ArticlesSilent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study
Introduction
Diagnostic intra-arterial angiography of the cerebral vessels and neurointerventional procedures harbour a small but definite risk of neurological complications.1, 2, 3, 4, 5, 6 However, studies on the risks of cerebral angiography have taken only manifest new neurological deficits as complications. Clinically unapparent damage, such as microscopic air embolism7 or silent thromboembolism,8 had not been taken into account. Experimental and clinical studies have shown that diffusion-weighted magnetic resonance imaging (MRI) allows sensitive and early detection of cerebral ischaemia within minutes of onset.9, 10 We aimed to prospectively assess the apparent neurological complication rate compared with the clinically silent embolism rate on diffusion-weighted MRI.
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Patients and procedures
100 intra-arterial angiographies of the cerebral vessels were done in 91 patients (41 men, 50 women, mean age 50 years [range 11–83]). Of these, 66 were diagnostic and 34 were interventional procedures. In all patients, the catheter was continuously flushed with saline unless a guidewire was used. The flushing system consisted of a high-pressure infusion system with a drop catheter (permanent pressure ⩾40 kPa) which was permanently attached to the catheter. In interventional procedures, the
Results
Before angiography no patient had a hyperintense lesion on diffusion-weighted MRI. After 23 angiograms (17 diagnostic, six interventional) in 23 patients (23% [95% CI 15–32]) 42 bright lesions were seen. No patient developed a new apparent neurological deficit after angiography. Size was less than 5 mm in 23 lesions, 5–10 mm in 12, and >10 mm in seven. Lesions were found only in vessel territories that had been studied during angiography (Figure 1, Figure 2, Figure 3). We saw only embolic types
Discussion
The risk of neurological complications after diagnostic angiography ranges from 0·55% to 3·2%.2 In patients with symptomatic carotid stenosis, a neurological complication rate as high as 10% has been reported.11 The definition of a neurological complication in previous studies has been a new focal deficit or change in mental status, but diffusion-weighted MRI has been used rarely to show a lesion in such patients.8
In our study, the frequency of lesions was correlated with the amount of contrast
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