Observations on the Tolerance of the Intracranial Arteries to Catheterization*

Observations on the Tolerance of the Intracranial Arteries to Catheterization*

ALFRED J. LUESSENHOP, M. D., AND ALFREDO C. VELASQUEZ, M.D. Didsion of Neurosurgery, Georgetown University Hospital, Washington, D. C.

EVERSIBLE segmental or diffuse narrowing of the larger cerebral arteries has been documented in the follow-

ing circumstances: 1) direct mechanical, chemical or electrical stimulation, 4,~~ ~) traction during surgery, 9 3) subarachnoid hemorrhage from saccular aneurysms, 1,~ and 4) secondary to angiographic contrast media when the arteries are in a state of hyperirri- tability. 11 Further we have observed, anglo- graphically, segmental narrowing persisting for weeks at the sites of applications of clips in postoperative patients with saccular aneurysms. In conditions with more generalized cerebral arterial involvement and slow- ing of the cerebral-circulation time, such as acute increased intracranial pressure, 2 cerebral trauma, s systemic hypertension and inhalation of hyperbaric oxygen, 3 the impor- tance of arterial spasm is less certain.

In a recent communication relating to the effects of other forms of arterial trauma, the responses of the larger cerebral arteries to the direct and saltatory passage of spherical plastic emboli were described. 6 This technique of artificial embolization has been useful in the treatment of certain inoperable arteriovenous malformations and the associated intraluminal trauma, similar to patho- logical embolization, does not induce spasm. Moreover, evidence indicates delayed proximal and distal dilatation may be a charac- teristic response. However, extension of this technique to include manipulation of delicate catheters or emboli within the intracranial arteries, as conceivably useful for the urgent

Received for publication November 20, 1962. Revision received August 14, 1963. * This work was aided by Grant H-05414-3 from the

National Heart Institute of the National Institutes of Health.

treatment of certain bleeding saccular aneurysms, would create much greater intraluminal trauma and possibly spasm similar to that following stimulation of the external wall. Further potential obstacles to catheterization are extreme tortuosity of the arteries of the cervical trunk and possible occlusion or thrombosis of the arteries by the catheter itself.

After preliminary laboratory work a satis- factory method for catheterization has been devised, and reported herewith are initial clinical observations of the arterial effects. These include maneuvering a catheter beyond the circle of Willis, inflation of the tip of a catheter within the terminal internal carotid artery and intraluminal occlusion of an aneurysmal orifice during acute increased intracranial pressure with subarachnoid hemorrhage.

Experimental Background

Forming the average configuration of an internal carotid artery are five sites of major angulation with a sixth site proximal to the carotid canal in approximately 5 per cent of patients. A scale glass model of the internal carotid artery was designed and with this various conventional and improvised plastic and rubber catheters were tested. The catheters which passed most easily through this model were tested in cadavers. In only a few instances catheters with very flexible tips could be passed to the terminus of the internal carotid artery. Mostly, there was a tendency for the tip to form a pocket in the wall of the artery at the acute anterior angulation of the siphon. Occasionally, the catheters ruptured the thin arterial wall at this site. For these reasons it was decided that an era- bolus must be used to carry the catheter

85

86 Alfred J. Luessenhop and Alfredo C. Velasquez

As shown in Fig. 1, initially the catheter is coiled in the glass bulb in a length permit t ing passage to the predetermined site. The connecting tubing to the ar tery then is opened and with gentle irrigation the embolus lead- ing the catheter passes into the arterial lumen and is carried by the flow of blood the full length of the introduced tubing. The connecting tube is then clamped and the bulb is irrrigated through a side arm to remove the accumulated blood. I f additional distance of catheterization becomes necessary, more tubing is introduced into the bulb and the process is repeated. With this apparatus a ~.5 mm. spherical embolus could carry a flexible Silastic tube accepting a # ~ needle. I t was perfected in dogs using the common carotid artery as a side arm and catheteriz- ing into the thoracic aorta.

Flo. 1. External glass catheterization chamber.

beyond the sites of major tortuosity. The intraluminal t rauma incurred would be no greater than the systolic blood pressure. Trials were carried out in dogs using the ab- dominal aorta which corresponds in size to the common carotid artery in man. I t was found tha t a delicate suture could be carried the desired distance by a spherical embolus introduced into the arterial lumen, but the increased drag when flexible Silastic tubing was employed was too great, and the tubing and embolus remained coiled within the arterial lumen. Furthermore, opening and manipulat ing the artery to introduce the catheter usually produced considerable local spasm. Therefore a silicone-coated glass bulb was devised (Fig. 1). This offered two impor- t an t advantages: 1) the initial coiling of the Silastic tubing within the bulb was through a wider circumference than the arterial lumen and accordingly the drag upon the embolus was considerably reduced; ~) excessive manipulat ion of the ar tery could be elimi- nated after the connecting tube was in place.

Clinical Observat ions

Case I. A 33-year-old housewife and waitress was admitted to Georgetown University Hospital on Jan. ~0,196~ for treatment of a cerebral arteriovenous malformation.

She had been well until 5 years previously when she noted a tendency to drag the left foot followed by progressing weakness gradually including the entire leg, and within 1�89 years, the left arm and face. Bilateral carotid angiograms (Dr. Paul M. DcLuca, Endicott, N.Y.) demonstrated an arteriovenous malformation in the midportion of the right hemisphere. I t was considered inoperable. One and a half years prior to admission she had a generalized seizure and thereafter remained on anticonvulsant medication. During the year before admission she experienced frequent epi- sodes of transient "numbness" of the left arm and leg and occasional throbbing, generalized and right-sided headaches. The left hemiparesis forced her to curtail work as a waitress.

Examination. Blood pressure was 110/70. She was alert and had no dysphasia. A systolic murmur was audible over the left eye. There was a ]eft spastic hemiparesis involving equally the face, arm and leg. Grip in the left hand was 50 per cent of normal, and her left ankle tended to in- vert after 4 or 5 steps. Strength in extension of the fingers was only 10 per cent of normal. Sense of position and graphesthesia were severely impaired in the left hand, and there was extinction with simultaneous stimulation over the left arm and leg. The left arm and leg were about ~ to 3 ~ F. colder than the right.

Catheterization of Intracranial Arteries 87

Routine laboratory findings were normal. An electroencephalogram was normal. Roentgeno- grams of chest and skull were normal. There was no cardiac enlargement.

Bilateral, serial carotid angiograms demonstrated an arteriovenous malformation, the nidus of which occupied a 4 X 4 X 3 cm. zone in the right insula and sylvian fissure. I t was supplied pri- marily by enlarged sylvian branches and pene- trating branches from the middle cerebral trunk. A medial portion of the malformation, in the region of the internal capsule, filled from the left side across the anterior communicating arteries to the proximal right middle cerebral trunk.

Operation. The malformation was embolized in two stages using the right internal carotid artery. At the first procedure 30 spherical Silastic emboli containing metallic radiological markers and measuring 2.5 mm. and 3.0 ram. were introduced stepwise with radiological control. This elimi- nated a large portion of the sylvian contribution. During the second stage the responses of the middle cerebral t runk and terminal internal carotid artery to an embolus held stationary and manipulated over a short distance were tested. A ~.5 mm. embolus attached to a 4-0 silk suture was introduced and permitted to pass to a point a few mm. proximal to the internal carotid bifurcation. Angiography showed no local or generalized alteration in the diameter of the adjacent arteries (Fig. 2). The embolus was easily retrieved aided by momentary reversal of the flow by clamping the proximal common carotid artery. A 3.0 mm. embolus was then introduced to a point in the middle cerebral t runk and maneuvered back and forth over several mm., again without angiographie evidence of arterial reaction. After adding more length of attached suture the embolus passed into the nidus of the malformation. Gentle traction on the suture could shift the position of the embolus over a short distance, but the traction necessary for retrieving provoked immediate narrowing of the terminal portion of the internal carotid artery. Therefore, the suture was cut and the freed end was permitted to float into the malformation.

Postoperatively the patient 's neurological status was unaltered but she complained of severe right retro-orbital pain which persisted for approximately 3 weeks before subsiding abruptly.

During 6 months after discharge the disability in use of left hand progressed slightly. Therefore, she was readmitted and at a third stage of embolization the terminus of the middle cerebral trunk was occluded with three 8.5 mm. emboli. She has been followed for l0 months thereafter. She has resumed working as a waitress and feels

Fio. 2. Arrow indicates a 2.5 mm. embolus held stationary and being manipulated in the terminus of the internal carotid artery. Other metallic markers are plastic emboli placed within the malformation.

that progression of her disability has ceased. She has had no recurrent headaches.

Comment. These observa t ions suggest t h a t a ca the t e r led b y an embolus can be m a n e u -

vered th rough the t e rmina l in te rna l ca ro t id

a r t e ry and midd le cerebra l t r u n k w i thou t

inducing spasm of the a d j a c e n t ar ter ies and

from these locat ions m a y be re t r i eved eas i ly

when a ided b y m o m e n t a r y reversa l of flow in the in te rna l ca ro t id a r t e ry . However , the t r ac t ion necessary to remove the ca the t e r

f rom a si te d i s ta l to the midd le cerebra l t r u n k p r o b a b l y d i s to r t s the t e rminus of the in te rna l ca ro t id a r t e r y and spasm a t this s i te p r o m p t l y ensues.

Case 2. A 51-year-old housewife was admitted to Georgetown University Hospital on Sept. 10, 196~ for treatment of a cerebral arteriovenous malformation.

At 14 years of age she became aware of inco- ordination of the left hand. Over the ensuing years this gradually increased to a left spastic hemiparesis. At age of ~1 years she had the first of a series of focal tonic-clonic seizures, usually starting in the left index and middle fingers. Re- current seizures were controlled on anticonvulsant medication, but in recent years she experienced


frequent sensory seizures in the left arm and leg. Her most disabling symptom was daily right- sided throbbing headache. Through much of the day she carried an ice bag on the right side of her head claiming this offered some relief.

One year prior to admission a carotid anglo- gram at Mt. Sinai Hospital, Detroit (Dr. Abe S. Goldstein) demonstrated a large arteriovenous malformation and in April 1963 she was referred to the National Inst i tute of Neurological Diseases and Blindness. More angiographic studies revealed an aneurysm of the junction of the posterior communicating artery and the right internal carotid artery which was the major feeding artery to the malformation. These lesions were judged inoperable, and she was referred to Georgetown University Hospital.

Examination. Blood pressure was 115/80. Gen- eral physical findings were within normal limits except for a Grade I I blowing systolic murmur at the apex. There was left hemiatrophy involving mostly the extremities. A blowing continuous murmur was audible over both eyes and temples, more pronounced on the right. There was a left spastic hcmiparesis with greatest involvement of the arm. She was barely able to use the left hand for eating and combing her hair. There was slight impairment in graphesthesia in the left hand.

Routine laboratory findings were normal. Roentgenograms of the skull showed slight thick- ening of the calvarium and increased vascular markings in the right frontal bone. A rheon-

cephalogram indicated abnormal cerebral circulation in the right frontal area and possibly deficient circulation in the territory of the right anterior cerebral artery.

Serial right carotid and vertebral angiography were performed (Fig. 3). The nidus of the malformation measured 4X5 cm. I t occupied the posterior frontal cortical area and extended medially in a conical shape to the lateral ventricle. There was no significant angiographic contribution from the basilar circulation. The medial portion of the malformation was supplied by both anterior cerebral arteries which angiographically filled from the left side.

Operation. All seven of the 3.5 mm. emboli employed were arrested at proximal sites in the feeding sylvian arteries, completely eliminating the middle cerebral contribution to the malformation. A catheter consisting of delicate flexible Silastic tubing with an enlarged inflatable t ip was then introduced. Using Polaroid films the tip was maneuvered to the intraluminal orifice of the saccular aneurysm and inflated with 50 per cent Hypaque to its maximum of 6 mm. (Fig. 4). The inner arterial diameter at this site had been measured at 5 mm. on previous angiographic films. Angiography with the catheter in place showed that the diameter of the artery had increased at the site of the balloon permitting passage of the medium around it and faint filling of the aneurysm. The balloon was permitted to deflate and the catheter was withdrawn with brief proxima

Fro. 3 (left). Large arteriovenous malformation of right posterior frontal lobe with an associated saccular aneurysm arising from internal carotid artery.

Fro. 4. (right). Same case as in Fig. 3, showing the tip of a catheter inflated to a diameter of 6 mm. with 50 per cent Hypaque at intraluminal orifice of the saccular aneurysm. Metallic markers indicate emboli placed previously in major feeding arteries of malformation.

Catheterization of Intracranial Arteries 89

FI6. 5 (left). Arteriogram showing a saccular aneurysm arising from internal carotid artery at approximately the origin of the ophthahnic artery.

FIG. 6 (right). Same patient as in Fig. 5. Arrow shows metallic marker in an embolus situated at intraluminal orifice of the aneurysm.

occlusion of the common carotid to reverse the flow in the internal carotid artery. The internal carotid was then permanently occluded in con- t inuity with a tantalum clip.

Course. During the 3rd and the 4th postoperative days there was slight increase in the spasticity of the left hand with moderate increase in the cortical sensory loss. This, however, cleared within a few weeks. There was immediate allevia- tion of the former pain in her head, and by 6 months later she had not had any significant headache and was carrying on her prior activities.

Comment . T h e m e a s u r e m e n t s m a d e f rom angiograms ind ica te t h a t the t e r m i n a l in te r - nal ca ro t id a r t e r y d i l a t ed s l igh t ly in response to r a p i d segmen ta l i n t r a lumina l d i s ten t ion . T h e m a x i m u m safe inflat ion of the ba l loon

had been reached p rec lud ing t e s t ing of the reac t ion to f i rmer d i s t en t ion and comple te

occlusion of the a r t e ry .

Case 3. A 31-year-old housewife was admitted to Georgetown University Hospital 1 hour after the abrupt onset of a subarachnoid hemorrhage. She became unconscious within a few minutes after onset.

Examination 1 hour later revealed that blood pressure was 100/60, pulse rate 110, and respira- tory rate 80. She was unresponsive to painful stimulation with equal but unresponsive pupils and flaccid extremities.

Lumbar puncture showed a pressure of 400 ram.

of cerebrospinal fluid and the fluid was bloody grossly. Bilateral carotid angiograms showed a saccular aneurysm at the junction of the internal carotid and ophthalmic arteries on the left, 3 mm. distal to the anterior crinoid process (Fig. 5). A few hours after admission she became bilater- ally decerebrate. A tracheotomy was performed. Her blood pressure gradually declined and an intravenous infusion of Aramine was used to maintain it at 90 mm. Hg systolic.

Operation. About 1~ hours after admission the bifurcation of the left common carotid artery was exposed and the catheterization bulb was joined to the external carotid artery. As the preliminary maneuver a spherical Silastic embolus, ~.5 mm. in diameter, with an attached suture was introduced to measure the precise distance to the aneurysmal orifice. When the embolus was held stationary at the intraluminal orifice it passed in- to the neck of the aneurysm (Fig. 6). Angiography immediately thereafter showed contrast medium passing the site of the aneurysm and filling the intracranial arteries without filling the aneurysm (Fig. 7). There was slight narrowing of the internal carotid artery at a site 8 ram. distal to the obliterated aneurysmal orifice. Angiography was repeated twice during the interval of an hour that the embolus remained in place and on each occasion revealed similar findings. With removal of the embolus there was brisk retrograde flow from the internal carotid artery. Angiography continued to show absence of filling of the aneurysm with filling the distal arteries despite


FIG. 7. Same patient as in Fig. 5. Angiogram with embolus in place at orifice of saccular aneurysm. The de- creased contrast filling of the distal arteries probably is secondary to dilution of the medium in the glass bulb.

approximately the same as the systolic blood pressure. Also, withdrawal of catheters from arteries immediately adjacent to the circle of Willis is not difficult when aided by momen-

tary reversal of flow in the internal carotid artery. However, passage of a catheter or embolus distal to the middle cerebral trunk may be hazardous because the traction necessary to retrieve it can distort the proximal arteries, resulting in spasm.

Catheterization as well as embolization of the intracranial arteries may have therapeu- tic usefulness particularly in the treatment of aneurysms and arteriovenous malformations. A variety of tips for the catheter is possible, 5

and a single observation, reported here, sug- gests that in certain locations an embolus held stationary at the intraluminal orifice of an aneurysm will be forced by the hemody- namics thereby produced into the orifice and remain impacted there.

slight increased narrowing 3 mm. distal to the aneurysm.

During the procedure it became necessary to initiate artificial respiration. She survived 10 more hours with artificial support of her respiration and blood pressure.

At autopsy there was an adherent clot in the neck of the aneurysm but the dome of the aneurysm was not clotted. There was no obstruction to flow through the parent circulation.

Comment . Apparent decrease in contrast visualization of the intracranial arteries distal to the aneurysm while the embolus was in place and immediately after its removal was in part secondary to dilution of the medium

by saline in the external glass catheterization chamber. Furthermore, it is likely that the

contrast medium (50 per cent Hypaque) played a role in causing the spasm distal to the aneurysm. About 90 cc. were used over a

~-hour interval.

Discussion

These experimental and clinical observations suggest that intraluminal manipulation of the intracranial arteries about the circle of Willis is possible technically and tolerated by these arteries when the forces involved are

Summary

A technical method for catheterization of the intracranial arteries is described with observations upon the reactions of the intra-

cranial arteries in ~ patients with arteriovenous malformations, and 1 patient with a bleeding saccular aneurysm.

Instrumentation and technical advice was furnished by the Dow Corning Center for Aid to Medical Research, Midland, Michigan, The Brunswick Manufacturing Co., Quincy, Mass., and Heyer-Schulte Corp., Santa Barbara, Calif.

References

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3. HUNT, W. E., MEAGHER, J. N., FRIEMANIS, A., and ROSSEL, C. W. Angiographic studies of experimental intracranial hypertension. J. Neurosurg., 1963, 19: 1033-1030.

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Catheterization of Intraeranial Arteries 91

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6. LUESSENHOP, A. J., GIBBS, M., and VELASQUEZ, A . C . Cerebrovascular response to emboli. Ob- servations in patients with arteriovenous malformations. Arch. Neurol., Chicago, 1962, 7: 264-274.

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Observations on the Tolerance of the Intracranial Arteries to Catheterization*