166

Neuroangiography: Review of Anatomy,

Periprocedural Management, Technique, and Tips
David Case, MD1 David Kumpe, MD FSIR2 Christopher Roark, MD1 Joshua Seinfeld, MD1

1 Department of Neurosurgery, University of Colorado School of Address for correspondence David Case, MD, Department of
Medicine, Aurora, Colorado Neurosurgery, University of Colorado Anschutz Medical Campus,
2 Department of Radiology, University of Colorado School of 12631 E 17th Avenue, Aurora, CO 80045 C307
Medicine, Aurora, Colorado (e-mail: David.Case@ucdenver.edu).

Semin Intervent Radiol 2020;37:166–174

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Abstract Neuroangiography (NA) is a minimally invasive procedure used to diagnose patients
with neurovascular diseases. Noninvasive imaging has improved dramatically in recent
years and is utilized more frequently; however, further evaluation with NA is still
required in certain cases. NA indications include intracranial (cerebral aneurysms,
arteriovenous malformations, dural arteriovenous fistula, cerebral vasculitis, cerebral
vasospasm, ischemic stroke, nontraumatic subarachnoid hemorrhage, intracerebral
hemorrhage, Moyamoya, vein of Galen malformation, intracranial tumors, and pseu-
dotumor cerebri) and extracranial (internal and common carotid artery stenosis,
vertebral artery stenosis, carotid artery blowout, vertebral artery blowout, epistaxis,
oropharyngeal bleeding, and carotid body tumor) pathologies which can help with
Keywords diagnosis and potential subsequent endovascular treatment. A thorough understand-
► interventional ing of normal and variant cervical/cranial vascular anatomy is required. In addition,
radiology periprocedural management, catheter technique, equipment needed, and underlying
► angiography disease pathology are paramount to successful and safe outcomes. This article will
► anatomy review basic neurovascular anatomy, periprocedural management, NA technique, and
► vascular anatomy tips for safe and successful outcomes.

Indications noninvasive imaging include nontraumatic subarachnoid

The indications for neuroangiography (NA) include intracra-
nial diseases (cerebral aneurysms, arteriovenous malforma-
tions, dural arteriovenous fistula, cerebral vasculitis, cerebral
vasospasm, ischemic stroke, nontraumatic subarachnoid
hemorrhage, intracerebral hemorrhage, Moyamoya, vein of
Galen malformation, intracranial tumors, and pseudotumor
cerebri) and extracranial diseases (internal and common
carotid artery stenosis, vertebral artery stenosis, carotid
artery blowout, vertebral artery blowout, epistaxis, oropha-
ryngeal bleeding, carotid body tumor). Advancements in
noninvasive vascular imaging have led to decreased NA
utilization; however, NA is still required for suspected dis-
eases that may be inconclusive with noninvasive imaging.
Examples of disease types that may be inconclusive with
hemorrhage, nontraumatic intracerebral hemorrhage, cere-
bral vasculitis, oropharyngeal bleeding, and dural arteriove-
nous fistula.
Neurovascular Anatomy
Aortic Arch and the Major Branches
The ascending aorta is approximately 5 cm in length as it
ascends behind the sternum. It continues as the transverse
aorta given rise to the aortic arch, which lies in the superior
mediastinum beginning at the level of the second right ster-
nocostal articulation. The aorta then projects posteriorly and
to the left over the left pulmonary hilum. The major branches
that originate from the aortic arch are the brachiocephalic
artery, left common carotid artery, and left subclavian artery.

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 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
The brachiocephalic artery is the most proximal and
largest branch. At the level of the sternoclavicular joint, it
typically bifurcates into the right common carotid artery and
right subclavian artery. The left common carotid artery
typically arises just distal to the brachiocephalic artery,
ascends anterior to the trachea, then passes posterolaterally.
The left subclavian artery typically arises just distal to the left
common carotid artery origin and ascends into the neck. It
then courses laterally to the medial border of the anterior
scalene muscle.
The most common variation of the aortic arch is a bovine
arch anatomy consisting of a common origin of the brachio-
cephalic and left common carotid artery (►Figs. 1 and 2)
which occurs up to 27% of the time.1 Additional common
variations include an arch origin of the left vertebral artery
which has been reported in 2.4 to 5.8% of cases,2,3 aortic arch
origin of the right vertebral artery (►Figs. 1 and 2), and
aberrant right subclavian artery seen in 0.6% of cases.1
Additionally, the aortic arch is classified into three different
aortic arch types (I, II, and III). The aortic arch type reflects
the vertical distance from the origin of the brachiocephalic
artery to the top of the arch in the parasagittal projection.
Type I arch anatomy has a vertical distance less than 1
diameter of the left common carotid artery, type II anatomy
has a vertical distance between 1 and 2 diameters of the left
common carotid artery, and type III anatomy has a vertical
distance greater than 2 diameters of the left common carotid
artery.
Fig. 1 Digital subtraction angiography with a 30-degree lateral
anterior oblique projection of a patient with bovine aortic arch
anatomy, a type II aortic arch, and an aberrant right vertebral artery
origin. BC, brachiocephalic artery; LCC, left common carotid artery;
LSC, left subclavian artery; LVA, left vertebral artery; RCC, right
common carotid artery; RVA, right vertebral artery, RVA origin, right
vertebral artery origin.
Case et al. 167
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Fig. 2 Computed tomography angiography sagittal image of the
same patient as in ►Fig. 1. BC, brachiocephalic artery; LCC, left
common carotid artery; LSC, left subclavian artery; RVA, right ver-
tebral artery.
External Carotid Artery
The external carotid artery (ECA) originates from the com-
mon carotid artery at the midcervical level typically at the C4
level. It is typically anterior and medial to the internal carotid
artery (ICA) with the internal jugular vein coursing poster-
olaterally to it. The ECA has eight branches. The eight
branches in order from proximal to distal are the superior
thyroid artery, ascending pharyngeal artery, lingual artery,
facial artery, occipital artery, posterior auricular artery,
superficial temporal artery (STA), and internal maxillary
artery (►Figs. 3 and 4).
The superior thyroid artery is typically the first artery that
arises from the ECA trunk, but approximately 20% of the time,
it arises from the carotid bifurcation.4 The superior thyroid
artery supplies the thyroid gland along with the larynx. It has
extensive anastomosis from the contralateral superior thy-
roid artery and inferior thyroid artery, which originates from
the thyrocervical trunk, a branch of the subclavian artery.
The ascending pharyngeal artery is typically a small and
the first posteriorly projecting ECA branch. It has anteriorly
directed pharyngeal branches and posteriorly directed infe-
rior tympanic and muscular branches along with the neuro-
meningeal branch, which supplies the lower cranial nerves
and dura. The neuromeningeal branch must be identified
prior to head and neck embolization procedures to prevent
nontarget embolization of the lower cranial nerves.5 In
addition, anastomotic supply between the ascending pha-
ryngeal artery and the vertebral/ICA circulations poses a
potential hazard during embolization with liquid embolic
agents.5
The lingual artery is the first anterior ECA branch and
provides vascular supply to the tongue and oral cavity.
Approximately 10 to 20% of the time it shares a common
trunk with the facial artery.6 The facial artery continues to
Seminars in Interventional Radiology Vol. 37 No. 2/2020
168 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
Fig. 3 Lateral digital subtraction angiography of the right external carotid
artery depicting a ruptured dural arteriovenous fistula with supply ema-
nating from multiple transosseous branches of the right occipital artery.
DAVF, dural arteriovenous fistula; EDV, ectatic draining vein of the DAVF;
IMAX, internal maxillary artery; MMA, middle meningeal artery; O, occipital
artery; PA, posterior auricular artery; STA, superficial temporal artery.
supply the ascending palatine artery, submental artery,
labial arteries, buccal branches, masseteric branches, and
the lateral nasal artery. The facial artery terminates as the
angular artery.
Fig. 4 Lateral digital subtraction angiography of the left external carotid
artery in a patient with recurrent oropharyngeal bleeding. AP, ascending
pharyngeal artery; F, facial artery; L, lingual artery; ST, superior thyroid
artery. The AP is the first small branch from the posterior aspect of the ECA.
This patient’s facial artery exhibits some caliber changes indicative of the
known preexisting head and neck cancer and previous radiation treatment.
Seminars in Interventional Radiology Vol. 37 No. 2/2020
Case et al.
The occipital artery originates from the posterior aspect
of the ECA and supplies the posterior scalp and neck, and
provides meningeal branch supply to the posterior fossa. It
frequently provides supply to dural arteriovenous fistulas
via transosseous branches, which can be associated with
preexisting head trauma. The occipital artery can have
extensive anastomotic supply between segmental
branches of the vertebral artery and ascending cervical
arteries from the costocervical trunk. This poses another
potential hazard during head and neck embolization pro-
cedures with liquid embolic agents.5 The posterior auricu-
lar artery is a small branch that arises from the posterior
aspect of the ECA, typically just superior to the occipital
artery origin. It supplies the scalp, pinna, and external
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auditory canal.
The STA originates from the superior aspect of the ECA. It
is the smaller of the two terminal ECA branches and supplies
the anterior two-thirds of the scalp, part of the ear, and
parotid gland. STA evaluation and caliber is an important
consideration prior to surgical STA to middle cerebral artery
(MCA) bypass for diseases such as Moyamoya. Anastomotic
supply between frontal branches of the STA and ophthalmic
artery poses a potential hazard during embolization with
liquid embolic agents.5
The internal maxillary artery (IMAX) is the larger of the
two terminal ECA branches. It arises in close proximity to
the parotid gland and projects into the masticator space.
The internal maxillary artery has anastomotic supply with
the facial artery and provides collateral blood flow to the
ICA. The middle meningeal artery (MMA) is typically
the largest branch of the IMAX and courses superiorly to
the foramen spinosum where it enters the skull. The MMA is
the classic artery implicated in traumatic epidural hemato-
mas. MMA embolization has been utilized with increased
frequency in the treatment of recurrent subdural hemato-
mas.7 In addition, the MMA frequently provides supply to
dural arteriovenous fistulas and vascular skull base tumors
including meningiomas. Other notable branches of the
IMAX include the middle pterygoid segment branches
(deep temporal arteries, masseteric and buccal arteries)
and distal pterygopalatine branches (infraorbital artery,
superior alveolar artery, greater palatine artery, and sphe-
nopalatine artery). The sphenopalatine is a specific branch
that is frequently a target for embolization in refractory
epistaxis cases.8 Distal IMAX and MMA branches provide
important anastomotic supply to ophthalmic artery
branches, which poses a potential hazard during emboliza-
tion with liquid embolic agents.5
Internal Carotid Artery
The ICA typically originates from the common carotid artery
at the level of C3–4 or C4–5 and projects posteriorly and
laterally to the ECA before coursing medial to the ECA as it
ascends toward the skull base. The newest classification
(Osborn) divides the ICA into seven segments. In order
from proximal to distal, the segments are C1 (cervical), C2
(petrous), C3 (lacerum), C4 (cavernous), C5 (clinoid), C6
(ophthalmic), and C7 (communicating).
 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
C1 (Cervical)
The cervical ICA consists of the carotid bulb and the ascending
cervical portion. The carotid bulb forms a focal dilation, which
exhibits altered flow dynamics with retrograde fluid eddies
making this a vulnerable location for carotid stenosis. The
ascending segment projects superiorly within the carotid
space. The carotid space encompasses the ICA, internal jugular
vein, lymph nodes, postganglionic sympathetic nerves, and
multiple lower cranial nerves. The cervical segment termi-
nates as it enters the carotid canal in the petrous temporal
bone. Tortuosity of the cervical ICA is relatively common and
needs to be carefully considered when performing cerebral
angiography in an effort to avoid arterial injury during
catheterization.
C2 (Petrous) and C3 (Laceral)
The petrous segment begins after the ICA enters the carotid
canal. The carotid canal lies anterior to the jugular foramen.
Two branches originate from the petrous segment. The vidian
artery is the first branch and passes through the foramen
lacerum. It can anastomose with multiple branches of the ECA.
The caroticotympanic artery is the second and passes through
the stapes to supply the middle ear cavity. Both branches are
rarely identified during NA. The laceral segment begins where
the carotid canal ends and courses above the foremen lacerum.
The laceral segment ends at the petrolingual ligament.
C4 (Cavernous)
The cavernous segment begins at the superior margin of the
petrolingual ligament and consists of three segments, which
are the posterior genu, horizontal segment, and anterior
genu. The cavernous segment exits the cavernous sinus
through the dural ring. Two notable branches originate
from the cavernous segment. The meningohypophyseal ar-
tery originates more proximally from the posterior genu and
provides supply to the pituitary gland, tentorium, and clivus.
This branch can be seen as a posteromedially projecting
blush in the region of the pituitary. It can also be a potential
supply to dural arteriovenous fistulas. The inferolateral trunk
is the second notable branch and provides blood supply to
the third, fourth, and sixth cranial nerves. Tortuosity of the
cavernous segment can make intracranial catheterization for
the treatment of ischemic strokes, intracranial aneurysms,
and other cerebral pathologies challenging.
C5 (Clinoid) and C6 (Ophthalmic)
The clinoid segment is the shortest of all ICA segments and
begins at the dural ring just above the anterior genu of the
cavernous segment. It ends at the distal dural ring where
the ICA enters the subarachnoid space. The ophthalmic
segment begins at the distal dural ring and ends proximal
to the posterior communicating artery. The largest branch
from the ophthalmic segment is the ophthalmic artery,
which arises medially to the anterior clinoid process as
the ICA exits the cavernous sinus. In 90% of cases, the
ophthalmic artery is intradural. The ophthalmic artery
has ocular, orbital, and extraorbital branches. The ocular
branches are the ciliary arteries and central retinal artery,
Case et al. 169
which supplies the retina and choroid. Although the central
retinal artery is rarely visualized, a choroidal blush is
frequently seen as a crescent-shaped vascular blush during
the late arterial phase. The orbital branches are the lacrimal
and muscular branches, which supply the extraocular
muscles. Ophthalmic artery catheterization and chemoem-
bolization have been performed more regularly for retino-
blastoma treatment.9
The second branch of the ophthalmic segment is the
superior hypophyseal artery, which arises from the poster-
omedial aspect of the ICA. This branch supplies the anterior
pituitary lobe, stalk, optic nerve, and chiasm.
C7 (Communicating)
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The communicating segment starts just proximal to the
posterior communicating artery origin and ends at the ICA
bifurcation. The posterior communicating artery is the first
branch and arises from the posterior aspect of the intradural
ICA. The posterior communicating artery anastomoses with
the posterior cerebral artery (PCA). It courses above the
oculomotor nerve and has several small anterior thalamo-
perforating arteries that supply the medial thalamus and
walls of the third ventricle. A posterior communicating
artery infundibulum is not uncommon and can be seen up
to 17% of the time.10 In addition, fetal origin (posterior
communicating artery has the same diameter as the PCA)
of the PCA is relatively common.
The second branch of the communicating segment is the
anterior choroidal artery, which arises from the posterome-
dial aspect of the intradural ICA. The proximal (cisternal)
segment projects posteromedially below the optic tract and
superomedial to the temporal lobe uncus. The distal segment
begins at the choroidal fissure and follows the choroid
plexus. The anterior choroidal artery supplies many impor-
tant structures including the posterior limb of the internal
capsule, cerebral peduncle, optic tract, choroid plexus, and
medial temporal lobe.
Persistent Carotid–Vertebrobasilar Anastomosis
Occasionally the primitive carotid–vertebrobasilar anasto-
moses persist and are identified during adulthood. These
primitive anastomotic connections provide temporary sup-
ply from the ICA to the longitudinal neural artery, which is
the future vertebrobasilar system. ►Table 1 details the four
types of carotid–vertebrobasilar anastomoses: the persistent
trigeminal, otic, hypoglossal, and proatlantal.
Anterior Cerebral Artery
The anterior cerebral artery (ACA) is the smallest terminal
branch of the ICA. The A1 segment, also called the precom-
municating segment, continues to the junction with the
anterior communicating artery. The A2 segment extends
vertically from the anterior communicating artery to the
genu of the corpus callosum. Multiple small medial lentic-
ulostriate arteries arise typically from the A1 segment, as do
additional perforating branches to the corpus callosum genu,
fornix, and septum pellucidum from the A2. The largest
penetrating branch from these segments is the recurrent
Seminars in Interventional Radiology Vol. 37 No. 2/2020
170 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
Table 1 Persistent carotid–vertebrobasilar anastamoses10
Persistent Most common type with an incidence
trigeminal of 0.5–0.7%
artery Originates from posterior wall of
cavernous ICA and joins the distal third
of the basilar artery
Persistent Extremely rare, only case reports,
otic artery debatably may not actually exist
First to regress
Should arise in the petrous segment ICA
Persistent Second most common with an incidence
hypoglossal of 0.027–0.29%
artery Originates from posterior wall of cervical
ICA between C1 and C3 levels and
courses through the hypoglossal canal
to form the vertebrobasilar artery
Persistent Originates from the common carotid
proatlantal artery bifurcation, ICA (type I), or ECA
artery (type 2) at the C2–4 levels
Joins the vertebral artery at the
suboccipital region and traverses the
foramen magnum
Abbreviations: ECA, external carotid artery; ICA, internal carotid artery.
artery of Heubner, which can originate from the A1 segment,
A2 segment, or anterior communicating artery.
The first cortical branch originating from the A2 segment
is the orbitofrontal artery, which supplies the inferior frontal
lobe. The second is the frontopolar artery, which extends to
and supplies the frontal pole. The A2 segment terminates
near the corpus callosum genu. It typically bifurcates into the
pericallosal artery and callosomarginal artery branches.
These arteries along with their branches are classified as
A3 segment branches, which then continue to the more distal
A4 segment branches. Leptomeningeal collaterals from distal
ACA branches to the MCA territory are critical in preserving
ischemic penumbra before definitive treatment can be per-
formed with ischemic stroke mechanical thrombectomy.
An important anomalous variant is the azygous ACA. This
occurs when the embryonic median artery of the corpus
callosum persists. A single ACA arises that supplies both ACA
territories. This has been reported with a 0.2 to 4% preva-
lence.11 A more common hypoplastic and contralateral dom-
inant ACA A1 segment can be mistaken for this anomaly.
Middle Cerebral Artery
The MCA is the largest terminal branch of the ICA with
roughly twice the diameter of the ACA. The first segment
is the M1. It has both a pre- and postbifurcation segment
prior to turning posterosuperiorly into the sylvian fissure
and becoming the M2 segment. The anterior temporal artery
typically originates from the M1 segment proximal to the
bifurcation and passes directly anteriorly and inferiorly over
the temporal lobe. In addition, the lenticulostriate arteries
arise from the M1 segment to supply the basal ganglia and
other deep structures of the brain including the caudate and
internal capsule.
Seminars in Interventional Radiology Vol. 37 No. 2/2020
Case et al.
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Fig. 5 Anteroposterior projection digital subtraction angiography of
the left internal carotid artery. A1, ACA A1 segment; A2, ACA A2
segment; C1, cervical ICA; C2, petrous ICA; C4, cavernous ICA; C7,
communicating ICA; CA1, contralateral ACA A1 segment supplied via
flash filling across the anterior communicating artery(arrow head);
M1, MCA M1 segment; M2, MCA M2 segment; M3, MCA M3 segment;
M4, MCA M4 segment; single arrow, MCA superior division; double
arrows, MCA inferior division; larger arrow, fetal PCA; curved arrow,
anterior temporal artery.
The M1 bifurcates and typically after the origin of the
anterior temporal artery, there are two major divisions
frequently referred to as the superior and inferior divisions.
The MCA continues as the M2 (insular) segment, which
includes multiple branch points near the anterior part of
the insula. The M2 segment then continues as six to eight
major branches that project over the insula while continuing
to the circular sulcus. The MCA continues at the top of the
circular sulcus as the M3 (opercular) segment and ends at the
surface of the lateral cerebral fissure. The M4 (cortical)
segment begins at the surface of the sylvian fissure and
continues as distal branches supplying the cortical surface of
the cerebral hemisphere (►Figs 5 and 6).
Vertebrobasilar System
The vertebral arteries typically originate from the subclavian
artery, although variants occur and are discussed previously in
section “Neurovascular Anatomy.” The V1 (extraosseous) seg-
ment is the first segment as it courses posterosuperiorly and
terminates as it enters the transverse foramen at the C6 level.
The V2 segment (foraminal) ascends and traverses the C3–6
transverse foramen and then passes through the C2 transverse
foramen laterally before projecting superiorly through the C1
transverse foramen. The vertebral artery continues as the V3
segment in a posteromedial direction around the atlantoocci-
pital articulation. The V3 segment then turns anteriorly and
upward toward the dura as it enters the foramen magnum. The
vertebral artery continues as the intradural V4 segment and at
the pontomedullary junction, the two vertebral arteries con-
verge to form the basilar artery.
 Neuroangiography: Review of Anatomy, Management, Technique, and Tips Case et al. 171

to the basilar artery bifurcation and can exist as a single,

duplicate, or triplet branch. The SCA courses below the
oculomotor cranial nerve and projects around the cerebral
peduncle to form two major distal branches, which supply
the superior and lateral cerebellar hemisphere, superior
cerebellar peduncle, dentate nucleus, and cerebellar vermis.

Posterior Cerebral Artery

The PCA originates from the basilar artery anterior to the
midbrain typically in the interpeduncular cistern. The P1
segment courses through the interpeduncular cistern and
continues to its anastomosis with the posterior communicating
artery. The P2 (ambient) segment continues from the posterior
communicating artery to the posterior aspect of the midbrain

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as it courses around the cerebral peduncle. As the proximal PCA
courses around the midbrain, it supplies many perforating
branches to the thalamus, brainstem, and ventricular system
Fig. 6 Lateral digital subtraction angiography of the left internal
including the thalamoperforating branches, thalamogeniculate
carotid artery. A2, ACA A2 segment; A3, ACA A3 segment; A4, ACA A4
segment; C1, cervical ICA; C2, petrous ICA; C3, laceral ICA; C4, branches, peduncular perforating branches, and medial/lateral
cavernous ICA; ID, MCA inferior division; OA, ophthalmic artery; M3, posterior choroidal artery branches. In addition, the proximal
MCA M3 segment; M4, MCA M4 segment; black arrow head, posterior and distal P2 segment gives rise to both anterior and posterior
communicating artery; small black arrow, anterior choroidal artery; temporal artery branches, which anastomose with the anterior
white arrow, MCA bifurcation.
temporal artery from the MCA.
The PCA continues as the P3 segment, which extends from
The vertebral artery has both muscular branches, which the quadrigeminal plate to the calcarine fissure. The P3 segment
supply deep cervical musculature and spinal branches. In projects medially within the perimesencephalic cistern before
addition, anterior meningeal and posterior meningeal arter- terminating as the distal P4 segment branches. The medial
ies can originate from the V2 segment. The anterior spinal division of the P4 segment branches divides into the parietooc-
artery is an important smaller branch, which can be seen cipital and calcarine arteries. The lateral division of the P4
during NA in certain patients. It typically arises from the segment continues as the lateral occipital artery (►Fig. 7).
distal vertebral artery and can project inferomedially to unite
with the contralateral anterior spinal artery.
The largest vertebral artery branch is the posterior inferior
cerebellar artery (PICA). It typically arises from the intradural
vertebral artery but can have an extradural origin as well
occurring 5 to 18% of the time.12 The PICA is divided into four
segments, which are the anterior medullary segment, lateral
medullary segment, posterior medullary (tonsillar loop) seg-
ment, and supratonsillar (cortical) segment. The anterior and
lateral medullary segments provide supply to the medulla and
the more distal segment branches provide supply to the
posterior inferior cerebellum. Of note, the vertebral artery
can terminate in PICA approximately 0.2% of the time.12 In
addition, there can be a shared anterior inferior cerebellar
artery (AICA)-PICA trunk which is common variant.
The basilar artery is the merging and continuation of the
two vertebral arteries near the pontomedullary junction. It
continues superiorly and terminates typically as the two PCA
branches in the interpeduncular cistern. Numerous perfo-
rating branches originate from the basilar artery during its
course in the prepontine cistern. These branches include
median, paramedian, and lateral pontine perforators. Fig. 7 Anteroposterior digital subtraction angiography of the left
The AICA is the smallest of the three main cerebellar vertebral artery with reflux into the contralateral vertebral artery. BA,
arteries and originates from the proximal basilar artery. It basilar artery; CPT, contralateral posterior temporal artery; CVA,
contralateral vertebral artery; P1, PCA P1 segment; P2, PCA P2
can arise as a single, duplicate, or triplet branch. It supplies
segment; P3, PCA P3 segment; P4, PCA P4 segment; V2, vertebral
the anterior and lateral portion of the cerebellum and artery V2 segment; V3, vertebral artery V3 segment; V4, vertebral
typically provides supply to the labyrinth (internal auditory) artery V4 segment; arrow, contralateral PICA; arrow tip, left
artery.13 The superior cerebellar artery (SCA) arises just prior AICA/PICA complex; small arrow, left SCA.

Seminars in Interventional Radiology Vol. 37 No. 2/2020

172 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
Clinical Evaluation and Preprocedural
Management
Preprocedural evaluation, history, and physical examination
are critical prior to NA. Communication with the referring
physician is highly recommended prior to the procedure to
fully understand the underlying problem that needs to be
answered. The physician should perform a focused history and
neurologic exam documenting known neurologic deficits in
clinic or prior to the procedure. Detailed informed consent
should be discussed including specific risks of the procedure
(pain, infection, bleeding, acute renal insufficiency, systemic/
cervical/intracranial dissection, stroke, and groin hematoma).
Relative contraindications to NA include renal insufficiency,
coagulopathy, and contrast allergy. At our institution, we use
32 mg of methylprednisolone 12 hours before and 2 hours
before the procedure. If chronic or acute renal insufficiency
is present, we prehydrate with normal saline and use mini-
mally needed amounts of iodinated contrast.14
The neurologic exam should include mental status,
orientation, memory, language, cranial nerve evaluation,
sensation, motor, and gait testing. An adverse event in the
course of NA is rare; however, calls to evaluate the patient
postprocedure are frequent. Having a detailed and docu-
mented neurologic exam will provide reassurance if known
neurologic deficits exist. Serologic evaluation before the
procedure should include a complete blood cell count, serum
creatinine, and protime/international normalized ratio, as
dictated by the patient’s clinical situation. Anticoagulants
should be held when possible. At the authors’ institution, oral
anticoagulants are held and low-molecular-weight heparin is
given in substitute 4 days before and 2 days after the
procedure. Patients should eat nothing by mouth 6 hours
prior to the procedure and the morning insulin dose should
be given in half its full dose.
Diagnostic Neuroangiography Technique
Sedation and Positioning
At the authors’ institution, a combination of fentanyl and
midazolam is used in minimum doses needed to achieve
comfortable conscious sedation. Presedation evaluation does
include American Society of Anesthesia and airway assess-
ment. The patient is positioned on the table supine with a
headrest. To reduce motion artifact, the patient is instructed
to hold still and in certain cases to hold their breath.
Uncooperative patients may require higher doses of sedation
and a head strap to reduce motion artifact.
Access
At the authors’ institution, the common femoral artery (CFA)
is the typical access site for NA. However, transradial and
transbrachial accesses are occasionally used and have been
more frequently utilized in patients with tortuous aortic arch
anatomy.15 Under ultrasound guidance, the periarterial tis-
sue is infiltrated with lidocaine and the right CFA is accessed
with a micropuncture set. After introduction of the micro-
puncture set dilator, a J-wire (curved atraumatic tip) is
Seminars in Interventional Radiology Vol. 37 No. 2/2020
Case et al.
inserted and a 5-Fr sheath (Cordis, Hialeah, Fl) is inserted.
This is connected to a continuous heparinized saline
infusion.
Catheterization, C-Arm Positioning, and Power
Injector Settings
Many catheters and wires are available for NA. Important
criteria to consider prior to selecting a catheter are vascular
anatomy, patient’s age, and preexisting arterial disease. At
the authors’ institution, we occasionally obtain cervical arch
aortography when there is a known aortic arch disease or an
anomaly that warrants evaluation. In addition, cervical arch
aortography may be needed when catheterization is chal-
lenging. At the authors’ institution, a 5-Fr pigtail catheter
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(Cook Medical, Bloomington, IN) is used. The pigtail catheter
is a multiside-holed flush 90-cm catheter, which provides
enough length to reach the ascending aorta proximal to the
brachiocephalic artery. Once the pigtail catheter is appropri-
ately positioned, the catheter is connected to the power
injector while carefully inspecting the catheter system for
any air. Cervical aortography is performed with a standard
injection rate of 20 mL/s for a total of 40 mL. A 30-degree
lateral anterior oblique projection helps elongate the trans-
verse aorta and separate the origins of the great vessels
(►Fig. 1). If aortography is performed at the beginning of the
procedure, the pigtail catheter is subsequently withdrawn
into the descending aorta and exchanged for the NA catheter
over a J wire.
As mentioned earlier, aortic arch anatomy along with the
patient’s age will help in identifying the appropriate catheter
for NA. Type I and Type II aortic arch configurations are more
easily catheterized with angled catheters, while reverse
curve catheters are frequently needed for Type III aortic
arches. For young patients with Type I and Type II arch
anatomy, a 5-Fr glide catheter (Terumo Interventional Sys-
tems, Somerset, NJ) is typically used at the authors’ institu-
tion. The authors believe the catheter tip is less traumatic
and poses a lower risk of vascular injury when selecting
vessels as opposed to catheters with more acutely angled
tips. If the great vessel origin has too sharp of a curve, then a
5-Fr Davis catheter (Cook Medical) is used. For challenging
Type III aortic arch configurations, a 5-Fr Simmons-2 catheter
(Cook Medical) should be considered for great vessel selec-
tion. In instances where a Type II or III arch occurs in
conjunction with a tortuous bovine arch configuration, a 5-
Fr VTK catheter (Cook Medical) is extremely helpful. In
certain instances, a 5-Fr H1 catheter (Cook Medical) is
necessary especially for tortuous brachiocephalic to subcla-
vian artery navigation when trying to select the right verte-
bral artery.
At times catheterization of the distal cervical arteries may
not be possible via the CFA route. If the distal portion of the
cervical artery of interest is impossible to select due to
tortuosity, a radial approach or in rare cases (i.e., ischemic
stroke) direct carotid puncture may be necessary. An addi-
tional alternative during NA is to utilize one of the afore-
mentioned catheters and position it in the proximal portion
of the great vessel. A Progreat 2.8-Fr microcatheter (Terumo
 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
Interventional Systems) can be inserted with a 0.014-in
Synchro 2 microwire (Stryker, Kalamazoo, MI) through the
NA catheter to select the more distal portion of the cervical
artery of interest. The Progreat microcatheter can then be
directly connected to the power injector for a power injec-
tion as it is rated to 1,000 psi.
Once the NA is selected, the catheter is advanced over a J
wire (if not already positioned) into the descending aorta at
the level of the umbilicus. The NA catheter is meticulously
flushed with heparinized saline, which helps minimize the
risk of air and thrombotic emboli propagation into the
cerebral vasculature. Next, the catheter is connected to a
Tuohy adapter, which is then connected to a three-way
stopcock. The three-way stopcock and catheter are con-
nected to a continuous heparin infusion (6,000 units of
heparin per 1 L of NS) which is run at a drip rate of
approximately 1 to 2 per second throughout the duration
of the procedure. Attached to the other end of the three-way
stopcock is a duct tube, which is connected to the power
injector via another three-way stopcock. A contrast syringe
or heparinized saline syringe can be connected to the other
side port of the three-way stopcock to allow for test injec-
tions during the procedure and to complete the system
flushing prior to NA. After the catheter system has been
inspected and all air has been removed, NA is performed.
Under fluoroscopic guidance, a 0.035-in glide wire (Ter-
umo Interventional Systems) is advanced through the NA
catheter positioned in the descending aorta. The glide wire is
advanced over the aortic arch and into the ascending aorta.
The NA catheter is advanced over the glide wire and posi-
tioned distal to the origin of the target vessel. The catheter is
pulled back gently into the origin of the great vessel. At this
point, the wire is readvanced carefully paying special atten-
tion to anatomic landmarks and utilizing tactile feedback to
select the target vessel of interest. In certain instances due to
atherosclerotic or tortuous cervical anatomy, a 0.035-in
tapered glide wire (Terumo Interventional Systems) may
be necessary. Once the wire is positioned in the desired
location of the target vessel, the NA catheter is advanced over
the wire. The wire is slowly removed to prevent any inadver-
tent vacuum effect if the NA catheter is obturating a small
artery or if the tip is against the wall of the target vessel.
If a Simmons-2 or VTK catheter is required, the catheter
must be formed prior to advancement over the aortic arch.
The Simmons-2 can be formed by selecting the contralateral
common iliac artery, positioning a stiff wire up to its primary
angle, and gently pushing the Simmons-2 catheter up the
descending aorta. This will form the catheter into its reverse
curve shape. A similar technique can be performed in the left
subclavian artery. The VTK catheter can typically be
advanced over the aortic arch without a wire in it. Once
advanced over the arch the VTK typically forms. Next,
the primary angle of the catheter is retracted into the target
artery. The glide wire can be advanced thereafter; however,
rapid advancement of a stiff glide wire can cause the catheter
to prolapse into the proximal aortic arch.
In addition to difficult aortic arch anatomy, extreme
tortuosity including 360-degree turns of the cervical vascu-
Case et al. 173
lature can make NA challenging. In these cases, a tapered
glide wire or 0.035-in stiff glide wire (Terumo Interventional
Systems) can be very useful. Once the wire is a certain
distance past the region of tortuosity, the artery typically
straightens allowing the catheter to be advanced to the target
location. In some cases, this may predispose the artery to
occlusion, vasospasm, or dissection; therefore, special atten-
tion during the test injection following catheterization is
extremely important. If this occurs, the catheter should be
removed. Vasospasm occasionally resolves on its own. In
certain cases at the authors’ institution, intra-arterial verap-
amil can be administered for catheter-induced vasospasm in
small doses of 5 to 10 mg while carefully monitoring the
patient’s blood pressure and heart rate for deleterious
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hemodynamic changes. At the discretion of the intervention-
alist, NA may need to be aborted if a vascular injury or
obturation of the artery occurs.
At the authors’ institution, we prefer direct catheteriza-
tion of the ICA and ECA (if needed) for many of the intracra-
nial diseases mentioned earlier as opposed to only common
carotid artery injections. If the patient is older or has a
history of cervical artery atheromatous disease, a hand
injection roadmap can be performed in the common
carotid artery prior to catheterizing the ICA or ECA. If a
hand injection is performed, the contrast syringe should be
held with the plunger facing up after removing all air bubbles
from the syringe. If a common carotid artery will suffice for
diagnostic evaluation, a power injection of 6 mL/s for a total
of 12 mL is performed. For common carotid arteriography,
we use standard anteroposterior (AP) and lateral projections.
A common landmark when positioning for a standard AP
view is to align the petrous ridges in the midorbit region.
If selection of the ICA or ECA is needed, the wire is gently
advanced into the artery of interest and the catheter is
subsequently advanced over the wire using the same tech-
nique described earlier. Special attention should be noted
during selection of the ECA to avoid vasospasm. Intra-arterial
verapamil can be administered in small doses for catheter-
induced spasm if needed. A hand injection using a contrast
syringe is performed to ensure no vascular injury, vaso-
spasm, or obturation of the artery has occurred. In addition,
this helps the interventionalist determine optimal injection
rates based on the vessel caliber. For ICA injections, the
authors typically use an injection rate of 4.5 mL/s for a total
of 9 mL. For ECA injections, the authors use an injection rate
of 2 mL/s for a total of 8 mL. For ICA and ECA injections,
standard AP and standard lateral projections are utilized.
Multiple oblique views are obtained to evaluate the ICA
summit, MCA, and ACA branches further.
The left vertebral artery is preferred over the right verte-
bral artery when only one vertebral artery is needed for NA
because it is typically the dominant vertebral artery. If right
vertebral artery pathology is not suspected or if adequate
reflux supplies the right PICA from the left vertebral artery
injection, left vertebral injection will suffice. Catheterization
of the vertebral artery can be especially dangerous because
the vertebral artery is prone to dissection and vasospasm.
Delayed washout after contrast injection raises the concern
Seminars in Interventional Radiology Vol. 37 No. 2/2020
174 Neuroangiography: Review of Anatomy, Management, Technique, and Tips
for obturation of the artery, vasospasm, dissection, or possi-
ble thromboembolic phenomenon from catheterization.
Once again, it is prudent to slowly remove the catheter to
identify the problem and determine if further action needs to
be taken (i.e., verapamil infusion, thrombectomy). For the
vertebral artery injection, the authors typically use an injec-
tion rate of 4 mL/s for a total of 8 mL. An AP Townes view
(align the petrous ridges with the top of the orbit) is utilized
along with standard lateral projection. Multiple oblique
views are obtained once again to evaluate the PICA, basilar
artery branches, and PCA branches.
Postprocedural Management and
Complications
After NA is complete, closure can be obtained with either
manual compression or percutaneous closure. At our insti-
tution, we typically hold pressure for approximately
20 minutes with a 5-Fr system. The authors use a ProGlide
(Abbott, Chicago, IL) if the CFA meets closure criteria (suffi-
cient diameter, puncture above the CFA bifurcation, no or
minimal atheromatous disease). We routinely examine the
patient after NA to ensure no neurologic changes have
occurred. If a neurologic change occurs, CT or MRI may be
warranted. Standard institution neurologic and groin checks
are performed while the patient recovers in the postproce-
dure area prior to discharge.
Complications can occur during NA. Older patient, increased
procedure time, number of catheter exchanges, and amount of
contrast are associated with increased rates of complications.16
Stroke is the main neurologic complication that can occur with
reported permanent neurologic deficit rates of 0 to 2.5%.16
Other complications include renal failure, systemic arterial
occlusions, dissections, and groin hematomas.
Conclusion
NA is an essential diagnostic tool to evaluate certain neuro-
vascular disease. An understanding of neurovascular anato-
my, NA technique, and image interpretation is paramount to
performing safe and successful evaluation. Periprocedural
care is of fundamental importance as well to ensure patient
safety and appropriate complication management if needed.
Conflict of Interest
None declared.
Seminars in Interventional Radiology Vol. 37 No. 2/2020
Case et al.
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