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Arteriography

A Useful Addition to the Technique

Charles G. Drake

Carotid artery injection with the needle attached directly to a syringe is not entirely satisfactory. In this Clinic the use of polyethylene tubing between the syringe and needle ( Fig. 1 ) has solved some of the problems and proven very helpful over a period of a year, during which time some 200 percutaneous carotid arteriograms have been done. Fig. 1. (1) Primary insertion of No. 18 needle into artery with needle attached to syringe. (2) After insertion, the polyethylene tubing is connected to the needle with a Luer-Lok adapter (Lemon 608/L † ). (3

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Bleeding Aneurysms of the Basilar Artery

Direct Surgical Management in Four Cases

Charles G. Drake

hypothermia, a preliminary dissection of the neck was done in which both common carotid arteries were isolated under tapes and both vertebral arteries were exposed for three-quarters of an inch just below the carotid tubercle in the vertebral triangle. Subsequently, to facilitate final exposure of the aneurysm, bulldog clamps were placed on the carotid arteries and the vertebral arteries were occluded by the fingers of an assistant assigned for this purpose. This permitted total interruption of the cerebral circulation for brief periods. These usually were planned for 5

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Charles G. Drake

). Lower: Left carotid angiograms. The basilar artery is filled only through the large right posterior communicating artery and only the upper cap of the aneurysm fills. The left vertebral artery fills retrogradely from the external carotid artery but it remains occluded above at the atlas Left: Lateral subtraction. Right: Subtraction, half-axial view. The patient had no recurrent bleeding. Angiography was repeated yearly and showed good postoperative filling of each vertebral artery above the clamp by collateral flow from deep cervical branches; the

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Charles G. Drake

. Left carotid angiography again was normal and in view of the presumed recurrent bleeding, operation was carried out on December 27th under hypothermia (28°C.) with urea. Three periods (3, 5 and 1½ min.) of complete occlusion of the vertebral and carotid arteries were used to complete the dissection of the aneurysm and occlusion of its neck with a McKenzie clip. There was little evidence of bleeding to account for his sudden deterioration the day before. Postoperative course . The postoperative angiogram showed the aneurysm to be obliterated and no other abnormality

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Charles G. Drake

posterior cerebral artery as it curves around the crus. The carotid artery is seen anteriorly. The posterior communicating artery is usually small, but even when large has not needed to be divided. The many tiny perforating vessels that usually arise from the communicating and posterior cerebral arteries should be protected and preserved. Deep to these structures, a mammillary body may be seen ( Fig. 4 ). Fig. 3. Orientation drawings for surgical exposure of basilar aneurysms. Fig. 4. Retraction of the crus. Separation of perforating vessels from the

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Charles G. Drake

with no increase in the oculomotor paresis. It was disappointing not to have been able to replace the clip but to have pursued this end would surely have ended in disaster. Although her immediate future is probably secure, the long term is less so. Case 26 This 61-year-old woman had had a large infundibulum of the right internal carotid artery clipped after a single hemorrhage 1 month earlier in another hospital. While recuperating, however, she had another hemorrhage and it was then realized that the infundibulum was not responsible for her bleeding

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Allan H. Friedman and Charles G. Drake

. Autopsy demonstrated SAH, with a 1-cm dissection of the right middle cerebral artery, 3 cm from the origin at the internal carotid artery. The dissection was through the media, which demonstrated cystic degeneration. 3. Crompton (1965): 5 Autopsy case of a dissecting aneurysm of the right vertebral artery between the confluence of the vertebral arteries and the PICA. The lumina of the vertebral artery and PICA were patent. No clinical data were given. 4. Gherardi and Lee (1967): 10 This 26-year-old known hypertensive woman presented with headache, coma

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Charles G. Drake and Sydney J. Peerless

six cases, the aneurysms occurred in patients with atherosclerosis. In the remaining 111 patients with giant fusiform aneurysms, etiology could not be determined. These aneurysms presented in patients of much younger age ( Table 1 ) than those with atherosclerotic aneurysms and had a slight male predominance (58 male:53 female). The frequency of occurrence of these giant fusiform intracranial aneurysms at each of the major sites varied widely, rarely involving the intracranial carotid artery and most often involving the basilar trunk and posterior cerebral artery

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Charles G. Drake, Sydney J. Peerless, and Gary G. Ferguson

, the administration of acetylsalicylic acid, and the assurance of adequate hydration have all been thought to be important in minimizing the risk of an embolus migrating from the thrombosing sac. The preoperative studies used to evaluate collateral flow have included angiographic demonstration of cross flow from the opposite carotid and ipsilateral posterior communicating artery (PCoA) to visualize the collateral flow at the circle of Willis; test occlusion of the carotid artery with a temporary, proximal balloon in the conscious patient; and cerebral blood flow

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Vertebrobasilar occlusion therapy of giant aneurysms

Significance of angiographic morphology of the posterior communicating arteries

David M. Pelz, Fernando Viñuela, Allan J. Fox, and Charles G. Drake

G iant intracranial aneurysms have arbitrarily been defined as aneurysms greater than 2.5 cm in diameter, and they comprise approximately 5% of all intracranial aneurysms. 8 They are most commonly located in the intracavernous portion of the internal carotid artery, and in the supraclinoid carotid artery. 10 Giant aneurysms of the vertebrobasilar system are uncommon, representing only 8% of all giant intracranial aneurysms. 7 A thorough angiographic evaluation is essential in all aneurysm cases, and this is particularly true of giant aneurysms. Multiple