http://exhibits.library.stonybrook.edu/mfp/files/original/dd6aa613ad864b41d42710aa943de4df.pdf e331912b9bfc1f22ac2706d3f155e8a5 PDF Text Text 5 ,ﬁ, . 1 Confinia Neurologica 9/ NEURQPHYSWLUEY [ABQRMURY HILLSIDE HOSPITAL GLEN OAKS' N' Y- Borderland of Neurology -— Grenzgebiete der Neurologie Les conﬁns de la Neurologie Edidit: E. A. SPIEGEL Basel S. KARG ER Separatum Vol. 12, Fasc. 4 (1952) : 3 . New York Printed in Switzerland From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellevue Hospital, New York City A Clinical Evaluation of Carotid Angiography by MAX FINK and JOSEPH M. STEIN ._.I I ‘ f .3 I Since carotid angiography has become a routine procedure in the management of intracranial conditions, an evaluation of its use is necessary. Both the indications and hazards of the procedure must be considered in recommending it for diagnostic purposes. It seemed valuable, therefore, to review the angiograms done on the neurological service of a general hospital. During the past 20 months, 117 percutaneous diodrast angiograms were completed by members of the resident house staff. The majority were done di- rectly by the authors. A variety of neurological conditions including suspected brain tumors, vascular anomalies, subdural hematomas, vascular diseases and diffuse degenerative diseases were selected by the attending staff as suitable candidates for angiography. In each case, a percutaneous carotid angiogram was performed according to the usual descriptions (1). Either local inﬁltration by novocaine or general anesthesia by pentothal or surital was used. A CournandGrino needle was inserted into the carotid artery at the level of the thyroid cartilage. In most instances the common carotid artery was cannulated; in a few instances the internal carotid alone. Ten to twelve cc. of 35 % diodrast solution were used in each injection. A simple manual multiple cassette holder was used. This permitted three consecutive lateral ﬁlms and a single anteroposterior (A—P) view. In each case the A—P and lateral ﬁlms were immediately developed, and, if indicated, the injection was repeated. If no pathology was noted on these ﬁlms, the procedure was repeated on the other side whenever advisable. Bilateral procedures were carried out in 26 subjects. �182 Max Fink and Joseph M. Stein Results Diagnoses of various conditions were made prior to angiography. Of these, “brain tumor suspects” made up the largest group; suspected vascular anomalies and subdural hematoma were the next largest groups (see Table I). The interpretation of the ﬁlms was based on descriptions by Moniz (2 a), Lima (2b), and Green and Arana (l b) . Brain Tumor Suspects Of 55 patients in whom intracranial masses were suspected, angiographic diagnoses of brain tumor were made in thirty. Of these, 25 were conﬁrmed by subsequent surgery or air studies. Conﬁrmation was not obtained in three patients because further studies were contraindicated by patient’s age or family’s refusal to give permission. In two cases the angiograms were interpreted incorrectly and these cases are described. Case I: D.H. a 48 year old woman was admitted to Bellevue Psychiatric Hospital because of headaches and progressive confusion. The examination revealed early papilledema, left central facial palsy, skull tenderness on the right and memory deﬁcits. An electroencephalogram showed a right cerebral focus. Bilateral carotid angiography under general anesthesia revealed deﬁnite elevation (displacement) of the parietal branches of the right middle cerebral artery. Subsequent to this procedure the spinal ﬂuid syndrome was noted to be positive for active syphilis. Anti-luetic treatment was instituted and the patient improved rapidly. Five weeks later, the right carotid angiogram was repeated. These ﬁlms showed the parietal vessels to have a normal conﬁguration. Case II: 0. 0., a 64 year old male was admitted because of recent onset of grand mal seizures and left-sided weakness. Examination revealed a mild left hemiparesis, most marked in the lower extremity. There was a positive Babinski response and increased reﬂexes. The cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under local anesthesia was performed and demonstrated good ﬁlling of the anterior and middle cerebral arteries. There was straightening and depression of the pericallosal artery on the lateral views; and increased vascularity near the termination of the anterior cerebral artery on the A—P ﬁlm. These changes were interpreted as evidence of a parasagittal tumor mass displacing blood vessels. A pneumoencephalogram was done and this did not demonstrate the mass. The patient improved without treatment and was discharged. He was readmitted a few weeks later with evidence of an acute brain stem syndrome. In View of the course of the illness and multiplicity of lesions, it was believed that the patient’s symptoms were due to degenerative changes, and not a neoplasm. No further studies were undertaken. In this group of suspected brain tumors 22 angiograms did not show any pathology. Eleven of these were conﬁrmed by air studies or autopsy. In two patients, however, satisfactory angiograms failed to demonstrate lesions later demonstrated by other studies. �A Clinical Evaluation of Carotid Angiography 183 III: F. M., a 57 year old man was admitted to the hospital because of left hemiparesis, bladder and bowel incontinence, and grand mal seizures of 4 weeks duration. On examination, there were severe personality changes, and a spastic left hemiparesis with pathological reﬂexes. Cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under pentothal anesthesia was done. Two sets of lateral ﬁlms and one A—P view were taken. The ﬁlms showed no evidence of cerebral tumor. One week later a ventriculogram demonstrated a large right fronto-temporal mass. The presence of a malignant glioma was conﬁrmed by surgery. Case IV: J. S., a 49 year old man developed left sided seizures and aphasia during hospital treatment for furunculosis. On neurological examination there was evidence of a lesion in the right hemisphere. On skull x-ray the pineal shadow was shifted to the left. An arteriogram on the right side under general anesthesia was done and no pathology demonstrated. A pneumoencephalogram, however, revealed a deformity of the right frontal born. The patient expired one month after angiography and at postmortem, multiple cerebral abscesses were demonstrated bilaterally. Case Other erroneous angiographic diagnoses were made in patients who proved to have vascular thromboses. In two patients with signs of a brain tumor, the angiograms revealed an avascular area in the parieto-temporal region with displacement of middle cerebral vessels. Surgical exploration revealed edematous necrotic brain tissue, without evidence of tumor. Each case came to autopsy, and TABLE I ANGIO GRAPHIC DIAGNOSES Group No. of Patients Intracranial Mass Vascular Anomaly and Aneurysms Suhdural Hematoma Occlusive Vascular Disease Other (f) 55 _ Pos. 30 Pos. Neg. Not Diagnosis Diagnosis Incorrect Neg. Diagnostic (3) Conﬁrmed Conﬁrmed Diagnosis 22 3 25 1 2 21 17 9 9 (d) ll 11 7 13 2 4 10 8 — — l ll 4 (b) 1 (c) 9 6 (e) 7 — 1 —— 5 —— —— Notes: (a) Technically unsatisfactory ﬁlms. (b) Two cases conﬁrmed by surgery but 7 other patients'with anomalies demonstrated on arteriograms were not subjected to further studies. (c) The 11 patients with negative arteriograms were not subjected to further study. ((1) Includes seven diagnoses of subdural hematoma, one of intracerebral hematoma and one of brain tumor. (e) F ailurc of the anterior or middle cerebral, or internal carotid artery to ﬁll on at least two consecutive injections, while the remainder of the circulation ﬁlled well. (f) Includes three “follow-up” angiograms, seven patients with diﬁuse degenerative disease and three patients with lesions of the skull. �184 Max Fink and Joseph M. Stein in both, thrombosis of a branch of the middle cerebral artery was found. The angiograms could not be differentiated from those seen in cases of tumors in the same region. Vascular Anomalies: Twenty-one patients suspected of intracranial vascular anomalies or aneurysms were subjected to angiography. The angiograms were bilateral in only three of these, and unilateral in the other nine. One set of ﬁlms were not satisfactory and were not repeated. Seventeen of these patients had manifested spontaneous subarachnoid hemorrhages. In nine cases an anomaly was clearly outlined on the arteriogram. Five of these were aneurysms at the base, and four, vascular malformations of the hemisphere. No anomaly was demonstrated in eleven cases. Conﬁrmation of ﬁndings by other methods of study was most difﬁcult to obtain in this group. In the nine cases where the anomaly was demonstrated, further conﬁrmation was achieved in two cases. In one, an angiomatous malformation was amputated at operation. In the other, an aneurysm of the anterior communicating artery was dissected at post mortem. Air encephalograms were normal in two patients, despite the angiographic evidence of a large angioma of the cerebrum. The speciﬁcity of angiography in the diagnosis of vascular malformations is demonstrated by such cases. Of the eleven patients with negative angiographic ﬁndings, two were subjected to air studies. These ﬁlms were normal. The other nine patients were discharged without further study. Subdural Hematoma: The diagnosis of subdural hematoma was made angiographically in seven of seventeen patients suspected of traumatic intracranial hematomas. The characteristic separation of the vascular patterns from the internal table of the skull as seen on the A—P projection was the basis for these diagnoses. In each of these cases the diagnosis was conﬁrmed by trephination. Furthermore, in the eight patients in whom a diagnostic vascular pattern was not seen, diagnosis of no blood in the subdural space was made. These diagnoses were all conﬁrmed by pneumoencephalography. In two patients angiography demonstrated an intracerebral mass, rather than a subdural process. In one case, this diagnosis made it possible for the surgeon to approach the lesion by a well localized and deﬁnitive procedure. The diagnosis was conﬁrmed in the second at autopsy. Vascular Disease: Angiographic studies were done in 11 patients in whom occlusive vascular disease was believed to be the basis �A Clinical Evaluation of Carotid Angiography 185 for their neurological ﬁndings. Failure of a portion of the vascular distribution to ﬁll on two consecutive injections was observed in seven of these cases, and normal vascular patterns were seen in the other four. In the ﬁrst group incomplete ﬁlling of the middle cerebral artery was seen in four cases; of the anterior cerebral artery in one case; and of the internal carotid artery in two cases. The vessels which appeared involved on the ﬁlms were in each instance the same vessels as indicated by the patient’s clinical syndrome. In four of these patients pneumoencephalography demonstrated areas of atrophy in the involved region of the brain. In one case, post mortem studies conﬁrmed the angiographic ﬁndings. No conﬁrmation was obtained in the other six cases. Miscellaneous Group: Of the 13 angiograms in the group, seven were done in patients with diffuse cerebral disease of a degenerative type. These ﬁlms were not characteristic but in each case air studies demonstrated an enlarged ventricular system without shift or deformity. In three patients with lesions of the skull angiography failed to demonstrate any cerebral involvement. Pneumoencephalograms were done in only two of these patients and were normal. Complications: In an evaluation of the indications for a diagnostic procedure the incidence and severity of complications must be considered. In this series of 117 angiographic studies, 36 patients suffered a total of 43 complications. There were ﬁve cases with severe and permanent complications. In all other instances the complications were mild and transient. Of the transient complications, 22 hematomas of the neck were recorded. This was recorded only when the hematoma was large. In one case, in a child, the hematoma was large enough to cause tracheal shift and respiratory difﬁculties. It was necessary to intubate the patient and maintain the airway during the evening of the procedure. Transient hemiparesis or transient increase in an existing hemiparesis was seen in 7 cases, and a grand mal seizure was observed in 2 patients. In each instance the phenomena disappeared within 48 hours. In 4 cases urticaria, chills and vomiting followed angiography, and seemed to represent an allergic response to the diodrast. In one patient, in whom a vascular anomaly was demonstrated, fresh blood was manifest in the spinal ﬂuid the morning after the procedure. Of the severe complications, death occurred within 24 hours of angiography in two patients (cases V, VI). In three other patients �186 Max Fink and Joseph M. Stein severe complications were directly related to angiography. In a young child an osteomyelitis of the transverse process of the ﬁfth cervical vertebra resulted after a difﬁcult cannulization (case VII). A permanent mixed aphasia (case VIII) and an intensiﬁcation of a pre-existing hemiparesis (case IX) were also observed. Case V: G. B. male, 62. Craniotomy, three months before arteriography, had demonstrated a right middle fossa spongioblastoma polare which was spreading along the sphenoid ridge and had crossed the midline. The patient completed a course of x-ray therapy and was alert and ambulant. A vertebral angiogram was suggested to evaluate the intracranial mass. The patient was sedated with demerol, scopolomine and luminal. Three injections of 11 cc. each of 35% diodrast, were made. The record states that: “while attempt was made to enter right common carotid, patient became cyanotic, respirations shallow, and pulsations of the artery, which were strong, became weak.” The patient expired within 20 hours after developing hematemesis, melena, and two grand mal seizures. No autopsy was obtained. Case VI: R. W., a 40 year old male, was admitted because of sudden onset of headache and stiff neck. The spinal ﬂuid was grossly bloody and the diagnosis of a spontaneous subarachnoid hemorrhage made. Patient developed pneumonia and ran a septic course. This responded to antibiotic therapy and patient seemed well one month after admission when he developed a second episode of subarachnoid bleeding. One week later, while patient was comatose, a right carotid angiogram was done. The ﬁlms were not diagnostic and patient expired within 18 hours of the procedure. An aneurysm of the anterior communicating artery with hemorrhage extending into the lateral ventricles was seen at post mortem. Case VII: N. B., a 5 year old girl, was admitted because of petit mal seizures for two months. Examination demonstrated left homonymous hemianopsia and an electroencephalographic focus of abnormal activity on the right parieto-occipital region. A right percutaneous carotid angiogram was done under general anesthesia, with difﬁculty, and a normal vascular pattern demonstrated. Patient had a large hematoma of the neck with tracheal shift, necessitating intubation that night. Patient recovered rapidly, but complained of pains in the neck and kept the head ﬁxed with chin turned to the left. Repeated x-ray examinations eventually disclosed an area of rariﬁcation in the transverse process of the ﬁfth cervical vertebra. This responded to immobilization and chemotherapy. When seen six months later, the child had recovered completely. Case VIII: M. C., a 30 year old male, was admitted to the neurological service because of left sided headaches of a few years duration and three episodes of loss of consciousness during the previous six months. On examination there was diminution in perception of tactile stimuli in the right hand. This defect was exaggerated by double simultaneous stimulation. Electroencephalography demonstrated a persistent focus in the left parietal region. The pneumoencephalogram was normal. A left percutaneous carotid angiogram was done. Four injections of diodrast were made. After the last injection a complete hemiplegia, hemisensory syndrome and hemianopsia was observed on the right. The patient was totally aphasic but responsive. During the ensuing weeks the weakness and sensory changes cleared, so that when seen one year after the episode, only minimal sensory changes in the �A Clinical Evaluation of Carotid Angiography 187 right upper extremity were observable. The aphasia, however, after some initial resolution, persisted. The patient expressed himself with difﬁculty and made many errors, could not carry out complicated commands, and made errors in imitating mouth and hand movements. The angiographic ﬁlms were interpreted as within normal limits except that the vessels of the middle cerebral group were few in number and widely separated. Case IX: E. B., a 64 year old man, was admitted because of headache and “nervousness” of some months duration; and repeated episodes of loss of consciousness without convulsive movements for one month. On examination there were mental changes, hyperreﬂexia and a positive Babinski on the left, but no manifest weakness or sensory changes. A right percutaneous angiogram was done with local anesthesia using four injections of diodrast. Immediately after the last injection the patient lapsed into a torpid state, his eye movements became dissociated, and the left upper and lower extremities were ﬂaccid. During the ensuing days, the torper diminished until the patient could respond verbally to command, but the hemiplegia became spastic. It persisted until the patient was transferred to another hospital one month later. The angiograms were interpreted as normal. A pneumoencephalogram revealed bilaterally dilated ventricles Without shift or distortion. A number of factors such as sensitivity to the contrast medium the amount of drug and rapidity of injection (3b), and existing hypertension (3 c), have been suggested as causes for complications. In the present series, these factors are not outstanding in the patients who developed complications when these are compared to the uncomplicated cases. Either conjunctival or intradermal diodrast sensitivity tests were carried out in every subject. In one case, the onset of wheezing, sweating, and palpitation after the intradermal test caused us to cancel the studies. In all other subjects, including the patients with complications, the sensitivity tests were negative. This was notably true in the four patients who developed “allergic-like” reactions of urticaria, chills, and vomiting, following the angiography, but who failed to react to the test dose. There is no apparent relation in the data between complications (excluding hematoma of the neck) and the number of injections of diodrast (see Table 2). (3 a), TABLE II No. of Injections No. of patients with complications No. of patients without complications * 1 1 3 more than 2 0 9 3 6 4 5 6 6 2 1 6 0 27 22 13 8 3 Total" 16 85 Excluding 16 uncomplicated cases in whom total dosage was not recorded. Similar analyses of the factors of anesthesia and the number of carotid punctures at one session (unilateral or bilateral angio- �188 Max Fink and Joseph M. Stein graphy), reveal no signiﬁcant correlation between these factors, taken singly, and the incidence of complications. Arterial hypertension was not a contraindication in the selection of patients for angiography. Ten hypertensives (all with diastolic pressures of 100 mm. Hg. or more, and systolic pressures of more than 160 mm. Hg.) were subjected to angiography, and in none of these were there any complications. Of the patients with severe or transient complications (other than hematoma of the neck) none had hypertension. Discussion Recent reviews have emphasized the diagnostic reliability of carotid angiography in vascular anomalies (4), suspected brain tumors (lb, 5), traumatic cerebral states (6), and occlusive vascular diseases (7). Our observations conﬁrm the recommendations of the authors in the ﬁrst three groups. Prior to angiography’, the diagnosis of vascular anomaly could not be conﬁrmed except by surgical exposure or autopsy. Since air studies are not reliable in demonstrating vascular anomalies or is choice of in establishing the procedure angiography aneurysms, such diagnoses. In 43 % of the patients in this series in whom such a lesion was suspected, the anomaly 'was satisfactorily demonstrated by angiography. In an unpublished series of similar cases studied by one of us (Fink) at Monteﬁore Hospital, ﬁve aneurysms were demonstrated in 14: suspects. Similar results are recorded by other authors (4), and numerous recommendations have been made to increase these results. Routine vertebral injection, combined with bilateral carotid punctures, will demonstrate anomalies in the posterior portion of the Circle of Willis (14). Oblique A—P views at 45 degrees have been recommended to demonstrate small aneurysms of the carotid (4 (1). With these modiﬁcations in the procedure, it is to be expected that the incidence of positive identiﬁcation of anomalies will increase. The role of angiography in the management of spontaneous subarachnoid hemorrhage is not clear. Recent reviews emphasize the importance of demonstrating the lesion where surgical intervention is indicated (4b, e). The effect of angiography during the acute phase of bleeding has not been clariﬁed. Many authors have recommended angiography only after the bleeding has ceased. Others, such as Wechsler and Cross (7 b), suggest early use of angiography during active bleeding. This principle of waiting until bleeding ceased was adhered to in the cases in this series, and no statement of the effect of angiography on bleeding can be made. �A Clinical Evaluation of Carotid Angiography I89 Angiography is the diagnostic procedure of choice when a supratentorial brain tumor is suspected. It is recommended for lesions located in the anterior two-thirds of the cerebrum. Occipital lobe, posterior fossa and some midbrain tumors are not consistently demonstrable by this technique. Angiography is recommended in subjects with papilledema, since this procedure, unlike air studies, does not make immediate surgical intervention necessary (5, 7). Furthermore, numerous reports emphasize the differences in the patterns made by gliomas, meningiomas, intracerebral hematomas and vascular tumors (1, 2, 3c, 5). Such clues are helpful to the surgeon in planning the operative procedure. In a few of our cases, multiple foci of a metastatic tumor were demonstrable on the ﬁlms, clarifying the management of the case. Such discriminations are usually not possible by other diagnostic techniques. The diagnostic reliability of angiography in cases of brain tumor is high. In this series, 25 of 29 conﬁrmed brain tumors were outlined by angiography. In a series of 96 brain tumor suspects, 39 of 42 veriﬁed neoplasms were demonstrated (5 a). In the series from Monteﬁore Hospital angiography revealed the neoplasm in 45 of 52 conﬁrmed cases. Similar satisfactory correlations are seen in the negative angiograms of these three series. This diagnostic reliability of 88 % compares favorably with encephalography. The value of air studies in brain tumor diagnoses has been frequently reported. In one such study by Grant (8), ventriculography demonstrated the lesion in 130 of 150 cases—an incidence of 87%; while pneumoencephalography in 69 cases, revealed the tumor in 81%. Further indications for angiography are in cases of traumatic intracranial hemorrhage. Numerous reviews emphasize the displacement of the anterior cerebral artery and separation of the ﬁne vessels from the calvarium on the A——P ﬁlm as diagnostic of subdural hematoma (6). Furthermore, angiography differentiates intracerebral and subdural lesions, altering the surgical approach (6 a). This was clearly demonstrated in two of our patients in whom subdural hematoma was suspected, but in whom the angiogram demonstrated an intracerebral mass. In cases of cerebral vascular accident angiography appears less helpful. Failure of a vessel to ﬁll may be due to a variety of reasons including slowing of the circulation, vascular spasm, and anomalies of the system. These factors have been emphasized (7b). Angiography, however, is not contraindicated in vascular disease. It provides a useful means in differentiating a thrombosis from an intracerebral clot, or from a tumor, in cases where the diagnosis is unclear. �190 Max Fink and Joseph M. Stein While the indications for angiography are many, they cannot be evaluated without a discussion of the risks involved. The complications of the procedure are of three types: (a) transient local phenomena; (b) transient cerebral vascular phenomena; (e) permanent severe deﬁcits. In the ﬁrst group of transient phenomena are burning pains in the head during injection, hematoma of the neck, and allergic reactions. Hematoma of the neck is a potentially dangerous complication (see our Case VII) but in a recent review no sequellae were observed (9). Allergic reactions are infrequent and usually mild. It was noted in this series that the routine intracutaneous or conjunctival testing for sensitivity was not found satisfactory in predicting these complications. Transient hemiparesis, aphasia, seizures and elevated blood this In (10). have been following angiography reported pressure series these complications were observed in nine cases—an incidence of 8%. A similar incidence was observed in the Monteﬁore Hospital series. That these phenomena are probably due to temporary vascular insufﬁciency (spasm?) is evidenced by the clinical pattern of neurological ﬁndings and their duration. Of seven patients with hemiparesis, the deﬁcits had disappeared within three hours in three patients, while in three others it was gone in 24 hours. In one of the subjects angiography was repeated in the other side six days later, without complication. In the seventh patient, arteriography had demonstrated an aneurysm of the internal carotid artery on the left and the common carotid artery was ligated on that side. One month later, angiography was repeated on the right side and following the ﬁrst injection of diodrast, the patient developed a right hemiplegia. This disappeared during the ensuing 72 hours. Vascular syndromes of the anterior and middle cerebral arteries have been observed. In one patient a lower limb monoplegia developed after two injections of diodrast. A third injection on the same side was done within 15 minutes of the appearance of the defect. The arterial views obtained showed good ﬁlling of all branches. The monoplegia disappeared within 12 hours. These complications were not observed in patients with hypertension. Deterioration of a patient’s condition or death following angiography has been reported in a number of instances. Bull (5d) summarizes the mortality rate of the procedure as 3 per 1000, which he states compares favorably to ventriculography. More recently, Dunsmore, Scoville and Whitcomb (10b) report three fatalities in 147 cases, and Olsson (11) reports three cases of “deterioration of patient’s condition” in a series of 360 angiograms. �A Clinical Evaluation of Carotid Angiography . 191 There were two fatalities in our present series, and one patient had a severe aggravation of a pre-existing hemiparesis. Each of these patients, like those of Dunsmore, Scoville and Whitcomb and Olsson, were severely ill before the procedure. In contrast to this are the large series of Curtis (5b), Wickbom (1 c), Torkﬂdsen (Sc), Lindgren (la), and Green and Arana (1b) wherein no deaths were related to the procedure. It is possible that with widespread use of angiography, subjects with more advanced cerebral lesions are selected for these studies and the risks thereby increased. A number of reports by Olsson and associates (3b, 11, 12) emphasize the summation of the toxic effects of large doses of diodrast given over a short period of time. They indicated the nature of the toxicity as an increased permeability of the blood vessels and a change in hemodynamics. Furthermore, the relation between concentration of diodrast and toxicity was demonstrated by Cross (13) when he introduced diodrast for angiography. His observation that seizures follow the use of 50% and 70% diodrast has been conﬁrmed by numerous investigators. Despite the use of 35% diodrast and low total dosages of diodrast, in this series, complications ensued. There was no signiﬁcant relation between dosage and complications. Other factors must be operative and some hint has been given in the observation on circulation time (41') and the effect of other injurious agents summating with diodrast (3). Conclusion Angiography is preeminent in the management of cases of intracranial disease suspected of vascular anomalies, supratentorial tumors, and traumatic hematomas. It is a satisfactory non-surgical method of demonstrating a vascular anomaly, malformation or aneurysm. In the diagnosis of supratentorial masses it will outline 90% satisfactorily. In addition to establishing the presence of a tumor, arteriography is superior to other diagnostic technics in yielding evidence as to the type of mass and its locus. In cases with papﬂledema, surgery is not made immediately mandatory by the procedure. It is not a satisfactory method in demonstrating obscure and diffuse lesions of the ventricular system, or tumors of the posterior fossa or occipital lobe. In cases of traumatic intracranial lesions, angiography is a satisfactory method in outlining subdural hematomas, and differentiating such lesions from intracerebral hematoma or tumor. �192 Angiography is Max Fink and Joseph M. Stein thromboses cerebrovascular in not clearly helpful and hemorrhages. would and not transient, the for most part, Complications are, are The complications in cases. most the limit procedure seem to bilatnumber or anesthesia, not directly related to hypertension, factors a Other play diodrast. of erality of injections, or amount is necessary. further and role study more important Summary reviewed were carotid angiograms A series of 117 percutaneous in involved angiography. risks and for indications the to evaluate studied including supraconditions were intracranial of A variety and hematoma traumatic anomalies, vascular tentorial tumors, of intraevidence with disease. patients Fifty-ﬁve cerebrovascular cranial tumors were subjected to angiography, and a positive in conﬁrmed were These diagnoses diagnosis was made in thirty. ﬁlms misinterpreted. the were subjects In two only of the cases. 83% in in conﬁrmed 50%; were the diagnoses Of the negative ﬁlms, demonlater lesion show fail a to did the angiograms only two cases intracranial with suspected 21 Of patients strable by air studies. of In two outlined angiography. by vascular anomalies, nine were air manifest on not revealed anomaly an these, the angiograms traumatic of suspected of seventeen patients studies. In a group in made seven was diagnosis positive intracranial hematoma, a in cases, eight ﬁndings the well negative as as These diagnoses cases. all conwere in two demonstrated cases, intracerebral tumors and lesions cerebrovascular of In studies. cases ﬁrmed by subsequent complications Transient value. of diagnostic not angiography was consisted and of the one-third patients, in of angiography were seen In urticaria. and seizures, of hematoma of the neck, hemiparesis, These and severe permanent. ﬁve patients (4 %) complications were discussed. factors the and described cases are cerebral of angiorisks limited the conclude that authors The of the in usefulness management its from detract do not graphy intracranial vascular malformations, suspected supratentorial tumors and traumatic lesions. Zusammenfassung 117 durch perkutane Injektion in die Arteria carotis gewonnene und Indikationen der Gesichtspunkte Angiogramme werden vom Gefﬁﬁanomalien, Tumoren, Gefahren besprochen. Supratentoriale der GehirngefﬁBe und Erkrankungen Haematome traumatische �A Clinical Evaluation of Carotid Angiography 193 werden besprochen. 55 Patienten mit Zeichen von intrakraniellen Tumoren wurden mit Angiographie studiert; in 30 wurde eine positive Diagnose gestellt. In 83% der Falle wurde die Diagnose bestatigt. In 2 Fallen wurden die Filme falsch gedeutet. In 50% der negativen Filme wurden die Diagnosen bestatigt. Nur in 2 Fallen vermochte das Angiogramm nicht eine durch Luftfiillung demonstrierbare Lasion zu zeigen. In einer Gruppe von 21 Patienten mit vermuteten intrakraniellen GefaBanomalien wurde in 9 Fallen die GefaBstﬁrung demonstriert. In 2 dieser Falle zeigte Angiographie die Anomalie, wahrend Luftfiillung ein negatives Resultat ergab. In einer Gruppe von 17 Patienten mit Verdacht auf traumatisches intrakranielles Haematom wurde eine positive Diagnose in 7 Fallen gestellt. Diese Diagnosen, wie auch die negativen Befunde in 8 Fallen, und intracerebrale Tumoren, die in 2 Fallen demonstriert wurden, konnten durch weitere Studien bestatigt werden. In Fallen von Gehirnlasionen, die durch GeféiBprozesse bedingt waren, hatte Angiographie keinen diagnostischen Wert. In 1/3 der Falle kam es zu voriibergehenden Komplikationen (Haematoma des Halses, Halbseitenlahmung, Kréimpfe, Urticaria). Bei 5 Patienten (4%) waren die Komplikationen schwer und dauernd. Diese Falle und ihre Besonderheiten werden besprochen. Die Autoren gelangen zu der SchluBfolgerung, daB die begrenzten Risiken der cerebralen Angiographie von der Anwendung dieses wertvollen Verfahrens in F ﬁllen von GefaBanomalien, supratentoriellen Tumoren und traumatischen Lasionen nicht abhalten sollen. Résumé Les auteurs passent en revue une série de 117 angiographies carotidiennes percutanées, dans le but d’évaluer les indications et les risques qu’elles comportent. La série d’aﬁ'ections intracraniennes étudiée comprend des tumeurs supratentoriales, des anomalies vasculaires, des hématomes traumatiques et des affections vasculaires du cerveau. Cinquante-cinq patients présentant une symptomatologie de tumeur intracranienne furent soumis a l’angiographie et un diagnostic positif put étre fait dans trente cas. Ces diagnostics se conﬁrmérent dans 83% des cas. Chez deux patients seulement, les radiographies furent mal interprétées. Parmi les angiographies négatives, 1e diagnostic clinique fut conﬁrmé dans 50% des cas; dans deux cas seulement les angiogrammes ne montrérent pas de lésion qui, plus tard, put étre mise en évidence par injections d’air. Parmi 21 patients suspects d’anomalie vasculaire �194 Max Fink and Joseph M. Stein intracram'enne, 9 purent étre révélés par l’angiographie. Dans deux cas, les angiogrammes révélérent une anomalie que les ventriculogrammes n’avaient pas rendu manifeste. Dans un groupe de 17 patients suspects d’hématome traumatique intracranien, un diagnostic positif fut conﬁrmé dans 7 cas. Ces diagnostics, de meme que les résultats négatifs de 8 autres cas, et les tumeurs intracérébrales démontrées dans 2 cas, furent tous c0nﬁrmés par des études ultérieures. Dans les cas de lésions cérébrales d’origine vasculaire, l’angiographie est restée sans valeur diagnostique. Des compli— cations passagéres de l’angiographie furent observées dans un tiers des cas et consistérent en hématomes de la région du cou, hémipareses, crampes, et urticaire. Chez 5 malades (4%), des complications durables et plus graves apparurent. Ces cas sont étudiés en détail et les facteurs on cause discutés. Les auteurs concluent que les risques limités de l’angiographie cérébrale ne sauraient faire renoncer a une méthode aussi utile pour le diagnostic des malformations vasculaires intracraniennes, des tumeurs supratentoriales et des lésions traumatiques. REFERENCE S 1. a) Lindgren, E.: Br. J. Radiol. 20, 326, 1947. — b) Green, J. B., and Arana, R.: Am. J. Roent. and Rad. Ther. 59, 617, 1948. — c) Wickbom, 1.: Acta Radio]. Suppl. 72, 1, 1948. — 2. a) Moniz, E.: “L’Angiographie Cérébrale”, Masson & Cie, Paris, 1934. — b) Lima A.: “Cerebral Angiography”. Oxford Univ. Press, London, 1950. 3. a) Olsson, 0.: Acta Radiol. 35, 65, 1951. b) Broman, T., Forssman, B., and Olsson, 0.: Acta Radiol. 34, 135, 1950. — c) Torkildsen, A.: Acta Psych. and Neur. Suppl. 55, 1, 1949. — 4. a) Lowman, R. M., and Duﬁ, S. D.: Amer. J. Roent. and Rad. Ther. 53, 341, 1945. — h) Poppen, J. L.: Radio]. 53, 347, 1949. — c) Wickbom, I.: Acta Radiol. 34, 387, 1950. — d) Lo'fstedt, S.: Acta Radiol. 34, 339, 1950. e) Wechsler, I. 5., Gross, S. W., and Cohen, I.: J. Neur. Neurosurg. and Psych. 14, 25, 1951. — f) Raney, R., Raney, A. A., and Sanchez-Perez, J. M.: J. Neurosurg. 6, 222, 1949. — 5. a) Culbreth, G. E, Walker, A. E., and Curry, R. W.: J. Neurosurg. 7, 127, 1950. — b) Curtis, J. B.: Brit. J. Surg. 38, 295, 1951. — 0) List, C. F.: Radio]. 55, 327, 1950. ~ d) Bull, J. W. D.: Postgrad. Med. Jour. 26, 157, 1950. — e) Fabritius, H. F., Frovig, A. G., and Kristiansen, K.: Arch. Neurol. and Psychiat. 61, 352, 1949. — 6. a) Wickbom, I.: Acta Radiol. 32, 249, 1949. — b) Kristiansen, K.: Surgery 24, 755, 1948. — c) Webster, J. E., Dawson, R., and Gurdjian, E. S.: J. Neurosurg. 8, 368, 1951. ~ d) Raney, R. B., and Haney, A. A.: Calif. Med. 73, 342, 1950. — 7. a) Govons, S. R., and Grant, F. C.: Arch. Neurol. and Psychiat. 55, 600, 1946. — b) Wechsler, I. S., and Gross, S. W.: J. A. M. A. 136, 517, 1948. — c) Lusignan, F. W., and Gross, G. 0.: Calif. Med. 73, 240, 1950. — d) Alorris, A. A., and Fulcher 0. H.: Surg. Clin. North Amer. 30, 1783, 1950. — 8. Grant, F. C.: Arch. Neurol. and Psychiat. 27, 1310, 1932. — 9. Berdal, P., and Emblem, L.: Acta Psych. and Neurol. 26, 1, 1951. — 10. a) Chusid, J. G., Robinson, F., and MargulesLavergne, M. P.: J. Neurosurg. 6, 466, 1949. b) Dunsmore, B., Scoville, W. B., —— -— —— �A Clinical Evaluation of Carotid Angiography 195 and Whitcomb, B.: J. Neurosurg. 8, 110, 1951. — 11. Olsson, 0.: J. Neural. Neurosurg. and Psychiat. 12, 312, 1949. — 12. Broman, T., and Olsson, 0.: Acta Radiol. 30, 326, 1948. — 13. Cross, S. W.: Arch. Neurol. and Psychiat. 46, 704, 1941. — 14. Sugar, 0., Holden, L. B., and Powell, C. B.: Amer. J. Roent. and Rad. Ther. 61, 166, 1949. �[ha / A M777, APP/f5; (#4)/7.rz. omen tummu W mm “KW W II: link, 3.». ma asap}: :1. Stein, IL». .7"*'*‘ , 9W .m § "v.1 "t; , ‘ waiver-1w canon of Indiana and the lam-01931.11 8min if the aura mun-u. hollow Rental, lav mark 633:. - .V T?!“ 1* ' = ' �line. antacid aaczozruphw tn mum of 1:1th an: bocgnn a ruuttun proaoﬁuro'xn cautions. In ovulation at 18.. no in nun-um. lath 15h. inﬂation and mm at cm proa«dun mt be amid-M in humans it for «lacunae aux-pom. It «and valuable, thereto”, to an.” tn «non-m am on tho Wei-clan um.“ or u acuml human . Min; m put to math, :17 panama“: Mount animu- nn can» put“ him-n or the minim hm amt. m mama were «at directly by tho “than . 5 variety of “urological amnion: including 11min Mon, moan: alt-mun, ”Maul hunts-nu, vascular dunno: Ion “law by tho dam“ and arm. “twang um: u with» «Midﬁe- ror WWW. In «ch mu, 9020qu met“ mien-u was performed «cording to the W1 «Manama (1) .' mum.- 10011 infiltration by normal” A 01f 3mm manhunt. by mutant}, or «mm m and. Gem-Grin» mu. m inﬁrm into the mend artery at tho 101010: 1'.» thyroid M11130. In no“ mum» the «non «3th WM" 0.. carotid artery 13th “an. .‘ m mm; in a In butane“ tho into!!!) M 1:0 mm: u. ref 35! “can“ inﬂation. A solution were and in «on «1:91. mm). “18133110 auntie Miner m and. that amounts." luau). 11m tad a um. mun. m: 130th yuurior (5-21 view. m In «on me the Au! and lateral £11m mantel: «#010904. lad, 1: indium. the injection In mutant. 1: no It: noted on than mm, the other 11¢. than» manna. pathology the vacuum at Bilateral mum on panam- urn �2. «aid but in 36 gnaw». .. mm amtlm‘ mu nu prior mum. Wu at the», ”bum W mu“ am 1m.“ my. :0 of " up the muted moun- manna lad «mu but... an an mt “m “wanna” or the film's!" («0 m1: m: mod tn «mimic» t7 In“ (a). amt»),- md ﬁrm I Am: 1m.» 1-). (1b). ‘ ‘ ' m amount). mm «spotted,at ammo nun-u «WWMMthMy. than. nu «ma «haunt sum or as: .m». continuum m not attained in turn ”that: boom mm than m quM B: gaunt“ m or “all”: W M cm ”mm“. In on» the mom I»! 1&th described. than» of 55 pun-nu in were by 25 - two tumour m m» m an A; 3.3». a #8 na- a:s.“ W m «Ilium to 1011mm humane mam been“ mm m manna" amt-n. m ail-inﬂux mallard «1-11 mum-u, 10ft mm rum pa”. mm Wu 0:: the ”at and nun «11:18:. m An rim 3mm}. “on Ilium-n1 mm magma under new“ mamas mound donut. olmtim (”apnea-ant} or the mum Who. of tho right W). Mm. museum in this ﬂaunt/annulus”: the a. .-. w. uphill mm Indra” m not“ to be We posits." for “’61" until” . Annama- mm: m taunted ' 11pm“ with. nw inks later, the right and the mum: mum mum as meat“. �“ > luv In want-um“ m ﬁr NHI II , mkamm WWW (Minimum: mutant—imam m» H CW u (CHI-um m ‘ . .‘ WWW‘rude-buﬂm �3. it... (11:: Innuud tho par1ota1 vantols ta have n nomlll cen— figuration. 6.3. II: 0.0., a yin: 91¢.la10 an: Idlitted buotule at roeunt onset at grina.unl aniline. .nﬂ lortantdcd untknoia, lxnuhntion rO'Dnlid a I114 10th bullpIrCItl, taut unwind in the 6% lénbr caﬁrunity. lhnru in: a punitive llbiulki response and incr¢:sod rutlaxtn.Moorutvuop1n31 fluid OIRQrUID III nounu1. A right curatld nn¢1o¢run undar local unauthonia III pur~ rarlnd and dIInnIttltod 390d 21111n¢ at tin Interior and l1ddlo oorobrn1 uttering. that. Ill straightening and dcprognian at tho pertain“). mar: am- the an... on up mm; um; and manned yum-mt: “mum. at cm manor mm: at»; on the 1.1- an. changes wort intorprutod Ian- 41-piuozn; blood vetucln. ll avtdlnoo at a pnruaagsitnl tumor ‘ pnnunninaophnlocrul,ula done and thin did not dclnnntruec thy IIII. It. patiant anarovud withaut troutncnt and lit dinohnrsod. In It: rtlanattod a to! lick! 1:10: with avid-not or an aunt. talin Ital syndronn. In '10! a: tin ¢uuruo a! uni 111ncll and.nultxplxoity of 1051.33, at in: bolicvod that the pntiaut'n uyggtanl A 1 ' taro duo to doccatrntiio ahnaccs, and net a unoplaun. lo turthgr Itudiou var. andnrtaknn. In this group or lunpcatod brain tumors 22 ausiogruln 414 not than any pathnlo;7. ilovcn at that. 10:. canrialnd by I1! studio: or tntapsy. In tun pationts, houovcr, untilrtotery angiogra-s failed to dalunltrutc lesions lttcr other Itudicl. mum to m danmmstrntod by an. m; n... .1 57:»:- em m m hospitdl koala-c of lift Inilplroutu, bladaor and and mud no.1 gum: or 1; inks aux-«zen. 6:: bcuul incontinence, man. than �#. never. poroonnlity ohoncoo, and o opootlo loft honiporoo1o with pathological roam: . embrupinll nun snare-o was nor»). . were right oorottd onciogron.undor pontothnl onoothnoin on: dono. outs of lotorll £11.. and on. to? via! Into taken. in: films A two thouod no ovidonoo or lorehrol tumor. can rock Into: a vantrtoulogrln dolonotrotod a large right con“ trontooto-porol IISI. Ibo protons. of a malignant slioln ill tin-0d by ournory. : Goo. IV; 3.3.é°:bzzkzoor old man developed loft stood toizuroo Iphlliu during/$rottlont for turunonlooil. on anurolucicll ennuinltion chore woo ovidonoo at n lotion in tho risho honiophoro. en Ikull x—ro: tho piuill outdo! In: shirtod to tho 102%. An ortorioaru on on right nu scum). mom-1a m and done ond no pathology dononotratod. ma A pnounoonoophnlosrln, houovor, revollod a dofornity of the right frontal horn. in: patient uzpirod on: lonth otter oust-graph: and ot pout. norm, mum} emu-u 0”qu mm anon-mm autumn. 9th.: erroneous onaiocrlphio d1oanoIOI our. and. in patient. who provod #0 have vooonlor throubosoo. In tlo potionto with Iisnl the oncxosru-o rovoolod on oraoaulnr are: in tho poricto-tonporol vision with dioplooonont o: Iiaolo oorohrll voooolo. Surgical exploration rovoolod odouotono necrotic brain tilooo, without ovidonoo of tolor. loch oooe oono to antopoy and in both or I brain only». man:- or . branch or. on. man «mm mm m rm. o:m angiogruno onulo not be dittoronttotod from thou. noon in on... tnnoro 1n the Inn: raglan. Vaoogggg.tnoup11oog ﬂuonty~ono patient: Iuopootod or intro» ' ornniol vaooulor Inouolioo or Quintin-o not. oubjootod to lnslo~ stools. 1h» Insaosrunl wort billtdrtl in only throo or thooo. and ��7. mt N contact“. um“. m nu In this aorta of 117 WWMB 36 ”tum- “from a to“: at is «unusual. and peanut «mutation. In an mm can with the «mutation and at in Of the a»: mo «Quantum. 22 m «W mm m an mum. man: mm. mm MmmuMuHthmm-uw. ammo. in am. mutumnmwummmmm' manta: mun It as mm to tntubtn m yum: mmmmmmmmmumpmmm; mun mom mm: man a «um mummuwmu. mnmmnmmomm a nun“. :3 Wk mm. m within . an ou- pm mm #8 W. talcum-Wont... cummmuurmmwowhy. all no.“ to rcpt-aunt an mung mpm h m atom-Mt. Inmautmh umummmmmmmrua Hummutumnmauammmm W.a: m mm causation. loath um um Mr. in in ”man (mu 7. n). In tum ash-r W or 1“ mm. Inamcuul‘uumum otmmvmupmuat th:mn mm mm mm m s difficult W31“ (mo m). W: m spa-nu (em um m mmmuu-n a: Mum mm“ («m I!) m an. «W. mum: sum emanation we «may “um 80 an A m mm. panamamumnmmmmmmmmmuu a Wow. than. 11mm Mm m twink“ I mm mm. tau ”Omnimtm ma. all... 63. elm was... an muons am and Mt. A completed a 13W and as most“ to «3.1qu war» a: may mm mam was ��10. at 1a.; or np1nud¢c on. mth. aunne1ausntgt u1thout convulu1vo unvunnne: for «nan-11:11:,» and a pou1t1vt lub1nlk1 on than mm mm tbs 10:1.ths no I sensory «Itasca am», Winn lua1tcut weaknass a: ‘ 1 31331 percutancona In31u3zun was inns u1th 10011 tainthna1n nn1n3 {our 1njoot1ons of diodralt. >xllad1a$oly Ittcr tho last 1nJ¢¢t1an thy pat1ont lapsed 1319 a 102911 3:11., M1: cyuruovanantt 3101.0 d1llo¢18ttd, and tan loft layer and In!!! tatul1t1o§ I09. N mum nonpanﬂ anon. am the tmu Mum mm m Vtrhully to «allnnd. but tum han1pl¢31t booinpit10at 00114 tplnt1c. It porn1ltad ant11 tn. put1on1 its trunnruraod to ancillt anap1¥I1 can nanth 11102. tn31usrnll I110 tatcrprttod an annual. A pnaulalnoaphnlo~ 3run.rovualtd b1latcrnlxy 61.301 vuntr1c10u u1thout nh1tt er 1%. .d1lvort1an.1 walker (31) the at stator: that’s: Ions111v1ty tn the eonsrust Indtwn, amt a; m me many at 1111009103 (33), and mum tar «aupl1ant1onl In in. prusuat 19:10., till. {natori It. nut ant-taun1n3 1n tn. pat1enta uh. 107110301 «unpliont1aa- when tunic tr. 01.31301 10 tin hwptrtonn1un (38), havu bola a133Ot$ed as OIIIOI _ unoonpl1enta1’onacs. l1thsr eonsaapt1v11 at 1ntaadnrlal aiadrnst gonn1t1v1ty tent: turn cnrr1od out 13,0?!93 luhaoot. In out cute, in: cane: at «humus, means, an: myzuum mu- the m: am» an to ouncol tan I9I11II. 3111th mm 1B1: In 111 1mm: 1n51ud1n3 an. athgr turnouts, amuuum, m Im1t1uty to». m mun. Ill notably true 1n tbs {tar pat1outs who dtvu1opod “n11.331c~ rsaot1ons of urtiolr1t, oh111n,“ van1t1n3, tolleu1a3 tho In31osraphy. but who £11101 to rule: to tbs tent 4916. Shaw. 1: an apparent rolae1an 1n tho ant: bntanon «anp11out1ons 11km” �13.. (luntudias hunttuun If In. it. acct) and tin ms it 13:00t10an 1 2 3 mania: or 1n1¢otzunn t 5 6 Iﬂﬂ"th‘ﬂ‘6 lo. .1 patiouta 11th cu-pzioctiaun'l e 6 6 I 1; lo. at pt... without «uncanny 3 9 1m :38 ' it Ebﬁazﬁ ' o 16 '3 as *Ixnluata; 16 Inna-plsnusad «Isa: 13.1huu tutu: data.» uua ngt rocordnd. o: m t’utoru or nae-than and m' author I: carotid punstaraa at on. Ion-1:: (unilaturtl or bilaterll Iagiacrlph!) rtvttl as significant entrolltton botluon thtao riotorl. 3mm mm» t3. inolaunno at calvlaltxaau. Arm-1n max-«mun m in a eonmuuan in m. poxootxon or patzants tar Ingtosrlphy. ihn.hw)hrtoanzvoa (:11 with diastnlia prisaurio at zoa-n. It. or'nnvi. and urtialto ar0§turtu at more than lﬁaun. In.) It». subjueted to nasitgrOphy, and in nan. at Shut. the. that. lay tonplioaticna. .0: thn paticnta with Icvorc up titan singly. and -- ‘tsnnszont oclplzsaﬁiaan («chit than hGIRQﬂlﬂ ot‘tho unak) aunt and V hrpdrﬂlnlzan. unseat mortal: hart alphlatlid tan diagnottta rtlzuhalat: it alrutid lasincruah: 1n vascular nan-alto: (k), auapoetod brutu talnru (lb. 5), tram-I310 aurchmt1~utdbn (6). tan ooaluntvu vascular axsaaaon (7). our ebucrvataons coatirn.thn rocounnadatzana at tho ham 1:. um run m m.in. _ diagnnst- a: van¢u1nr nan-n17 could nut he ountlmuld Cincpt iv insulin} Impaiurt at luttpuy. Itnte sir trudiyi are nut vuiiuilo 1n dlnanntrntins vautnlur annualaos a!”IEIIrIIIITMInﬂtﬂcrlrhr“tﬁmiﬁlﬁpiiﬂtiuri"ttwin%00w%nwiiitblllhins Iran? to ausiouruphw. �13. sign ailsnnsts. Xn-haﬁ at th@“p&t10nﬁs in this surint-An shun.nnth , n luntan was unspoctea, tho yam-p1: was natzutaggarilr“dauauntmatad um «am: or miagrap‘hy; man ‘mnu‘blishad w am» um“ lbnte£tta0lnbsp£bai, five anenrwnnn wore dn-waatritoa-an la anapoota. ﬁtnilar ”caulk: are rooardea by tthar ﬁlth!!! {¥), can anagrams mmemuona have. hem nae ta inn-cue than Wis. Routine mtehml injectim, scanned with bilateral 6:th panama. will «laminate maladies 1n the posterior portion at the 611-010 at ‘ﬂillin (1!). Oblique A.P views tt #5 403:... have been ruoanuoadnd to damonltratc until aneurysms er tn. aaratid (#d). with thtne noditicatiana 1n~the prooed&re, 1t 13 to—bq§gxpeoted that the incidence at positive 1d¢ntﬂiut1m at will the rule of angiogrnphy 1n the management or apontansaua am” mm. Iuharaahnoid hannrrhnes 13 not alear. Recent review: emphlstxo in. 1n»9rt&a¢e of alnnnltrtting tha Xenian nhmrs turaiaal intervaattun 1! indiettnd (ﬁt. a.) !hc affect of Iaszonxlphw 03:13: twat. it. 53:10 a: blending his act beta a1nr::1¢d. lung nuthnra tutu roan-acalid :a;1¢lxnphy only :ttor tho blending has 09:306. 0th.». such an (m. mm «:1: m u mama-v man m nun mm. m. mun um... um um mu m tn in 5::o0t in mum: and adhorul at 4 or the cases thin 3095's, and no ntutqnnnt of tho Inciozraphw an binoding can be undo. Aagiogrnyh: in tho diagnoctio panoodnro o: «halt. visa a Quaratoatawiil human tumor :1 auspoetod. it 1: rcounnandnd tar Ionian: lecaﬁol in :3. Iatortcr tlu~thsrds a: tht_¢¢rolvun. ana$p1tt1 1th.. posterior toast and nuns unabrszu innnru a». uni conntttnntly Mutable by this Hath pip111@dama, team”. 11mm“! in lawn” WW ant unltki ztntc than venucdnro, lit ntuditc. anon ��1‘. In snot: or cnrcbgll vuucniqr;acutdant,Inciﬂlllvi¥~tnrﬂﬁrl,1003 helpful. .rlilurv 0:,a rental to £111 any Do an: t. u.vurtety t: mamas 310m»:ntm1umut1m. .mmm min. in! ”mm at m sum. mm mum mm boon ”but!“ (75). 1;- aot ,imwmwludzu Mimi!» mum man. It proud” \- mam. mu 1i: arm-gamut” o. twain tron m tntrusarnhmtl 010%, or f!!! a tunes, in OIIOI Ihnre tho I1tsnonll-as mucus W. unelcwr. ' ﬂhile the indications tar angiography are many, that cannot be evaluated uithuut ; aincuauian at thy risk: involved. ‘iha emm911a1~ ,tiuau or the praceanre are a: turccthpoat.(n) trunnient latul phcnunanlg (b) trannient cerebral vascular phenlnnnlg (o) pcmlanant 2mm «£1411». , xn the vburaias Dﬂlnl 1n the :1“:ng at trmniont mama m m It‘d during 1nJooeton, hauttuul in.tho noak, and ullorzie venetiann.. numatann.1n the acek in a potentially dangcraus samplicntien (see aur.Caso VII) but in a ragent review no Inqucllas varc,aha§rve¢=(9). »Allor¢10 notation: «we larreqaant and usually llld. .1: in: nat¢¢ in thin action that ﬁns manila. intvaautlanouu or csngunntivua talking tar sensitivity It: not fauna untitraotorw $n prudiottus ﬁnale-clnpliotticnl. lblnninat,hun1paanszs. aphlltl. :eiunros nna citritod blaod pruuunre haw: hath reported fallouina unstogrtphv (16). In that series than. qunmlieationn n!!! OttarVQdfin nine canal »~ an incidenae of 35. {A similar tantdanao uni-nhucrvud In tho lbntcrluao Ibnpaell 30:103. lint.th030 Philll'n!.!rﬁ pribttly in: to tunporary vaaaulnr innutriuionﬂr (I’lﬂlﬂ) 1: I71lnnn¢d by the cliniunl pattorn at nourolngzctl findings and thair‘dnrutzun.. at asv¢u 3:310:90 with �it. M101” 15. m an tin-00 unwanted 01ml: than. 0m:- it no so” in an laws. In m panama, mu m of the amsun autograph: m "mm in a. 0M um 01: an um, 01MB «manna. In tho 0mm: mum, Woo-0m banana-«10, and tm mammmuumamummuamnmm left me the 0min 1mm that m m»: later, in» first 0m may m 0100. an mm m mind”that run an tho 0100 and mum M01090! 0 right M4- 13:00:10! 0: 01941-0“. tho MWMmth-Wﬂm. Vacant OW M 0mm mm.» 9103“. of that mun-101- hue been observed. 02:0: m 13300151”: in: do» within 15 010010 plant 0 1000: am manna 007010904 0:? “can”. third Quintin 0: m "I! 0140 In an. A mm 0: tin 09m“ 3: m «rent. an. m mumnmnwsmnmgumma. within Wu. omnuum m0 not unwind: 61mm m. 19 in ”#103150 01th W103. 6menoun-1mm.» a: 0 ”um '0 condition or men nun-1a; wemyhymummmmammumm. mud) , them-.1319“: ormpmuamxm. mam Mm :um «mare; “may to «unanimity. um many. and mu.» (1») mart «no 1080110100 mm.and80011110 0: “data-imam u: clown (11) than 1n mu mm. anus, 1." ”that“ ”mum” in a «£100 a! 36° won-000. no" mo in «hung: in an:- pmmt 005-100. an: m patient and 0 «m. nunvation 0f than at 0. pvt-mung Mum. 111 b01020 W10. 80071110 and tin pmodm‘e. in contrast 00 this In! 0! than 90810330, 111:. mum at 910003. 1:090 0010:“: m the 10:30 has.“ of M1: (53); , �(5e), Won (14), m um he), muten w deaths ﬂare related ta precadure.‘ (1b) thawein no 16. and mm It 13 tum passablc adrlannd that with vidnupread use a: angzoeraphr, Iubﬁeatu titl.naro cerebrul lesions tru selccted far these stud1eu and tha rink: ﬁharlhv 1n¢rcanod. A what 9: mm: by 01:36:: am manta: (BB. 11, 12) alphantxs tho-launntxon at tho taxis atteatn o: 31:30 limit a: diodmalt given ovar a abort 99:10! a: ﬁans. '1hor tailgatic in. nature at the toxicity Is an inoréégea permanbility at tho blood 1.33:1! and u chanxe 1n hennaynlaieh. Furthlxﬂﬂliy aha rolatian between canoentrt~ ma taunt; m, mean-am I» am: (13) when no am or introauegd dladraxt far Instagruphy. a1: abtathtiun that seizures £0116! thc use at 595 and 70% éiearaut has been ovatimnné by unmitiul amt invautizatarb. auspite thc use at 351 diodrast and law total Gasman: er diodraat, in this series, eumplications ensued. share I81 no nisni~ tioaat rnlntiaa between.dosasc 1nd canaliettionn. ethar raetars ' not he ”mum and same elrculntian tint (#t) and mung ma «team: V ' H 31.3 ‘71... i mummy mt. has been given in the “amnion an tau affect of other 1nJurious ﬂaunts (a). eri 8h. moment a: em: or man. cranial aiaenaa :uupoeted or raueular animalios. an;znt¢atar1t1 talcum. and traumatic hu-Itunns. IS 1: n natintcetory non*lurzie¢1 ntthad at dtnunutrntina I Visuallr annuals; nnltoznation or ‘nourrnn. 1. 1:: in: dilsnoail of Iupratuntorill.llnlts it will takiinc 9Q! tttinruntarlly. In,udﬂ1t1¢u to catnblzlhinz thn pzoqanao at a kunnr. :rtorauarapny 1! unparacr ta 0th.: asnannstto tookaios 1n yialazna calling. I: to it. typo ot’lnul lad 1t. local. In Cl!!! with In �17. a not and. Wkly “at”: by tn mm ohacuro 13 mined-II». It alt a Inttlthstaww'litind'13.!UIlaatulﬂmaa or ﬂu. and mm. mum of tho nah-unlu- min, or mimic: fun w ”0199.15”. I»... 1. a in «us of tantrum mam, m Mm» «turns»: arm "ﬂunk: mm proucdnri. m: mm mm. a intricarutrll hilatlll tiastlt-Ilah MW m emu mum «now am» mu. at taunt. 10.113» tram 1: 1. eon-punts” mg. “I? tho mt pm, Wink. and would not in no“ mu. he savanna.» m no. tn was ﬂu not "mm u human-1m math-nu, min or tutor: uncanny d: tunings. a sum: of «mu. r010, and "My 1. mum. pm a mu W mm m W «mud Woman part-mt Mm m rm an: m mm "an“ mm: mm”no: a: A 117 hum. mam o: ta risk: of Ingiography. no author. «mum: that the 1mm taliﬁttionl and mt: ot at the mum” do «mu m autumn: an the meant or mean: alumna”, mum mmtarial brain Wm ms! was not 13th 1.1;- 10am. ' u ,____ __ _#».47.L_...;M._.z _,_..._.,___L__, .__u “A, . �RUIIARY eeriee a: 117 pereuteneoue oerotid ensiosreee were revieeed to eveiuete the indidetione for end rieke involved in engiosrephy. Petieute with e veriety or intredreniei conditione were etudied including eupretentoriel tenure, veeeuier endeoliee. A treaeetio heeetaee end eerebroveeduler dieeeee. titty-rive petiente with evidence at intreoreniel tenure were eueJeeted to engiogrephy, end e poeitive diesnoeie eee eede in thirty. fheee diesnoeee were auntie-ed in 83$ or the eeeee. ’ In duly tee eabjedte were the tiiee eieinterpreted. or the aegetive tilee. the diegnoeee were dentineed in 50!; in only tee men an the ensiosreee teii to aim e leeion um- deeenetrehie b7 eir etudiee. or 21 petiente eith euepeeted intreereniel veeduler endedliee, nine were outlined by ensiosrephy. In tee of theee, the engiosreee reveeled en end-e11 not eeniteet on eir etudiee. In e group at eeveuteen petiente euepeeted o: treneetie intreoreniei heeeteee, e poeitive diesnoeie wee eede in seven eeeee. Theee diesnoeee ee well ee the necetive findinse in eight ceeee, end intreeerehrei theere deeonetreted in ten ceeee, eere e11 contimeed by euheeeuent etudiee. In oeeee at cerebroveeduier leeione ensiogrephy wee not at diecnoetio veiue. Treneient ddeplieetione of engiogrephy were eeen in one—third of the petieute, end edueieted or heeetaee or the neck, heeipereeie. eeieuree, end erticerie. In five petiente (I!) eoepiicetiene eere eevere end peeeenent. Sheee oeeee ere deeerihed end the restore diecueeed. Ehe ‘Vl eethere deecrihe the ueetulneee or engiosrephy in �“Hermann“ been»: intact-mill condition: . they canal“. that tho united risk: of cerebral miomphy 69 not data“ from it: ”0mm”. in the summon: a: mammal vacant alternations. unopened «panama-1.1 man and human hum. the variety or ��mm rams. LG. and mummy, L: mum...» my... warms,anion-mph: ma cox-chm than”. mu.lgu_gnl.mz¢hiat. omml Q}, 359“"368: ‘9’11: 39”intmmiu (1) new. I. : mummy in polt~trmtio 2w¢2583 “tam; 19‘9. 910‘ ES. 4““ WWI. m at in the (1») lumbar, 19W. intmmid 3.: 9mm}. maximum? 755468, W001: (o) 5. 6. WI! New ' . _ mm. 3!; 3.8.: m dammit er mum. B. m 3.!" mm, by intact-unis! tutu-mic humane axiom”. J. Imam- . (6) Q5, 363~376o N17. 1951- LB. and um. ‘.l.8 Eh. contribution at «roam 1950. mm. angina-mm in “tannin. «mam. : m $2-3m, catcher, of (3) mm. 3.3. and mm. 1.6.: Wriemphic visualisation 600-618, 251. lesions. mh.!m1.ggzehiu. ammuni19‘6“3.; (b) mm. 1.3. and mm, mm carom}. Marion-why in191.8. nub-mountain Mum. g.i.l.i.. 1.36: 517-581, M... (a) mzm. 1.1:. am mm. 6.6.: mum-min autograph: in the tmmnt at «1'0an maul” accident: . can: .M. , m (4) 7. ,_ V (a) LA. and mm, 9.3.: carotid minmtw; It: ".1130 sum. in pun-.11 t 121th conditim. M£11mgorth “or. , 8. m, the mmmolwruzohint. 31; : thrionlmaphy m mmmmw. mu- um. be. 1.31m: . localization had tram: or 111%”:er 1310-13“. June, 1932. m, P. and Pmuunum «mud miouaphy: m, "farm” ine“ iota blob. laurel” I»: complications in th- and pun-ms. ‘10 . 11. b with special 11: been to the larynx. 16;; 1-6, Juan-r1. 1951. 1. sad mum-amen, 1.2.: umimt 3.6., trauma,with. cyan. union-why. Lima“. unbnl 32-191. in unpainted 19‘9466 “ll, number. g; of (b) mm, 3.. 36mm. VJ. and unseen, 3.: cmuaum 1951. 110418, angina-why. g4, mum. , g; ham, India a: tar emtmt 0. cerebral unplug £01m» won, 312-316, lov.,19't9. a: dim» type. 1 .lmu Joni-elm. "paint. E; (u) a » to a aid 01,8861. 0.: 103.3ch of «mm: bland vouch 336~3#8, Indian or the “adult group. mm We}... 32; lava-tho, 1m. pines in aux-01min]. 13. @038, am. u 8mm}. ”tomography: It: 704-711., Oct... 12 . 1*. mm, contra-t ‘1'. ‘ «lanolin. Arch.lm¢1.ﬂgguat.. 53!. 6.. mm , run. and 3.3.: Vertebral 'W tokﬂﬂnt. ‘ rm. 166.5182, "bm’lg‘g. ‘ u‘doMc; £12. 19“. Wm. 83131 o � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A clinical evaluation of carotid angiography. Confin Neurol. 1952; 12(4): 181-95. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-5-007 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Stein, Joseph M. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and publication. Confinia Neurologica. From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellvue Hospital, New York City. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Basel; New York: Confinia Neurologica Contributor An entity responsible for making contributions to the resource Spiegel, E. A. Published