title: Improved image interpretation with combined superselective and standard angiography (double injection technique) during embolization of arteriovenous malformations.
abstract: OBJECTIVE
  Interpretation of angioarchitecture during embolization of intracranial arteriovenous malformations (AVMs) is critical to optimizing results. We describe an adjunctive technique to aid in the interpretation of AVM embolization and improve safety.
  
  
  METHODS
  In the past 100 consecutive patients who underwent AVM embolization by a single surgeon (RAM), each AVM nidus was selectively catheterized and microangiography was performed. After the microcatheter contrast exited the AVM, guiding catheter angiography was performed during the same digital run. The microangiogram was digitally superimposed on the guiding catheter angiogram to delineate important landmarks such as the nidus perimeter, draining veins, and microcatheter tip, which were then drawn on the digital subtraction angiographic monitor with a marking pen in two orthogonal views.
  
  
  RESULTS
  Important landmarks were continually visualized during the embolization procedure despite subtracted fluoroscopy ("blank" roadmap). These techniques qualitatively helped to: 1) appreciate the overall size and morphology of the nidus, 2) clearly visualize the safe limits of the embolic injection within the nidus perimeter, 3) clearly visualize draining patterns to help avoid premature venous embolization, 4) decipher small draining veins from arteries, 5) continuously monitor the location and status of the microcatheter tip, and 6) increase the confidence of the surgeon during prolonged embolic injections.
  
  
  CONCLUSIONS
  The double injection technique, with marking pen demarcation of the nidus perimeter, venous drainage, and microcatheter tip position, was qualitatively useful in every case.
authors.affiliation: Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2380, USA.
authors.forename: Tom L
authors.initials: TL
authors.lastname: Yao
authors.forename: Eric
authors.initials: E
authors.lastname: Eskioglu
authors.forename: Michael
authors.initials: M
authors.lastname: Ayad
authors.forename: Arthur J
authors.initials: AJ
authors.lastname: Ulm
authors.forename: Robert A
authors.initials: RA
authors.lastname: Mericle
mesh_terms: D002533:Cerebral Angiography / Q000379:methods*; D003287:Contrast Media / Q000008:administration & dosage*; D004334:Drug Administration Schedule; D004621:Embolization, Therapeutic / Q000379:methods*; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D007267:Injections / Q000379:methods; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging* / Q000628:therapy*; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
chemical_list: D003287:Contrast Media