint Section of Cerebrovascular Neurosurgery, and the American Society of Neuroradiology (ASNR) recommend the performance of at least 100 diagnostic angiograms before entering neuroendovascular training (Iserson, J Emerg Med, 5:45–48, 1987). This handbook authors’ preference, however, is for a neurointerventionalist-in-training to perform at least 250 diagnostic cerebral angiograms prior to becoming the lead operator in neurointerventional cases.

Purpose Increasing in number and complexity, interventional neuroradiology (INR) procedures are becoming an important source of radiation exposure for patients. In accordance with the ALARA principle, radiation exposure during INR procedures should be curtailed as much as possible while reaching successful treatment outcomes. Moreover, the extent of radiation exposure should be one outcome measure used to assess new technologies and procedural efficacy, and training programs should include techniques for exposure limitation. This study provides a methodology and preliminary data to assess radiation exposure during different INR procedure types. Materials and methods All patients undergoing endovascular procedures in two biplanar dedicated neuroangiography suites at a major academic medical center were monitored according to procedure type, pathological indication, fluoroscopy time and machine-generated patient dose estimates between April 2006 and July 2008. Results 1678 patients underwent cerebral arteriography during the study period. Women (62.1%) accounted for the majority of patients, but men (38.9%) were more likely to undergo an interventional procedure than women (32.8%). Diagnostic studies accounted for 64.9% of procedures. Variable exposures were found between diagnostic and interventional procedures. Exposure differed depending on indications for the procedure and procedure type. Conclusion Radiation exposure is an increasingly important consideration in the development of minimally invasive neurological procedures including cerebral angiography and INR. The type of procedure and lesion type allow the practitioner to estimate radiation exposure. Such information informs the clinical decision making process. Normative data should be collected and used for comparison purposes as one measure of technical and procedural success.

Transcranial Doppler ultrasonography (TCD) is being increasingly used for its ability to provide cerebral hemodynamic information in stroke. Few studies have explored its association with cerebral arteriographic changes and stroke subtype. This study explored the relation of TCD changes in acute stroke with stroke subtypes, MR cerebral arteriography and clinical outcome in Omani population.Adult patients presenting with acute ischemic stroke within 4 days of stroke onset were subjected to TCD through the temporal and suboccipital windows using a 2 MHz probe; flow velocities, pulsatility and direction of flow were recorded from arteries at the skull base. MR arteriographic (MRA) changes on corresponding arteries were graded on a scale of 1-4. ANOVA, student's t test and ROC analysis were used to evaluate TCD in relation to stroke type, outcome and stenosis on MRA.Of 60 patients recruited, 52 (M:F::36:16; mean age: 60 + 13 years) had adequate bone window for TCD study. Large artery stroke occurred in 30 (58%) patients; lacunar stroke-11 (21%); cardioembolic and mixed groups 9 (17%), other specificed causes-2 (4%). 86.5% had evidence of intracranial disease. 10/52 patients (19%) died while 33 (63%) had good outcome (modified Rankin Score 0-3). Of the 186 arteries studied by the two methods, 52 had TCD evidence of stenosis while 42 were abnormal on MRA, giving a sensitivity of 60%, specificity: 81.25%; positive likelihood ratio: 3.18 and negative likelihood ratio: 0.5. 29/52 (56%) of patients had TCD changes in the arteries corresponding to stroke location. Abnormal TCD was associated with large artery strokes (p = 0.007), poor outcome (p = 0.038) and mortality (p = 0.01).This study of TCD in acute stroke in Omani population demonstrates a relatively higher burden of intracranial arterial disease. TCD changes are associated with type of stroke and outcome in this population. TCD is a simple and fairly useful method of evaluation in patients with acute stroke. Adopting TCD in evaluation of stroke patients may provide useful information regarding the pathophysiology which could enhance patient management.

An infant with neurofibromatosis developed recurrent cerebrovascular accidents beginning at 3 months of life. Cerebral arteriography demonstrated large-vessel occlusive disease and bilateral severe moyamoya. At autopsy these lesions were apparent on gross examination, and advanced intimal and medial dysplasia was seen on microscopic examination of both the anterior and posterior circulations. Although rare, neurofibromatosis cerebrovasculopathy may occur in young infants and may account for some strokes in this age group.

An aberrant internal carotid artery (ICA) in the middle ear is rare and difficult to diagnose, and may lead to severe complications. We present here a case of aberrant ICA with a deficiency in the origin of the anterior cerebral artery. The only symptom was aural fullness, and a nonpulsatile and white tympanic mass in the anteroinferior area was noted. Computed tomography (CT) and magnetic resonance angiography (MRA) are useful tools that provide excellent visualization of the temporal bone for the diagnosis of aberrant ICA by the following features: intratympanic mass, enlarged inferior tympanic canaliculus, absence of the vertical segment of the ICA canal, and absence of bone covering the tympanic portion of the ICA. In addition, in this case, a deficiency in the origin of the anterior cerebral artery on the same side was identified by MRA, and cerebral arteriography and a carotid occlusion test were performed. Because of the deficiency in the origin of the anterior cerebral artery, the ICA compression revealed that there was almost no cross flow from the other ICA. Our experience illustrates that after confirmation of the diagnosis of aberrant ICA, localized treatment and/or surgical procedures should be considered carefully.

Resume Les auteurs rapportent l'observation d'une forme grave de migraine avec coma, chez un patient âge de 43 ans, ayant necessite une hospitalisation de 9 jours en service de reanimation. Une arteriographie cerebrale a probablement ete le facteur declenchant.

We present a 57 year-old man with a pericallosal aneurysm causing parenchymal hemorrhage in the preseptal region of the frontal lobe with extension into the fornix. We briefly discuss the literature pertaining to ruptured pericallosal aneurysms and their bleeding patterns.

The Tc-99m HMPAO brain imaging confirmed marked hypoperfusion secondary to anomalous cerebral venous drainage of the Sturge-Weber syndrome. Until now, this had been a hypothesis suggested by results obtained from conventional brain scans and cerebral arteriography.

Background and Purpose Results of North American and European trials of carotid endarterectomy published in 1991 may have affected the frequency of the procedure in the United States. Therefore, data from a national survey of hospital discharges were examined to determine whether rates of carotid endarterectomy and arteriography increased after 1991 and whether race and sex variations in rates have persisted. Methods Data from the National Hospital Discharge Survey were examined for the years 1980 through 1993. Estimated numbers of procedures performed in nonfederal US hospitals were used to compute rates per 100 000 population by year, age, race, and sex. Results In persons aged 65 years and over, the rate of carotid endarterectomy increased rapidly between 1980 and 1983 with a slight further increase through 1985. A marked fall in the rate occurred between 1985 and 1988, followed by a plateau and a sharp upturn in 1992. After 1985, there was a steady decline in the rate of cerebral arteriography procedures in hospital. No reliable data were available on outpatient cerebral arteriography. Throughout the period, whites had estimated rates of carotid endarterectomy procedures over four times higher than blacks. Whites also had higher rates of cerebral arteriography, but the disparity was not as great as for endarterectomy. Rates of carotid endarterectomy were 60% higher in men than women, but rates of cerebral arteriography were only 9% higher in men than women. Conclusions Rates of carotid endarterectomy increased sharply after the 1991 publication of trial results. Marked racial disparities in the use of this procedure persist and require further evaluation.

In an attempt to eliminate the morbidity, mortality, and cost associated with arteriography, surgeons are relying increasingly on duplex scanning of the extracranial arteries as the primary preoperative evaluation prior to carotid endarterectomy (CEA). This study was initiated to evaluate the need for cerebral arteriography in the preoperative evaluation of patients for CEA. One hundred five patients undergoing 114 CEA procedures are included in a retrospective review to determine whether the addition of cerebral arteriography changed the operative management of these patients. In 58 of 105 patients (55%), color-flow duplex scanning and cerebral arteriography were performed in the workup prior to CEA. In four patients a discrepancy was found between the duplex results and the arteriogram, leading to a change in the operative approach in two. The remaining 47 patients (45%) underwent color-flow duplex scanning as the definitive preoperative study; the surgical management was altered because of the operative findings in one patient. Although color-flow duplex scanning does not provide absolute concordance with cerebral arteriography, in most instances it can be used as the definitive preoperative study prior to CEA. We define the indications for cerebral arteriography in patients undergoing CEA.

✓ The use of magnetic resonance (MR) angiography as a safe, accurate, and reliable substitute for invasive cerebral arteriography has been anticipated as refinements in this technique are introduced. We present the case of an unruptured, 11-mm pericallosal arterial aneurysm not visualized on high-resolution MR angiography. Although this case may be atypical, we caution against complete reliance on this test for exclusion of the presence of cerebral aneurysms.

OBJECTIVES To evaluate the diagnostic efficacy of an intra-arterial electroencephalographic recording and determine which patients obtain most benefit from this technique, to compare the results obtained using other recording techniques and to establish a standard for recording. PATIENTS AND METHODS We made 64 intra-arterial recordings in 30 patients from one of three groups: persons with drug-resistant temporal epilepsy; patients with epileptic seizures of any type who required cerebral arteriography and patients whose illness required selective anteriography for any reason. We used a Seeker 10 guide-wire, the end of which acted as an electrode and a 2 minute recording was made. The position of the electrode varied depending on the site of the patients disorder. Activity was simultaneously measured with surface electrodes. Using the chi squared non-parametric test, we analysed the efficacy of the test. The paired t test was used to establish the concordance between observers. We compared the results obtained from the intra-arterial EEG with the simultaneous surface recording. RESULTS We found three types of electroencephalographic patterns. The commonest was defined by the presence of high-voltage multi-spiked acute waves. The sensitivity of the test was 93.33%, the specificity was 80% and the overall value of the test was 86.66%. The chi squared test showed its reliability in the diagnosis of deep epileptogenic foci. There was high concordance between the observers in the study. No complications were seen in the patients in this study. CONCLUSION The intra-arterial EEG recording is a semiinvasive test which may be useful in a selected group of patients and has high sensitivity and specificity.

OBJECTIVE To show the importance of the cerebral arteritis as etiology of the language and the intellectual involution in children. CLINICAL CASE A boy started to show psychic and language involution since 18 months of life to arrive to an autistic behavior. After showing normal results in all the studies performed in order to investigate the possible etiologies, cerebral arteriography was performed. Cerebral arteritis affecting especially the right opercular artery was disclosed. Oral nicardipine administration was follow-up of a complete recuperation. CONCLUSIONS Cerebral arteritis is very seldom managed as the cause of intellectual and/or language involution in children as it also occurs with the syndrome of acquired aphasia. However, this pathology has a good response not only to corticoids but also to calcium channel antagonists as it occurred in our patient.

• Seven patients had superior sagittal sinus thrombosis diagnosed by cerebral arteriography. We recommend that anti-coagulants not be used in the therapy of this entity, but rather that one should rely on antiedematous agents and anticonvulsants.

Computer analysis of complications of 5,000 catheter cerebral arteriograms performed at four hospitals (two training and two nontraining) revealed a total of 68 complications (1.4%). Eight (0.16%) of these complications were major: five patients required thrombectomy or embolectomy, two had permanent neurologic deficits, and one patient died. The complication rate for the training hospitals (3.9%) was significantly higher than that for the nontraining hospitals (0.9%), but the rates of permanent complications were identical in both groups (0.1%). Reporting criteria and complication types are described.

Nine children with clinically suspected brain death were evaluated by radionuclide cerebral imaging and four-vessel dye contrast cerebral arteriography. The scans showing absence of cerebral blood flow were verified by arteniography in all children. There was complete agreement in all cases. It was concluded that failure to detect cerebral blood flow by radionuclide cerebral imaging in children is a valid demonstration of absence of cerebral circulation for purposes of determining brain death. The scan is significantly less expensive than dye-constast arteniograms. The test is portable, and thus it eliminates the need for transportation of extraordinarily ill patients. The scanning technique is noninvasive and may be particularly helpful in the diagnosis of brain death in patients in whom intravenous infusions of barbiturate might otherwise obscure the clinical and EEG examination.

In most patients with head or neck trauma, a single angiogram is sufficient to guide therapy. For those who improve slowly or not at all, however, this is not an adequate basis for diagnosis. Angiography should be repeated after an interval of time to exclude development of a surgically correctable lesion, such as pseudoaneurysm or intracerebral or extracerebral fluid collection.

We have shown that a simplified model, generated quickly in response to an emergency consultation, may provide useful insights in certain situations. A more developed model was useful in verifying these insights. Because the more complex model considered a longer time horizon than the simple model, it allows us to consider questions regarding long-term benefits of aneurysm repair. When modeling any problem, the most important reason for performing decision analysis is to gain insight from analyzing the clinical setting and from constructing the model. The quantitative results are usually of only minor importance. However, our most important insights are sometimes gained by looking beyond the quantitative level to understand the interactions of various effects within the model. In this case, it was those insights that were of the greatest benefit to the patient in arriving at a decision to have cerebral arteriography.

Cerebral ischemia and infarction have been produced in the Rhesus monkey using an autologous clot embolization technique. Preliminary findings suggest that cerebral arteriography may be used to study experimental cerebral infarction and ischemia, and the resulting cerebral edema and also that cerebral arteriography may be used as a tool for the evaluation of various types of therapy now used clinically in the treatment of these entities. The present experimental study in the monkey suggests that whereas steroid therapy initiated immediately following the onset of cerebral ischemia reduces morbidity and hastens clinical recovery, pretreatment with steroids in these same cases of cerebral ischemia may be hazardous and may increase the risk of cerebral infarction.

Emphasis has been recently given to automatic segmentation of vascular network observed by means of Digital Subtraction Angiography. This paper details a new algorithm which determines the medial axes and the contours of the vessesl in the whole vascular tree.

Intravenous digital subtraction angiography is often used for evaluation of the extracranial and major intracranial vessels. The information obtained by this examination concerning cerebral perfusion is usually judged visually. In 50 patients a time-density curve at a specific point was analysed using 128 X 128 matrix. The level of grey scale at the moment of arrival of the bolus permits estimation of the haemodynamics of the intracranial vessels and provides a simple demonstration of differences of perfusion.

Analyses of 67 cases again emphasized that the following factors are critical in management: 1) early cerebral arteriography, followed by definitive surgery if indicated; 2) immediate pulmonary assessment with normalization of respiratory performance; 3) constant vigilance for associated injuries and appreciation of known medical diseases; 4) consideration of the use of ventricular pressure monitoring and drainage in suitable cases.

Resume La definition spatiale des tumeurs cerebrales est facilitee par la tomodensitometrie et l'angiographie en conditions stereotaxiques. Le logiciel standard du scanner est utilise pour l'obtention des coordonnees stereotaxiques de n'importe quel point de l'espace intracrânien. Effectuees sur la base de la topographie tridimensionnelle, les biopsies etagees stereotaxiques fournissent un diagnostic histologique precis et detaille, y compris le degre de malignite, l'extension et le volume des tumeurs. L'exploration stereotaxique vise a une meilleure comprehension des liens entre le cerveau et la tumeur, afin d'orienter le choix de la methode de traitement. Les resultats de notre experience qui porte sur une serie de 401 cas sont presentes.

Cyanoacrylates, a group of rapidly polymerizing adhesives, have found widespread uses in oral and general surgery as well as surgical subspecialties, for example as hemostatic and anastomotic agents. They have been utilized most recently as materials for embolotherapy of complex cerebral and extra-cerebral vascular anomalies. The histopathology that results from their deposition in human tissues is thus an important consideration, and the subject of this review. Particular attention is given to the fate of cyanoacrylates in cerebral lesions after iatrogenic embolization procedures. The apparent toxicity of these plastics on blood vessel walls is discussed in relation to experimental observations. It is imperative that clinicians who use this group of substances evaluate their potential functions in the light of the pathologic findings.