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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.13 no.4 São Paulo Dec. 1955

http://dx.doi.org/10.1590/S0004-282X1955000400010 

REGISTRO DE CASOS

 

Angiografia vértebrobasilar retrógrada acidental. A propósito de dois casos

 

Two unexpected cases of retrograde vertebro-basilar angiography

 

 

José Zaclis

Neurorradiologista

 

 


RESUMO

São apresentados dois casos de angiografia vértebro-basilar em pacientes submetidos a angiografia cerebral via carótida. Na discussão do mecanismo dessa eventualidade angiográfica é admitido o refluxo da substância radiopaca até a artéria subclávia de onde o contraste seria levado, pela corrente sangüínea, para o interior da artéria vertebral. Para que o contraste pudesse progredir em sentido contrário ao normal, é forçoso admitir a existência de uma oclusão da carótida acima do ponto em que ela fôra puncionada. Quanto à causa determinante do bloqueio vascular julgamos provável que se trate de uma válvula artificial resultante da laceração da íntima, como no caso de Sirois e col.
Tendo a atenção despertada pelos casos relatados neste trabalho, pudemos obter, deliberadamente, angiografia do sistema vértebro-basilar injetando o contraste na carótida primitiva (punção percutânea) e ocluindo êste vaso, mediante compressão digital acima do nível da punção. Para maior aproveitamento do contraste, um manguito insuflado, até o desaparecimento do pulso radial, é colocado no braço. Com êste artifício visamos impedir que parte do contraste seja levado, inutilmente, para os vasos do membro superior. Os pormenores do método e os resultados serão descritos em trabalho que será publicado oportunamente.


SUMMARY

Two unexpected cases of retrograde vertebro-basilar angiography are presented. In both instances a percutaneous puncture of the right common carotid artery was performed and when the contrast medium was introduced into the vessel, instead of progressing upwards, it went downwards, contrary the blood stream, to the subclavian artery. After reaching the stream of this vessel, the contrast passes on to fill the arteries of the entire vertebrobasilar system. The back flow of contrast medium was caused by occlusion of the common carotid artery just before its division, as can be clearly seen by examining the angiographic pictures. The subject to be discussed is concerned with what caused the artery to get blocked; occlusion was complete but disappeared soon after the first injection in both cases. Such a transitory block can not be ascribed to a thrombus within the vessel; thrombosis would rather cause permanent obstruction. Neither could arterial spasm be responsible for the above mentioned vascular occlusion, owing to the important diameter of the lumen of the common carotid artery. In addition the bow shaped cranial tip of this artery, as seen in figs. 1 A and 2 A, brings further evidence against the spasm mechanism. Since neither thrombosis nor spasm can be responsabilized for the occlusion of the vessel, the only reasonable mechanism is that described by Sirois et al. These authors reported an unusual case of local complication of percutaneous angiography consisting of complete arterial block caused by an artificial valve just at the level where the common carotid artery divides into external and internal. At autopsy they got sure that the above mentioned valve was made up by a flap of the intima, which had been lacerated in the transverse direction and partially dissected by the tip of the needle. Furthermore, our preference for the latter mechanism is based on the similarity of the cranial end of the carotid artery in our cases and that which can be seen by examining the pictures inserted in the report of Sirois et al.
By carefully analysing the cases of accidental vertebro-basilar angiography it occurred to us to acchieve deliberate filling of this vascular system by introducing the contrast medium in the common carotid and ocluding the vessel by digital compression above the level where the needle is inserted; in order to avoid the most of the dye to be lost by following the stream of the humeral artery, we think that a cuff of a sphygmomanometer around the ipsilateral arm would be a helpful device. We have already employed this method for vertebro-basilar angiography successfully. Detailed description of the technique and further results will be published in the future.


 

 

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BIBLIOGRAFIA

1. MONIZ, Egas - L'angiographie cérébrale. Masson et Cie., Paris, 1934, cap. 6.a        [ Links ]

2. ALMEIDA LIMA, P. - Cerebral Angiography. Oxford University Press. Londres-Nova York-Toronto, 1950, pág. 55.         [ Links ]

3. SIROIS, J.; LAPOINTE, H.; CÔTÉ, P. E. - Unusual complication of percutaneous cerebral angiography. J. Neurosurg., 11:112-116 (janeiro) 1954.         [ Links ]

 

 

Trabalho da Clínica Neurológica da Fac. Med. da Univ. de São Paulo (Prof. A. Tolosa).
Clínica Neurológica. Hospital das Clínicas da Fac. Med. da Univ. de São Paulo - Caixa Postal 3461 - São Paulo, Brasil.

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