STEP BY STEP GUIDE TO PERFORM

CEREBRAL ANGIOGRAPHY.
Faculty of Health Sciences
Bachelor in Medical Imaging

Introduction Cerebral angiography is a radiologic study of the blood vessels of the brain.
The primary purpose of cerebral angiography is to provide a vascular road map
that enables physicians to localize and diagnose pathology or other anomalies
of the brain and neck regions.

Related
anatomy

Indication and Clinical Indications

contraindicatio Intracerebral and subarachnoid haemorrhage (in the investigation of suspected
n intracranial aneurysms and arteriovenous malformations)
Aneurysms presenting as space occupying lesions
Cavernous sinus syndromes
Carotico-cavernous fistula
Cerebral ischaemia both of extracranial and intracranial origin
Preoperative assessment of cerebral tumours
Suspected venous sinus thrombosis.
Contraindications
Patients with unstable neurology (usually following subarachnoid haemorrhage
or stroke)
Patients unsuitable for surgery
Patients in whom vascular access would be impossible or excessively risky.

Patient Nil orally 4-6hrs.

preparation On trolley
In hospital gown
Groin shave
 Medical records
Should be well hydrated
Should void before procedure
Peripheral pulses marked
I.V line in place
Informed consent.
Equipment’s Equipments
and Apparatus Single or biplane digital subtraction angiography apparatus, with a C-arm
allowing unlimited imaging planes, high quality fluoroscopy, and preferably a
road mapping facility. There should be good access for the radiologist and
anaesthetist to the patient and appropriate head immobilization facilities.

Apparatus
 Selective Cerebral Catheters (Headhunter, Sidewinder, Newton,
Bentson& Mani)
 Arterial sheath
 Medicut
 Guidewires
 Contrast Medium( Omnipaque 100ml)
 Connector/100cm tubing
 Surgical blade
 Saline
 5cc & 10cc Syringes
 Local anesthesia.
 Heparin
 Surgical Gloves
 Elastoplast
 Cerebral Catheters
Hinck-Hilal(headhunter) catheter used for 4 vessel studies.
For more tortous and elongated arch preferred Bentson Hanafee Wilson
(JB2,JB3) Simmons (SIM2)
Contrast Media Contrast medium
Nonionic monomer e.g. iohexol, iopamidol. The concentration required is
equipment-dependent, but with a good DSA set, about 150 mg I/ml will be
suitable, i.e. 50% dilution of a standard 300 mg I/ml solution.
50ml of diluted contrast media is enough to do a standard cerebralangiogram
with total 8 projections
Approximately 5-8ml diluted contrast/injection.
Contrast medium volume
1. Into the common carotid - about 10 ml by hand in about 1.5-2 s.
2. Into the internal carotid - about 7 ml by hand in about 1.5 s.
3. Into the vertebral artery - about 6 ml by hand in about 1.5 s.

Procedure
steps

Gaining arterial Selective arterial Image Closure of Post Processing

access catheterization Acquisitions arterial access Films & CD

Catheterization Catheterization
The femoral approach is preferred for catheter insertion. The catheter is
advanced to the aortic arch, and the vessel to be imaged isselected. Vessels
commonly selected for cerebral angiographyinclude the common carotid
arteries, internal carotid arteries,external carotid arteries, and vertebral arteries.
Technique Cerebral angiography is increasingly performed by a diverse range of
specialists, and this diversity has prompted the publication of qualification
requirements for diagnostic and interventional procedures. 3 With
miniaturization and other advances in catheter technology and the
development of nonionic contrast agents, cerebral angiography is now usually
a straightforward procedure that takes 30 to 60 minutes to complete. Cerebral
angiography is painless and can generally be performed with the use of local
anesthesia administered at the groin and no or mild sedation. General
anesthesia is required only in patients unable to cooperate or in children. With
the use of a closure device4 such as a collagen plug or percutaneous
arterial suture for hemostasis, patients may be ambulatory within 1 hour after
the procedure is completed, and anticoagulation need not be halted before the
procedure. However, closure devices are only used in a select population of
patients. Without closure devices, the patient can usually ambulate within 6 to
8 hours.
Vascular access is most often obtained via the common femoral artery and
rarely via the brachial or axillary artery. After arterial puncture, an arterial
sheath is placed into the artery. A sheath is a short catheter with a diaphragm
at its exterior end that allows the passage and manipulation of additional
smaller catheters without damaging the femoral artery. Catheterization of
the aortic arch and further selective catheterizations are performed with the
combined use of a catheter and a guidewire. A plethora of catheters and
guidewires are available. Selection of the catheters and guidewires used in a
particular patient is based on the patient’s vascular anatomy, the diagnostic
question to be answered by the procedure, and the preferences of the
operator. A hockey stick–shaped catheter and a guidewire with a simple 45-
degree curve are commonly used, both with hydrophilic coating. For difficult
anatomy, other catheter shapes are available. The catheter is continuously
flushed with heparinized saline to prevent thrombus formation.
The precise vessels catheterized depend on the indication for the procedure.
Sometimes catheterizing only one vessel is all that is required, for instance, for
immediate follow-up evaluation after aneurysm clipping. At other times, the
bilateral vertebral arteries, bilateral external and internal carotid arteries, and
bilateral common carotid arteries all must be catheterized. In many
instances, catheterization and angiography of the aortic arch and three to four
vessels are necessary. The injection variables employed may alter contrast
bolus delivery and have considerable effects on the opacification of
 downstream arteries, parenchyma, and veins.Standardized technique is
therefore important for comparison of angiographic results.
At the very end of the procedure, the common femoral artery sheath is
removed, and manual compression is applied at the access site until
hemostasis is obtained. Arteriotomy closing devices are now routinely used.
These are essentially tools that percutaneously place a suture into or a plug at
the puncture site to obtain immediate hemostasis. The indications for the use
of a percutaneous closure device vary among institutions. One common
approach is not to use these devices for routine angiography, but to reserve
their application in patients who are undergoing anticoagulation, who are being
treated with thrombolytics, or who have coagulation deficits from other causes.

Radiographic 90° LEFT LATERAL

image LEFT VERTEBRAL
sequences. AP CRANIAL 30 °

AP CRANIAL 20°

LEFT INTERNAL
LAO20° CRA 30°
CAROTID ARTERY

90 ° LEFT
LATERAL
CEREBRAL
ANGIO
AP CRANIAL 20°

RIGHT INTERNAL
RAO20° CRA 30°
CAROTID ARTERY

90 ° RIGHT
LATERAL

90° RIGHT LATERAL

RIGHT VERTEBRAL
AP CRANIAL 30 °

Radiographic
images and
related
anatomy
Example of
pathology
(images)

Basilar artery occlusion in the middle and distal segment. (yellow arrow)

Left internal carotid artery injection with blood pressure at baseline, early arterial phase,
shows that the left middle cerebral artery is occluded (white arrow).

Cerebral angiogram of the left internal carotid artery (LICA) confirms diffuse cerebral arterial
aneurysms. Arrow points (red arrow) to the left MCA M2 segment fusiform aneurysm measuring approximately 5 mm.
MCA, middle cerebral artery.
Post-
procedural i. After the catheter is removed compression is applied to the puncture
steps site.
ii. Bed rest for a maximum of 4 hours
iii. During rest patient is monitored and vital sign like peripheral pulse like
distal to puncture are regularly.
iv. Extremity is also checked for warmth, colour numbness to ensure
circulation has not been disrupted.
 CEREBRAL ANGIOGRAPHY

Imaging

Digital C-arm equipment is preferred for cerebral

angiography. The imaging sequence selected must include allphases of the
circulation—arterial, capillary, and venous. The projectionsrequired depend on the
vessels being examined. Examplesfollow.

Common carotid arteriography

Carotid arteriograms are among the most frequently performedcerebral angiography

studies. Occasionally, cervical carotid arteriesare injected before catheterization of
the cerebral branches The right common carotid artery is demonstratedin the
posteroanterior (PA) (fluoroscopy tube under table)projection and the lateral position
for examination of this artery andits bifurcation into internal and external carotid
arteries. The area ofbifurcation is studied carefully for occlusive disease (see
arrows).

The left common carotid artery is studied in a similar manner duringthe examination.

Internal carotid arteriography

A second cerebral arteriogram demonstrates the internal carotidarteries.

Representative subtracted images of the arterial phase ofa left internal carotid
angiogram are shown in the radiographs of

Figs. 17-51 and 17-52. PA and lateral images allow visualizationof the bifurcation of
the internal carotid artery into the anterior andmiddle cerebral arteries