Angiographic appearances in acute intracranial hypertension

Abstract

A series of 17 cases is described in which, at angiography, narrowing of the internal carotid artery in the neck was found and the intracere-brai vessels could not be demonstrated. In none of these cases was there any evidence of anatomic obstruction. All were cases of subarachnoid hemorrhage in which the intracranial pressure had risen acutely, and the majority of the patients had had intraventricular bleeding. The similarity of the angiographic appearances to those of carotid occlusion is stressed, and the relevant diagnostic criteria are reviewed. The likely causes of the findings are discussed, and it is concluded that they are the result of a grossly slowed cerebral circulation resulting from greatly increased intracranial pressure. It is felt that there is no evidence to suggest that the appearances are due to arterial spasm. The opinion was formed that, if such a case were encountered and the lateral ventricles tapped, filling of the intracerebral vessels would result. This hypothesis was tested in a patient, a woman of 22 who had suffered a coma-producing subarachnoid hemorrhage. The left common carotid artery was punctured, but the contrast column never reached beyond the carotid syphon, even though films with up to 9 seconds delay were taken. With the carotid needle still in place, the right lateral ventricle was tapped and the angiogram repeated immediately with the ventricular needle still in situ. This time, there was good filling of the left internal carotid artery and its branches outlining a large choroid plexus angioma, the films being taken at the normal one-second interval.