neuroir

Subclavian artery branches

VITamin C & D

  • Vertebral
  • Internal mammary
  • Thyrocervical - inferior thyroidal, superficial cervical, and suprascapular
  • Costocervical - ascending cervical, supreme intercostals, anterior spinal
  • Dorsal Scapular

Axillary artery - sup thoracic, lateral thoracic, thoracoacromial, subscapular, thoracodrosal, scapular circumflex, circumflex humeral.  Close proximity of median, ulnar, and radial nerves.

Brachial artery terminal branches are the radial, ulnar, and interosseous arteries. 

    Classification nomenclature for dural arteriovenous fistulas

    Borden  

    Type I Venous drainage directly into dural sinus or meningeal veins  

    Type II Venous drainage into dural sinus with CVR  

    Type III Venous drainage directly into cortical veins only

    Cognard  

    Type I Normal antegrade venous drainage into dural sinus  

    Type IIa Retrograde venous drainage into dural sinus  

    Type IIb Retrograde venous drainage into cortical veins (CVR)  

    Type IIa + b Retrograde venous drainage into dural sinus with CVR  

    Type III Direct venous drainage into cortical veins without venous ectasia  

    Type IV Direct venous drainage into cortical veins with venous ectasia >5 mm  

    Type V Direct venous drainage into spinal perimedullary plexus

    • CVR, cortical venous reflux.

    Some Basic NeuroIR Catheter Techniques
    1. Puncture common femoral artery above the bifurcation using ultrasound.  If not using ultrasound then palpate ASIS and Pubic symphysis with hand and draw imaginary line (representing the inguinal ligament), then puncture 2 finger breadths below (about 1 cm) the line over the pulse.

      (image from:  http://icuroom-december08.blogspot.com/2008/12/monday-december-15-2008-q-whats-danger.html)
    2. After sheath is placed attach flush bag making sure there are no bubbles. 
    3. Place berenstein with Benson or Glide wire into the sheath and up to the arch near the ascending aorta. 
    4. Using index finger and thumb of the dominant hand hold the catheter in the location where it enters the sheath and slowly move it clockwise/counterclockwise with a rolling motion so that it is facing up.
    5. Slowly pull back the catheter, making sure it is pointing up at all times, until it pops into the vessel.  (good idea to look at imaging study first to make sure there is no variant vessel anatomy)
    6. Always inject contrast to make a roadmap and to confirm you are in the right vessel before attaching to injector. 
    7. If in the CCA, make roadmap (after removing wire), then replace the wire and follow it into the ICA with your catheter. 

    Double Flush Technique to prevent clot formation in catheter by stagnant blood:

    1. attach syringe with saline to the catheter or stopcock attached to catheter.  make sure the stopcock hub is clear.
    2. open the stopcock, flick the syringe to remove air bubbles, and slowly pull back to allow blood to enter the syringe.  make sure the syringe is angled at 60 degrees or more so air rises to the top. 
    3. remove the syringe and take another, clean syringe with saline (or contrast)
    4. attach the syringe to hub again using steps 1 and 2 above.
    5. now, with syringe almost vertical, inject the small blood and saline in the syringe into the catheter to clear it of the blood that is now filling it.
    Watch on radiologyreview.tumblr.com

    Simmon’s Catheter

    Source = The Requisites, Vascular and Interventional Radiology, Kaufman and Lee

    Subclavian Steal
    • Retrograde flow down R CCA
    • Retrograde flow down R VA
    • Reversal of flow in smaller subclavian artery branches (thyrocervical trunk and internal mammary artery)
    • Internal mammary artery reversal of flow in patient with cardiac bypass can cause angina.

    Source = The Requisites, Vascular and Interventional Radiology, Kaufman and Lee

      Carotid Dissection
      Symptoms
      • Headache
      • Neck pain
      • Loss of superficial temporal artery pulse
      • Horner syndrome
      • Aphasia
      • Unilateral facial weakness
      • TIA
      • Hemiparesis

      Etiologies

      • Trauma
      • HTN
      • Marfan
      • Ehlers-Danlos
      • FMD

      Source = The Requisites, Vascular and Interventional Radiology, Kaufman and Lee