Aneurysm DSA

Subarachnoid Hemorrhage - Sentinel Bleed.

Axial Non contrast CT shows a focal hyper dense subarachnoid blood in left parietal cortical sulcus.
Sentinel bleed is a warning bleed due to minor blood leakage, precedes aneurysm rupture by a few hours to a few months, present with sudden focal or generalized headache, should not be overlooked must be screened on time to rule out underlying aneurysm with non invasive MR Angio or DSA.
Subarachnoid Hemorrhage – Massive and diffuse.

Axial Non contrast CT shows diffuse sub arachnoid bleed in basal cistern, interhemispheric fissure and sylvian fissure.

Most common causes of spontaneous SAH are rupture of a saccular (berry) aneurysm (80%) and rupture of an arteriovenous malformation (AVM) (10%). Causes of non aneurysmal SAH include amyloid angiopathy, blood dyscrasias, fibromuscular dysplasia, Moyamoya disease, vasculitis (10%)
As per the Law of La Place, the tension on the wall is proportional to the diameter. Thus, the rate of rupture is directly related to the size of the aneurysm.
Aneurysms usually occur at arterial bifurcations and mostly arise from the anterior circulation of the Circle of Willis (85%).

Left ACA Aneurysm

ACom Aneurysm

Basilar tip Aneurysm

MCA bifurcation Aneurysm

ICA Tip Aneurysm

Pcom Aneurysm

Primary CNS Vasculitis DSA

A 35 yo male with basal ganglionic infarcts.

Cerebral Angiogram; Right ICA injection (oblique view) showing irregularities involving right ICA cavernous supra clinoid portion and ACA A1 segment; Multiple dilatations and focal narrowings giving "beaded" appearance suggestive of Primary CNS Vasculitis / Arteritis - appears to be HIV associated as meanwhile patient found to be TRIDOT Positive.
HIV’s CNS complications result either from direct HIV infection or as a consequence of opportunistic infections.
HIV related CNS vasculitis is a direct neurological complication of HIV, where intracranial vessels develop aneurysmal dilatations and is associated with either infarction or bleeding.

Moyamoya Disease DSA

Cerebral Angiogram : Left Internal Carotid Artery injection (AP view) show stenosis involving cavernous portion with prominent collateral vessels giving puff of smoke appearance of Moyamoya disease, a rare idiopathic disorder characterized by progressive narrowing of the distal internal carotid arteries and their branches.
It is typically seen in children, although rarely reported in adults.
As the carotid artery is compromised, there is progressive enlargement of the collateral circulation, especially among the lenticulostriate vessels. This results in a characteristic angiographic picture of a blush or "puff of smoke" in the area of the lenticulostriate vessels.
Typically presents with recurrent infarcts where as in some cases, the fragile collaterals can rupture resulting in intra cranial bleed.

Vertebro basilar stenosis DSA

Lateral view showing mid portion basilar stenosis

Towns view showing severe mid basilar stenosis

Left intracranial vertebral stenosis near formation of basilar

Cervical vertebral stenosis at its origin

Posterior circulation stroke
Syn :  Vertebra basilar insufficiency can result from either stenosis or complete occlusion of Vertebral and or basilar.

Anatomy: 
The posterior circulation consists of the vertebral arteries, the basilar artery, the posterior cerebral arteries and their branches. These arteries, through short penetrating branches and circumferential branches, supply the brainstem (medulla, pons, and midbrain), the thalamus, the hippocampus, the cerebellum, and medial portion of temporal and occipital lobes.
The vertebral arteries originate from the subclavian arteries and course through the vertebral foramina of C6-C2, around the atlas, and through the foramen magnum.  At the pontomedullary junction both vertebral arteries join to create the basilar artery.  The vertebral arteries supply the medulla, the pons and the cerebellum. The distal vertebral arteries and the basilar artery give rise to superior, anterior, posterior, and inferior cerebellar arteries that supply the cerebellum.
The vertebral arteries are prone to stenosis at their origin and at the junction with the basilar artery.
The basilar artery and its branches supply the pons and the cerebellum.  Distally the basilar divides into the posterior cerebral arteries.
Stenosis can occur anywhere along the trunk of the basilar.
The posterior cerebral artery (PCA) supplies portions of the midbrain, the thalamus, medial temporal and occipital lobes.

Clinical presentation: 
Patients may present with a wide variety of syndromes.
Neurological dysfunction includes hemi or quadriparesis, cranial nerve deficits (III-XII), respiratory difficulty, altered sensorium, vertigo and ataxia. Multiple cranial nerve signs indicate involvement of more than one brainstem level.
Patients may present with only hemiparesis, which may progress rapidly to quadriparesis or a locked-in syndrome. The onset of symptoms may not be as abrupt as with anterior circulation strokes.
As the posterior circulation supplies the brainstem, cerebellum, and occipital cortex, the symptoms frequently involve the "5Ds": dizziness, diplopia, dysarthria, dysphagia, and dystaxia.
The hallmark of posterior circulation stroke is “crossed findings,” with cranial findings on the side of the lesion and motor or sensory findings on the opposite side.
The exact symptom complex depends on the precise location of the infarct.

ICA stenosis vs occlusion DSA

ICA stenosis: 

DSAs showing significant ICA stenosis at origin.

Note the sluggish distal filling of the internal carotid artery.








Patients with ICA stenosis often present with transient ischemic attacks, cortical border zone infarcts, amaurosis fugax that is transient monocular blindness which results from reduced blood flow through the ophthalmic artery, the first major branch off the internal carotid artery.
Patient with symptomatic high grade ICA stenosis benefit from stenting compared with conventional medical treatment.



ICA Occlusion: 
DSAs showing complete cut off of ICA at its origin without any distal filling implies to occlusion.

In such patients, the carotid Doppler or MR Angiogram most of the time mentions complete occlusion of ICA. But on DSA there is thin / sluggish distal filling of the internal carotid artery goes in favour of stenosis.
This distinction is important because patients with high grade stenosis benefit from carotid end arterectomy or stenting and those with complete occlusions are not surgical candidates.