HISTORY:
FLUORO TIME:
CONTRAST:
PROCEDURE: Informed consent was obtained from the patient after explanation of the risks and benefits including the risk of stroke and death. Patient had no further questions and agreed to the procedure.
Time out procedure was performed.
Conscious sedation was performed using a total of 1mg of Versed and 25ug of Fentanyl. A dedicated nurse was present monitoring the patient’s vital signs and clinical state throughout the entire procedure.
A complete neurologic examination including cranial nerve examination was performed prior to the start of the procedure.
Using standard technique, the right common femoral artery was accessed on the first attempt using a micropuncture set, and a 6-French short sheath was placed. Over a Bentson wire, a 90-cm long pigtail catheter was obtained into the descending aorta and digital subtraction angiogram of the arch and great vessels were obtained in the LAO projection. Double flush technique was used for the entire procedure to prevent distal emboli. Afterwards, using a vertebral hydrophilic tapered 5-French catheter, and a soft Glidewire, the common carotid arteries were subselected bilaterally and angiogram was performed in oblique projections delineating the internal carotid artery origins. After confirming the wide patency without unstable plaque formation, and the catheter was further advanced over the soft Glidewire into the proximal aspect of the internal carotid arteries and angiogram of the cerebral circulation were obtained in frontal and lateral projections. Delayed venous phase were also obtained. Vertebral arteries were not studied as it was clinically irrelevant.
Afterwards, catheters and sheath were removed and the main hemostatic device was deployed without difficulty. Patient had baseline femoral and pedal pulses after the procedure. No immediate complications occurred. Patient had baseline neurologic examination after the procedure without change.
FINDINGS:
The common and internal carotid arteries are widely patent bilaterally. After confirming the patency without plaque formation in the internal carotid arteries, catheter is seen to be within the proximal internal carotid arteries prior to injection. There is a non-clinically significant mild vasospasm of the right proximal internal carotid artery without flow compromise. The intracranial segments of the internal carotid arteries are widely patent with no stenosis or dilatations. Cerebral circulation is normal with the major branches of the circle of Willis to be normal in course, contour, and caliber. No aneurysms are seen. No focal areas of vasospasm or stenosis is seen.
In particular, the cavernous segment of the internal carotid arteries are widely patent with no early filling of the adjacent cavernous sinus to suggest a fistula formation. No early draining veins or anomalous venous structures are seen in this area. Ophthalmic artery is appear patent on both sides. Delayed venous phase demonstrate patent major deep venous sinuses of the head.
IMPRESSION:
There is no evidence of carotid cavernous fistula with no early draining veins or early filling of the cavernous sinus with bilateral internal carotid artery injections.
Circle of Willis and the major branches are normal in course, contour, and caliber with normal appearing intra-cranial arterial circulation.