Practical Neuroangiography 3rd Edition

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Practical Neuroangiography
Third Edition

Pearse Morris, MB, BCh

Director of Interventional Neuroradiology
Professor of Radiology and Neurosurgery
Wake Forest University School of Medicine
Winston-Salem, North Carolina

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Library of Congress Cataloging-in-Publication Data

Morris, Pearse.
Practical neuroangiography / P. Pearse Morris. — 3rd ed.
     p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-4415-4 (alk. paper)
I. Title.
[DNLM: 1. Cerebral Angiography. 2. Cerebral Arteries—anatomy &
histology. 3. Cerebrovascular Disorders—radiography. WL 141.5.C4]
616.8'107572—dc23
2012045723

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 To Viki, as always.

(c) 2015 Wolters Kluwer. All Rights Reserved.

 Preface
to the Third Edition

Performing neuroendovascular procedures competently and be judged is the degree to which its newer generation outshines
ethically demands experience, specific manual skills, and the older. If the field is to mature, then the professional goals
the ability to make decisions with only the patient’s interests of new trainees need to stretch far beyond simply attaining the
in play. These attributes cannot be acquired from a book. On levels of procedural competence which they witness in their
the other hand, they cannot be developed without the body mentors. The challenges facing new trainees are different from
of knowledge which I have tried to include within this text- those of 20 years ago. Technologic innovations from compet-
book. The first edition of Practical Neuroangiography was ing vendors have become more exciting and diversified, all
written with the intention of being the textbook that I wished with the promise of greater efficacy. But when or whether to
had been available at the beginning of my own fellowship. use these new devices are often open questions. Much of what
The third edition has been revised with the same goal, that we do is driven either by the availability of technology or is
is, to provide the new fellow with the background knowl- done in emulation of standards set in other fields, particularly
edge that will allow him/her to understand these procedures, those of interventional cardiology. The developments of the
the unusual variant anatomy which can be pivotally impor- past 20 years have established what can be done, but they do
tant in certain patients, and the limitations of our abilities. not tell us what should be done. There is an onus on the new
This revision of Practical Neuroangiography retains generation to return the focus to outcomes, patient safety, and
much of the basic instruction of its predecessors but is also cost-efficacy. If this textbook can play some small role in help-
adapted to bring attention to new understandings of entities ing the new generation to get started along the road to becom-
such as pediatric cerebral arteriopathy, cerebral vasospasm, ing better physicians than their mentors were, then its purpose
venous occlusive disease, and radiation use, as well as deal- will have been well met.
ing with technological innovations for common and rare
cerebrovascular diseases.
One important measure of the success by which the field of Pearse Morris, MB, BCh
endovascular neurosurgery/interventional neuroradiology will Wake Forest University School of Medicine

vii
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 Preface ix

Preface
to the First Edition

The purpose of this book is to help the reader become a more of masses and other structural lesions of the central nervous
competent neuroangiographer. It was created to provide a system. In tandem with these changes, interventional neuro-
complete and concise introduction to neuroangiography and radiology has become a dominant force in the management
neurovascular diseases for radiology residents, a more com- of neurovascular and other diseases. Increasingly, the modern
prehensive review for diagnostic and interventional neuro- mission of cerebral angiography is not simply diagnostic, but
radiology fellows, and a modern perspective to readers who instead requires the acquisition of critical data needed for deci-
trained in the past. Physicians in the related fields of neurol- sions on how to manage patients surgically or endovascularly.
ogy and neurosurgery, with whom we make clinical deci- Technical and anatomic discussions in the following chapters
sions, will also find much here that is useful. reflect this new responsibility of the neuroangiographer.
I hope that this book will save the reader a great deal of Moreover, the field of interventional neuroradiology
time. I endeavored to include a range of knowledge, refer- is gathering momentum; emergency procedures are being
ences, practical hints, and lessons that would otherwise be expected of neuroradiologists who have not had such expe-
time-consuming to research or acquire. It is the book that I rience. The final chapters introduce the reader to funda-
wish had been available at the start of my fellowship. The mental interventional principles and common emergency
emphasis throughout is on practicality, concision, and safety. procedures.
The past 20 years have brought great changes to the prac-
tice of neuroradiology. MRI and CT have supplanted the use of Pearse Morris, MB, BCh
angiography and pneumoencephalography for the evaluation Wake Forest University School of Medicine

ix
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 Acknowledgments
A book of this nature can only be put together when one has illnesses by the nursing, technical, operating room, and
had the privilege and good fortune to work with superbly ICU staff of the same hospitals with universal levels of dili-
generous friends and highly gifted colleagues over several gence and professional commitment that have been a privi-
years. My inestimable gratitude goes to current and former lege to behold. Finally, the fellows and residents of Wake
colleagues from the neuroradiology, neurosurgery, neurol- Forest University School of Medicine deserve my most sin-
ogy, ENT, ophthalmology, and anesthesia departments of cere thanks for making the work fun. It is in the hope that
the Massachusetts General Hospital, Brigham and Women’s they might find something worthwhile within these pages
Hospital, Massachusetts Eye and Ear Infirmary, Boston that this book goes forth.
Medical Center, Fletcher Allen Health Care in Vermont, and
Wake Forest University Medical Center in North Carolina. Pearse Morris, MB, BCh
The patients described in this book were cared for in their Wake Forest University School of Medicine

xi
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 Contents
Preface to the Third Edition......................................................... vii 17 The External Carotid Artery and
Extracranial Circulation.............................................. 231
Preface to the First Edition...........................................................ix
Acknowledgments.......................................................................xi Section III
Vascular Diseases: Diagnosis and Treatment 248
SECTION I
Techniques and Safety 1 18 Intracranial Aneurysms, Diagnosis
and Treatment............................................................ 249
1 History and Introduction................................................ 2
19 Vascular Malformations of the Brain.......................... 291
2 Performing a Cerebral Arteriogram.............................. 11
20 Cranial Dural Vascular Malformations........................ 322
3 Spinal Angiography: Technical Aspects........................ 52
21 Vascular Malformations of the Spine......................... 351
4 Pediatric Neuroangiography: Technical
Aspects........................................................................ 58 22 Pediatric Ischemic Stroke and Arteriopathy............... 368
5 Safety and Complications............................................ 65 23 Carotid-Cavernous Fistulas........................................ 375
6 Radiation Risks and Safety.......................................... 82 24 Nonaneurysmal Perimesencephalic
Subarachnoid Hemorrhage........................................ 387
Section II 25 ENT Bleeding and Tumor Embolization...................... 394
Anatomy 99 26 Reversible Cerebral Vasoconstriction Syndrome....... 426
7 Embryology of the Cranial Circulation........................ 100 27 Vasculitides Involving the Central
Nervous System........................................................ 434
8 Aortic Arch................................................................. 109
28 Bow Hunter’s Stroke.................................................. 442
9 The Circle of Willis..................................................... 114
29 Dural Sinus Occlusive Disease................................... 445
10 The Internal Carotid Artery......................................... 132
30 Cerebral Vasospasm.................................................. 457
11 The Anterior Cerebral Artery...................................... 161
31 Angioplasty and Stenting of Atherosclerotic
12 The Middle Cerebral Artery........................................ 175 Disease...................................................................... 465
13 The Posterior Cerebral Artery.................................... 183 32 Endovascular Treatment of Ischemic Stroke.............. 485
14 The Extradural Vertebral Arteries............................... 195 33 Vein of Galen Malformations...................................... 498
15 The Arteries of the Posterior Fossa............................ 206
16 The Venous System................................................... 217 Index................................................................................. 505

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 I
Techniques and Safety

“Avoir toujours un grand soin pour

éviter l’entrée de l’air”
—Egas Moniz

(c) 2015 Wolters Kluwer. All Rights Reserved.

1
History and Introduction
than “A woman might piss it out”—destroyed the City of
Key Points London. Under most circumstances, such a litany of politi-
• Willis and Moniz lived in very inauspicious times and cal and natural disasters might account for the decline of
circumstances. Using only the most primitive of tools, a nation into penury and obscurity, but the 17th century in
both left monumental legacies to medicine through England was an anomalous period. England entered the age
their diligence, unflagging curiosity, and hard work in the provincial homespun of a local dominant entity in an
with gifted colleagues. archipelago of isles off the coast of Europe, and despite all
that happened somehow emerged from it on the brink of
• The lessons of the Thorotrast debacle are as relevant becoming a world empire.
today as they were in the 1930s. Well-intentioned It was an age in which giants such as Isaac Newton,
medical devices can be very dangerous. ­William Napier, Christopher Wren, Robert Boyle, Wil-
liam Harvey, and Robert Hooke milled about in gangs.
As a forum for sharing their discoveries, they founded the
Royal Society, putting to the sword the long stultified medi-
CCThomas Willis (1621–1675) eval dogmatic approach to knowledge with its exclusive
Thomas Willis was born on January 27, 1621, in Great emphasis on rote learning and mind-numbing Aristotelian
Bedwyn, a small village in Wiltshire, England, and died in philosophy, and laid the foundation for the growth of mod-
London on November 11, 1675, having lived his life in what ern science. Willis was one of that group of intellectuals,
the ancient Chinese maledictum refers to as “interesting laboring throughout at his medical practice in the town of
times.” He had a busy and productive life, taking a Bachelor Oxford in the midst of political turmoil, which is not to say
of Arts degree at Oxford in 1639 at age 18, a Master of Arts that he was oblivious to the political events around him. His
in 1642, and a Bachelor of Medicine in 1646 (1). In 1657 he family was identified with the Royalist side, and it is known
married Mary Fell, thus becoming the brother-in-law of the that he took a break from his studies during the first Civil
unlovable Dr. Fell of doggerel lore. Thomas and Mary had War to drill with the Royalist Oxford militia. His father died
four children, only one of whom survived to adulthood. He in 1643 “snatcht away by the Contagion of a Camp-feaver”
is buried in the north transept of Westminster Abbey. during a siege of Oxford (3). Following this we are told that
The 17th century, which encompassed his entire life Willis the Younger “betook himself to Oxford, being the
span, was a period of unparalleled political upheaval in Tents of the King as well as the Muses; where listing him-
English history, featuring several civil and religious wars, self a souldier in the University Legions, he received Pay for
usurpation by a wart-faced tyrant, crypto-Catholicism, some years, until the Cause of the Best Prince being over-
gunpowder plots, Long Parliaments and Rump Parlia- come, Cromwell’s tyranny afforded to this wretched nation
ments, regicides and restorations (2). It was a time of inter- a peace more cruel than any war” (4).
nal feuds and external threats. Dutch agent provocateurs Thomas Willis began his medical studies at Oxford in
skulked louchely behind every hedgerow, and one could not 1643 at a time when the curriculum at English universi-
throw a stone in any corner of the kingdom without hitting ties was a hide-bound 3-year course of lectures in Galenic
some popish agent plotting sedition of one form or another. and Aristotelian cant, declaimed every Tuesday and Fri-
To compound the misery of the populace, adultery was day morning at eight o’ clock by the Regius Professor of
declared a capital offence in 1650 by the Puritan Parlia- Medicine. Students had to submit evidence that they has
ment, although, curiously, only female transgressors could been present at the dissection by a surgeon of two corpses,
be found to receive the sentence. Otherwise, the courts were usually procured after the Lenten assizes, but medical
clogged with proceedings related to victimless crimes such knowledge as such was not required. Indeed, an alternative
as swearing and lechery. The population declined or at least pathway to graduation was available through the offices of
stagnated at several reprises in the latter half of the century the Archbishop of Canterbury, who had the power to bestow
due to the effects of disease and “warres,” while roiling epi- a medical degree. European universities were, by compari-
demics of plaque, smallpox, and typhus stalked the realm. son, considered much advanced, and ambitious students pre-
In 1666, a massive fire—initially dismissed by the Mayor, ferred to go abroad, as had, for instance, William Harvey in
Sir Thomas Bloodworth, as being of no greater merit an earlier generation.

2
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