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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - ORIGINAL ARTICLE
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 1154-1158

Complications associated with diagnostic cerebral angiography: A retrospective analysis of 644 consecutive cerebral angiographic cases


1 Department of Neurosurgery, Neurovascular Diseases Research Center, Second Affiliated Hospital Anhui Medical University, Hefei, Anhui Province, People's Republic of China
2 Department of Neurosurgery, Neurovascular Diseases Research Center, Second Affiliated Hospital Anhui Medical University; Department of Neurosurgery, Neurovascular Diseases Research Center and Skull Base Tumor Research Center, Anhui Medical University, 678 Fu Road, Hefei, Anhui Province, People's Republic of China

Date of Web Publication18-Jul-2018

Correspondence Address:
Dr. Bing Zhao
Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Neurovascular Diseases Research Center and Skull Base Tumor Research Center, Anhui Medical University, 678 Fu Road, Hefei, Anhui Province - 230601
People's Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.237018

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 » Abstract 


Aim: This study was conducted to evaluate complications (minor and major) that occurred in patients who underwent modern cerebral angiography.
Materials and Methods: A retrospective assessment of 644 consecutive cerebral angiographic cases was undertaken with specific emphasis on complications.
Results: The most common complication of diagnostic cerebral angiography was groin hematoma seen in 10 (1.55%) patients. One patient had complications arising from the development of a femoral artery pseudoaneurysm. Neurologic complications occurred in 4 (0.62%) cases. Three (0.47%) cases had transient complications which resolved completely within 24 h. One patient (0.16%) was left with permanent hemiplegia. There were 6 (5%) cases of contrast-induced nephropathy out of the 120 cases in whom subarachnoid hemorrhage had occurred and who possessed complete data of kidney function tests. Five of them were reversible, and one was permanent. One patient (0.16%) died from air emboli.
Conclusions: Neurologic complications following cerebral angiography are rare but must be minimized by careful case selection and training. Although the risk is small, complications such as permanent disability or even death cannot be completely obviated.


Keywords: Cerebral angiography, contrast-induced nephropathy, neurologic complications
Key Message: The complications occurring within 48 hours after the performance of a diagnostic angiography are discussed in this study. The incidence of headache following an angiography is often underreported. In patients with a subarachnoid haemorrhage, the incidence of contrast induced nephropathy was in the range of 5%.


How to cite this article:
Shen J, Karki M, Jiang T, Zhao B. Complications associated with diagnostic cerebral angiography: A retrospective analysis of 644 consecutive cerebral angiographic cases. Neurol India 2018;66:1154-8

How to cite this URL:
Shen J, Karki M, Jiang T, Zhao B. Complications associated with diagnostic cerebral angiography: A retrospective analysis of 644 consecutive cerebral angiographic cases. Neurol India [serial online] 2018 [cited 2018 Aug 17];66:1154-8. Available from: http://www.neurologyindia.com/text.asp?2018/66/4/1154/237018




Among various imaging techniques, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are now frequently used for preliminary screening for cerebrovascular diseases. These modalities have the advantages of a faster processing time and fewer complications compared with digital subtraction angiography (DSA).[1],[2]

For patients with subarachnoid hemorrhage (SAH), a 64-slice cranial CTA has the diagnostic sensitivity and specificity of greater than 90%.[3] For peri-mesencephalic non-aneurysmal subarachnoid hemorrhage (PNSAH) that has been diagnosed by cranial plain CT scan images, the cranial CTA can serve as an alternative to DSA in ruling out aneurysmal SAH.[4] However, CTA can hardly provide the complete visualization of the intracranial vessels and may fail to detect an arteriovenous malformation, vasculitis, a dural arteriovenous fistula, and an aneurysm of size smaller than 3 mm.[5],[6] Therefore, a three-dimensional DSA is still considered the gold standard for the diagnosis of cerebrovascular diseases. A complete understanding of the complications associated with DSA can help in improving the treatment strategy. In a retrospective analysis of 644 consecutive cases in whom a DSA was performed, it was determined if the CTA can serve as a safe alternative to DSA for the screening of cerebral aneurysms. In patients in whom the initial angiogram was negative for a lesion that could have been responsible for the SAH, the requirement of an additional re-confirmation cerebral angiography was also determined. Moreover, we also analyzed the incidence of contrast-induced nephropathy in all those patients who underwent a cerebral angiogram.


 » Materials and Methods Top


General information

From January 2011 to December 2014, a total of 644 consecutive patients underwent cerebral angiography (often, multiple sessions of cerebral angiography were also provided to the same patient) at the Department of Neurosurgery of Second Affiliated Hospital of Anhui Medical University. 283 male and 361 female patients were included in the study, who had an average age of 50.7 years. Among them, a cerebral angiography was performed in 595 cases with a spontaneous intracerebral hemorrhage, in 18 for ischemic vascular diseases, and in 31 for a meningioma or other intracranial lesions. Among the 120 cases with SAH and having complete data regarding their kidney function tests, 6 cases suffered from contrast-induced nephropathy. In five of them, the kidney functions were restored, while one who had chronic kidney injury prior to undergoing cerebral angiography, deteriorated.

Informed consent was obtained from all the recruited patients. Routine blood tests, blood coagulation function tests, liver and kidney function tests, an electrocardiography, and a chest X-ray were performed before the cerebral angiography. Nimodipine was administered using an intravenous pump one day before the cerebral angiography. In patients having loss or alteration of consciousness, a sedative or even general anesthesia was administered, if deemed necessary. Modified Seldinger technique was adopted in the right femoral artery. Iodixanol was injected as the contrast agent, with an average dose of 150 ml. Cerebral angiography was performed using a 5F flexible catheter, a pigtail catheter, and a Simmons catheter. The catheters were continuously flushed with heparin solution. No heparin was injected intravenously during surgery. Local compression of the puncture site was performed for 15 min, followed by pressure bandaging for 15 min. The patients with SAH underwent kidney function tests within 48 h after surgery. After this initial testing, kidney function tests were again performed on an intermittent basis.

The diagnostic criteria for contrast-induced nephropathy included the following parameters:[7] The absolute serum creatinine values obviously increased 1 to 2 days after the performance of the cerebral angiography as compared with that before the angiography. If the level reached over 44.2 μmol/L or there was an increase by over 2%, or a reduction in the creatinine clearance rate by over 2% as compared to the baseline value, with other reasons for an acute kidney injury being excluded, then a contrast-induced nephropathy was considered.

The presence of complications was determined by the appearance of any symptoms or signs associated with cerebral angiography within 48 h after the procedure.


 » Results Top


The most common complication was groin hematoma, which was seen in 10 (1.55%) cases. One case was complicated by a femoral artery pseudoaneurysm. These two complications accounted for 1.7% of the total cases. In one of these patients, stent-assisted embolization of the aneurysm was performed and he presented with a local subdermal hematoma on the first postoperative day, and a femoral artery pseudoaneurysm on the second postoperative day. Moreover, color Doppler ultrasonography indicated the presence of a fistula [Figure 1]a and [Figure 1]b, which disappeared after local compression [Figure 1]c. None of the patients suffered from local infection or required surgical treatment. Neurologic complications occurred in 4 (0.62%) cases; 3 (0.47%) of them had a transient ischemic attack (TIA). One of the patients who developed TIA showed ipsilateral facial paralysis during the performance of an angiography of the external carotid carotid system for determining the vascularity of a skull base meningioma. The symptoms disappeared spontaneously about 30 min after the angiography. The remaining patient suffered from severe dizziness and vomiting during angiography of the vertebral artery. Nimodipine was administered after angiography using an intravenous pump along with fluid supplementation therapy and vasodilation therapy. The symptoms were relieved approximately 10 h later. Another case had transient motor aphasia. One patient, initially hospitalized for a SAH, developed acute cerebral infarction induced by angiography. On the preliminary angiography that was performed on him, no lesion was detectable. However, mild hemiplegia occurred on the left side after the second angiography 3 weeks later. Cranial magnetic resonance imaging (MRI) indicated multiple scattered infarcts in the right cerebral cortex [Figure 2]a and [Figure 2]b. Six cases had contrast-induced nephropathy, accounting for 5% (6/120) of the patients in whom this factor was assessed. Two patients had complications induced by errors. One of them had epilepsy due to the mistaken injection of 5 mL of additional lidocaine. This case recovered with sedation and dexamethasone treatment without the development of persistent neurologic sequel. The other patient died due to the development of intracerebral air emboli [Figure 3]a and [Figure 3]b.
Figure 1: (a and b) Doppler ultrasonography shows the pseudoaneurysm with arteriovenous fistula; and, (c) Doppler ultrasonography shows disappearance of the fistula after local compression

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Figure 2: (a-b) MRI shows multiple scattered lesions suggestive of acute infarction

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Figure 3: (a-b) Axial CT scan shows air emboli

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 » Discussion Top


The most common complication related to cerebral angiography is groin hematoma. Thus, a sufficient compression of the puncture site is important for preventing this complication. For those patients receiving anticoagulation therapy and antiplatelet therapy after angiography, more preventive care is needed at the puncture site. Headache is also common after an angiography. Kwon et al.,[8] found that 55.6% of 277 cases suffered from headache after a cerebral angiography. As the headache is reversible, these cases are usually alluded to in the studies reporting on complications of cerebral angiography in the literature. The incidence of neurologic complications was 0.62% in our study and that of permanent complications was 0.15%, as opposed to 0.34–2.63% and 0–0.5%, respectively, in other studies reported in the literature.[9],[10] The most common neurologic complications that occur are TIA and ischemic stroke. The early literature on the subject tended to report a higher incidence, which is now reduced due to the flushing of the blood vessels with heparin and the utilization of automated techniques for dye infusion during angiography.[11] The presence of cerebral atherosclerosis and a past history of TIAs may indicate a higher risk of TIA and ischemic stroke during the course of angiography. The difficulty in negotiating through blood vessels and the varying length of the vessels traversed during the performance of the angiography across the individuals, are also factors responsible for the complications that occur. Generally, cranial MRI is only performed in patients presenting with persistent neurologic symptoms, and therefore, the small infarcts as well as lesions in nonfunctional regions of the brain may be missed out, often leading to a higher incidence of complications than has been reported in the literature.[12],[13] Theoretically speaking, injection of the contrast agent will increase arterial pressure and the risk of bleeding from an aneurysm. In the present study, however, no patients suffered from bleeding of an aneurysm during the course of the angiography. Lim et al.,[14] studied 1896 cases with a ruptured aneurysm; 184 of them (9.7%) had a second rupture before treatment and 11 of them (0.58%) had a rupture and bleeding during the course of the angiography. However, no consensus has been reached regarding the risk of aneurysmal rupture due to the angiography. For patients with SAH, who have not revealed an aneurysm or any other vascular lesion during the preliminary angiography, the second angiography is often needed after the episode of cerebral vasospasm is over. This is because a negative result during the preliminary angiography may be the consequence of aneurysmal thrombosis, cerebral vasospasm, a small-sized aneurysm, distal position of the aneurysm on the parent vessel, and insufficient amount of contrast agent. For a typical SAH, a repeat DSA will reveal an aneurysm in 10% of the cases.[15],[16] In PNSAH, that has been diagnosed by a CT scan, some believe that a high-quality CTA is effective for diagnosing or excluding a posterior circulation aneurysm, without the need for a repeat DSA.[17],[18]

However, the incidence of contrast-induced nephropathy has been rising due to the frequent use of contrast agent. The risk factors associated with contrast-induced nephropathy include the presence of a chronic renal disease, diabetes mellitus, heart failure, anemia, and/or left ventricular systolic dysfunction.[18] The reported incidence of contrast-induced nephropathy in the low-risk population is 3–6%,[19] and it was 5% in our study. The risk of acute renal injury is lower in those patients who have a normal kidney function before their angiography, and the injury is usually reversible.[19],[20],[21],[22],[23],[24],[25],[26],[27] In the present study, one patient having chronic renal insufficiency prior to his angiography, deteriorated after the performance of the procedure [Table 1].
Table 1: Literature review focusing on complications related to cerebral angiography

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 » Conclusions Top


Aneurysmal and arteriovenous malformation rupture are life-threatening conditions and need to be treated timely and properly. However, a misdiagnosis based on the CTA and MRA findings may lead to disastrous consequences. Cerebral angiography can achieve a higher diagnostic accuracy. Although permanent neurologic complications occur rarely, the lack of operative skills may still lead to lethal consequences. Therefore, a thorough training and a special attention to details are very important in avoiding severe complications.[19],[20],[21],[22],[23],[24],[25],[26],[27] Interpretation of the imaging results by two physicians independently is another way of avoiding a missed diagnosis. Through this retrospective analysis, we have found that patients suffering from headache caused by cerebral angiography receive less attention, and the radiological data concerning venous drainage in SAH patients, who have a negative result in the preliminary screening, are usually absent. These are the points that deserve a greater attention in the future.

Acknowledgements

We would like to thank Dr. Chandra Prakash Yadav, Dr. Dejun Wu, Dr. Li Dekun, Dr. Jian Tao, and Dr. Wang Shao Hua at Department of Neurosurgery, Anhui Medical University for their valuable suggestions that helped in improving our illustrations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

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Kwon MA, Hong CK, Joo JY, Kim YB, Chung J. Headache after cerebral angiography: Frequency, predisposing factors, and predictors of recovery. J Neuroimaging 2016;26:89-94.  Back to cited text no. 8
    
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Dawkins AA, Evans AL, Wattam J, Romanowski CA, Connolly DJ, Hodgson TJ, et al. Complications of cerebral angiography: A prospective analysis of 2,924 consecutive procedures. Neuroradiology 2007;49:753-9.  Back to cited text no. 9
    
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Bendszus M, Koltzenburg M, Burger R, Warmuth-Metz M, Hofmann E, Solymosi L. Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: A prospective study. Lancet 1999;354:1594-7.  Back to cited text no. 12
    
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Lim YC, Kim CH, Kim YB, Joo JY, Shin YS, Chung J. Incidence and risk factors for rebleeding during cerebral angiography for ruptured intracranial aneurysms. Yonsei Med J 2015;56:403-9.  Back to cited text no. 14
    
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Bakker NA, Groen RJ, Foumani M, Uyttenboogaart M, Eshghi OS, Metzemaekers JD, et al. Repeat digital subtraction angiography after a negative baseline assessment in non perimesencephalic subarachnoid hemorrhage: A pooled data meta-analysis: A systematic review. J Neurosurg 2014;120:99-103.  Back to cited text no. 16
    
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Agid R, Andersson T, Almqvist H, Willinsky RA, Lee SK, terBrugge KG, et al. Negative CT angiography findings in patients with spontaneous subarachnoid hemorrhage: When is digital subtraction angiography still needed? Am J Neuroradiol 2010;31:696-705.  Back to cited text no. 17
    
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