Gambaran DSA Pada AVM Dan CVT PDF

GAMBARAN DIGITAL SUBTRACTION ANGIOGRAPHY (DSA)
PADA ARTERIOVENOUS MALFORMATION (AVM) DAN

CEREBRAL VENOUS TROMBOSIS (CVT)
Pembimbing :
dr. Hernawan, Sp.S
Disusun Oleh:
Titik Fadhilah
1810211003
SMF ILMU PENYAKIT DALAM RSUD PROF. DR. MARGONO SOEKARJO

FAKULTAS KEDOKTERAN
UNIVERSITAS PEMBANGUNAN NASIONAL VETERAN JAKARTA
PURWOKERTO
2018
Pendahuluan
 Apa itu angiografi pada DSA (digital subtraction
angiography) ?
- Angiografi merupakan tehnik pencitraan yang digunakan
untuk melihat lumen bagian dalam organ dan pembuluh darah
- Prosedur tindakan untuk menggambarkan aliran darah untuk
dari dan ke otak menemukan adanya penyempitan arteri vena
pembuluh darah
- Gambar angiografi diambil 2-3 frame per detik untuk
mengevaluasi aliran darah dengan tepat menggunakan DSA
https://www.gleneagles.com.sg/id/specialties/medical-specialties/neurology-and-neuro-surgery/dsa
 DSA (digital subtraction angiography) adalah pemeriksaan
yang memberikan gambaran vaskuler yang diperoleh
dengan menggunakan mesin sinar X , media kontras
khusus yaitu ‘dye’; cairan bening dengan kepadatan tinggi
yang disuntikan ke aliran pembuluh darah dari kaki ke
aliran organ tubuh lainnya agar lebih mudah tampak
adanya suatu kelainan.
 Untuk mengidentifikasi adanya abnormalitas vaskular :
sumbatan, stenosis, plak dan aneurisma.
https://www.gleneagles.com.sg/id/specialties/medical-specialties/neurology-and-neuro-surgery/dsa
; Princeton University, 2000 hlm.15
ANATOMI VASKULARISASI
OTAK
Medical Mini Note Neurology Edition, 2017, hlm.42
Anterior Cerebral a.
Middle Cerebral a.
Posterior Cerebral a.
http://www.fmritools.com/kdb/arteries/vertebral-artery/basilar-artery/posterior-communicating.html#previous-photo
Apa itu AVM (arterivenous malformation)?
 Malformasi arteri vena serebral merupakan suatu
keabnormalan pembuluh darah bertekanan tinggi yang
menyebabkan manifestasi klinis neurologis seperti kejang,
iskemik, atau perdarahan (Samuel, K, 2018 hlm.314).
 AVM adalah kelainan kongenital dimana arteri dan vena

pada permukaan otak dan parenkim saling berhubungan
secara langsung tanpa melalui pembuluh kapiler.
Bagaimana Gejala Klinis ?
 Nyeri kepala hebat
 Serangan kejang mendadak
 Penurunan kesadaran
 Vertigo
 Tuli progresif
 Penurunan penglihatan
 Kebingungan/confusion
 Demensia
 Halusinasi
 15% dari populasi tidak menunjukan gejala (asimptomatis)
 Hidrosefalus
 Kaku kuduk positif
 Stroke Hemoragik
 Variasi gejala berjalan dengan tipe kerusakan serebrovaskular
(Samuel.,Kalb 2017)
AVM
https://www.sciencedirect.com/sdfe/pdf/download/eid/3-s2.0-B9780323431408000202/first-page-pdf
Kalsifikasi AVM berdasarkan
Spetzler Martin
Parameter Skor
Ukuran nidus
< 3 cm 1
3-6 Cm 2
>6 cm 3
Drainase Vena
Superficial 0
Profunda 1
Kelancaran berbicara
Tidak lancar 0
Lancar 1
https://www.sciencedirect.com/topics/medicine-and-dentistry/digital-subtraction-angiography
(Cheng,Y, 2014)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036458/
http://www.ajnr.org/content/39/10.complete-issue.pdf
AJNR Am J Neuroradiol 39:1867–70 Oct 2018
AJNR Am J Neuroradiol Oct 2018
 A 34 years old woman an unruptured,
small, left medial frontal arteriovenous
malformation, once treated with
gamma knife (A), the small remnant
nidus persisted at 3,5 years from the
initial radiosurgery (b), a red
arrowhead shows the remnant nodus ).
The actual treatment planning of the
secondary treatment (c) shows that
3D rotational angiography left column
successful depicts the faint remant,
while both time of flight (middle
column) and galdolinum enhanced TI
image (right column) fail to depicit it.
The nidus was finally obliteranted (d)
at 1,5 years from the secondary
treatment. Yellow lines shoe the
prescription isodose lines.
http://www.ajnr.org/content/39/10.complete-
issue.pdf
AJNR Am J Neuroradiol Oct 2018 hlm. 1869
ARTERIOVENOUS MALFORMATION (AVM)
An 11-year-old boy with a right pericallosal
AVM revealed by hemorrhage and treated 11
months ago by surgery. Residual nidus (arrow)
and venous drainage (arrowhead) are seen on
DSA (A,
B) but not on 4D-MRA (C, D) by both
readers. Retrospectively, a part of the
nidus may be visible (arrow)
http://www.ajnr.org/content/35/10/1903
American Journal of Neuroradiology October
2014, kutip kasus
ARTERIOVENOUS MALFORMATION (AVM)
A 16-year-old adolescent girl with a left
frontal AVM revealed by transitory neurologic
symptoms; treated by embolization then
radiosurgery 2 years and 10 months earlier.
When the drainage is early, the vein dilated,
and the nidus compact, depiction is easy.
The residual nidus (arrowhead) and venous
drainage (arrow) were visualized by both
readers in DSA (A, B) and 4D-MRA (C, D).
3 American Journal of Neuroradiology
October 2014, kutip kasus
Cerebral VenousTrombosis
 CVT merupakan penyakit serebrovaskular yang ditandai
dengan edema serebral fokal, vena serebral infark, kejang dan
hipertensi intracranial (Scheffer 2017, Lou Y,2018 pp1)
 Sinusdura atau sinus venosus merupakan aliran dari vena-
vena superfisialis dan profunda serebri.
 Sinus dura terdiri dari : sinus venosus kranialis, sinus sagitalis
superior, sinus rectus, sinus transverses, sinus sigmoides, sinus
kavernosus
 Terjadinya oklusi pada salah satu daerah sinus venosus yang
disebabkan oleh thrombus disebut dengan cerebral sinus
venosus thrombosis
Cause of and predisposing factors for CVT
 Local conditions
◦ Brain and skull damage
◦ Intracranial and local regional infections
 Systemic conditions
◦ Hormonal (pregnancy, steroid therapy)
◦ Surgery immobilization
◦ Hematologi and hiperkoagulan diorders
◦ Connective tissue disease
◦ Malignancy
◦ Systemic infection
◦ Dehydration
 Idiopathic causes (12,5%)
https://www.researchgate.net/publication/6744321_Cerebral_Venous_Thrombosis_and_Multidetector_CT_Angiography_Tips_and_Tricks1
Cerebral Venous Trombosis (CVT)
Paralysis dari gerakan extraocular, ptosis dan

Paralisis dari gerakan
menurunnya extrsocular,
sensasi rasa pstosis dan
→ gangguan
menurunnya sensasi rasa dapat
nervusmenganggu
trigeminal
nervus trigeminal
Trombosis sinus cavernosus → menghambat
Trombosis sinus
venacavernosus
optalmica → menghambat
yang venadengan
berhubungan optalmica
yang berhubungan dengan
proptosis danprotosis
edema dan edema periorbita
periorbital ipsilateral
ipsilateral
TrombosisTrombosis padasagital
pada sinus sinus sagitalis
superiorsuperior
dapat menimbulkan
paralisi → menimbulkan
kemudian paralysis
menyebar unilateral
kesisi bagian yangyang kemudian
lain /paraplegia
dapat menyebar ke sisi bagian yang lain
(paraplegia)
Secara umum berikut beberapa gejala yang mungkin terjadi :
 Onset dapat tiba-tiba atau perlahan selama beberapa jam atau beberapa
hari
 Sakit kepala, mual, muntah, pandangan kabur
 Defisit neurologis fokal seperti : hemisparese dan hemisensoris, kejang,
kelemahan berbicara (afasia), heminanopia, konfuse, penurunan kesadaran,
peningkatan tekanan intrakrania contohnya seperti ada papiedema.
 Pada kasus-kasus thrombosis sinus venosus, perburukan klinis yang nyata
dapat terjadi pada waktu yang sangat singkat, kemungkinan dalam beberapa
jam. Keadaan tersebut biasanya diakibatkan keterlibatan vena interna
serebri atau perdarahan intraparenkim yang luas. Cerebral dAVF
diklasifikasikan oleh risiko dapat menyebabkan hipertensi vena atau
perdarahan karena ada tidaknya drainase vena kortikal.
Anatomi Sinus Venosus Normal
https://www.researchgate.net/publication/6744321_Cerebral_Venous_Thrombosis_and_Multidetector_CT_Angiography_Tips_and_Tricks1
CEREBRAL VENOUS THROMBOSIS (CVT)
On the left DSA images of a patients of a

patient with a DAVF, notice the direct
communication between the branches of
the external carotid artery and the
transverse sinus (blue arrow)
http://www.radiologyassistant.nl/en/p4befacb3e4691/cerebral-venous-
thrombosis.html
Angiography is only performed in severe

cases, when an intervention is planned.
On the left images of a patient with
venous trombosis, who was unconsious
and did not respond to anticoagulant
therapy. There is trombosis of the superior
sagital sinus (red arrow), straight sinus(blue
arrow) and transverse and signoid
sinus(yellow arrow)
http://www.radiologyassistant.nl/en/p4befacb3e4691/cerebral-venous- thrombosis.html
https://www.researchgate.net/publication/6744321_Cerebral_Venous_Thrombosis_and_Multidetector_CT_Angiography_Ti
ps_and_Tricks1
https://www.researchgate.net/publication/6744321_Cerebral_Venous_Thrombosis_and_Multidetector_CT_Angiography_
Tips_and_Tricks1
Case 1. A–B, FLAIR images
showing hyperintensities sparing
the basal cisterns and involving
the sulci of the right convexity,
compatible with an acute
subarachnoid hemorrhage.
C, T1-weighted spin echo image
revealing signal changes within
the superior sagittal sinus
(arrow).
American Journal of Neuroradiology March 2001,
kutipan kasus
Case 2.
A, E, Plain CT scan showing a bihemispheric subarachnoid
hemorrhage, predominating in the left insular sulci.
B, F, FLAIR images showing hyperintensities within the
subarachnoid spaces.
C, FLAIR images showing absence of signal changes in the
basal cisterns and revealing a hyperintensity within the left
transverse sinus (arrow).
G, T2-weighted image in the frontal plane confirming
the presence of a hypersignal within the left transverse
and superior sagittal sinuses (arrows), raising the
suspicion of sinus thrombosis.
D, H, Venous phase of the digitized subtracted angiogram
(A–P views) of the left carotid (D) and the left vertebral (H)
arteries confirming the occlusion of the left transverse and
superior sagittal sinuses. The right transverse sinus is not
seen medially but fills laterally from venous collaterals and
drains into the right sigmoid sinus.
Kutipan
A–D, Large pacchionian granulation at the top
of the straight sinus (arrowheads).
Pacchionian granulation is hypointense on
reconstructed sagittal and source axial
images (A and B) of 3D contrast-enhanced
MP-RAGE (13.5/7/1, TI = 300, flip
angle = 15°) and hyperintense on T2-
weighted image (C). DSA image
(D) shows filling defect in corresponding
region (and could be misdiagnosed as a
sinus thrombus)
American Journal of Neuroradiology March 2001
A–D, Diffuse sinus thrombosis (arrows,
arrowheads) in a 37-year- old woman with a
history of abruption of placenta and diabetes
insipidus. The diagnosis of thrombosis may be
possible from the sagittal MIP image of 2D-
TOF MR venography (25/9/1, flip angle
= 30°) (A) and by the indirect finding of lack of
visualization of the affected sinuses. With 3D
contrast-enhanced MP-RAGE (13.5/7/1, TI =
300, flip angle = 15°), however, the
reconstructed sagittal and source axial images
(B and C) show the extent and size of the low
signal thrombosis (arrows) as well as the
patency of the affected sinuses, which is
confirmed on DSA image (D)
kutipan kasus
A–E, Postoperative sinus thrombosis (arrows)
in a 62-year- old man. The coronal source and
MIP images of 2D-TOF MR venography
(25/9/1, flip angle = 30°) (A and B) show no
flow signals in the left transverse and sigmoid
sinuses, which may be difficult to differentiate
from hypoplasia of the sinuses (see fig 5). The
reconstructed coronal and source axial images
(C and D) from a 3D contrast-enhanced MP-
RAGE sequence (13.5/7/1, TI = 300, flip angle
= 15°) clearly show the thrombosis in the left
transverse and sigmoid sinuses, which is
confirmed on the DSA image (E)
American Journal of Neuroradiology March
2001, kutipan kasus
Daftar Pustaka
Aoki, S, Yoshikawa, M,Hori, K, Istigamr, A, Nambu, Kumagai, T, Araki (2000). TWO dimensimal Thick slide MR digital
substraction Angiography For Assesment of cerebrovaskular occlusive disease.
Neuroradiology, Yamayashi University. Vol 10(2): 1859-1860. Available at:
http://link.spinger.com/article/10.1007/30033300000584/
Brass LM. Stroke: Anatomi Vaskularisasi Otak. Available at
http://www.med.yale.edu/library/heartbk/18.pdf.
Cheng ching,Yu, Huang Cheh chen , Chen Hao Wu ect. (2014). Magnetic Resonance Angiograpy in the Diagnosis of
cerebral Arteriovenous Malformation and Dural Arteriovenous Fistulas:
Comparasion of Time Resolved Magnetic Resonance Angiograpy. Iran Journal Radiology; available at
Hasegawa, S, Hanakita, Shin,Kawa shima, Kin, T, Takahashi, ect. (2014) Integrating 3D rotational Angiographhy into
Gamma knife planning, ANJR America Journal Neuroradiol 39: 1867 . available at
Kumar, S. 2011. Patient Resources: Digital Subtraction Angiography (DSA).
http://neurointervention.blogspot.com/2011/09/digital-subtraction-angiography.html. Diakses pada 27 Oktober 2018.
Kevin Royalty, Pengfei Yang, David Niemann, Azam Ahmed, Beverly Aagaard-Kienitz,
Mustafa K Başkaya, Sebastian Schafer, Charles Strother (2014). 4D DSA a new technique for arteriovenous malformation
evaluation: a feasibility study Carolina
https://jnis.bmj.com/content/8/3/300.long Accessed on 5 november 2018
Samuel ,Kalb, Bradley A, Gross, Peter Nakaji (2017). Vaskular Malformation (arteri venous malformation and dural
arteriovenous fistulas). Available at
https://www.sciencedirect.com/sdfe/pdf/download/eid/3-s2.0B9780323/first-page-pdf
Yaxi ,Lou, Xian Tian and Xuang Wang (2018). Diagnosis and Treatment OF Cerebral Venous Thrombosis :A review. Frountier in
Aging Neuroscience: Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797620/

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GAMBARAN DIGITAL SUBTRACTION ANGIOGRAPHY (DSA)

PADA ARTERIOVENOUS MALFORMATION (AVM) DAN

SMF ILMU PENYAKIT DALAM RSUD PROF. DR. MARGONO SOEKARJO

 AVM adalah kelainan kongenital dimana arteri dan vena

Paralysis dari gerakan extraocular, ptosis dan

On the left DSA images of a patients of a

Angiography is only performed in severe

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