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Cerebral angiography is a form of
angiography Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is perform ...
which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as
arteriovenous malformation Arteriovenous malformation is an abnormal connection between arteries and veins, bypassing the capillary system. This vascular anomaly is widely known because of its occurrence in the central nervous system (usually cerebral AVM), but can appe ...
s and
aneurysm An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus ( ...
s. It was pioneered in 1927 by the Portuguese neurologist Egas Moniz at the
University of Lisbon The University of Lisbon (ULisboa; pt, Universidade de Lisboa, ) is a public research university in Lisbon, and the largest university in Portugal. It was founded in 2013, from the merger of two previous public universities located in Lisbon, th ...
, who also helped develop thorotrast for use in the procedure. Typically a
catheter In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cat ...
is inserted into a large artery (such as the
femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the fe ...
) and threaded through the circulatory system to the
carotid artery Carotid artery may refer to: * Common carotid artery, often "carotids" or "carotid", an artery on each side of the neck which divides into the external carotid artery and internal carotid artery * External carotid artery, an artery on each side of ...
, where a
contrast agent A contrast agent (or contrast medium) is a substance used to increase the contrast of structures or fluids within the body in medical imaging. Contrast agents absorb or alter external electromagnetism or ultrasound, which is different from radioph ...
is injected. A series of
radiograph Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
s are taken as the contrast agent spreads through the brain's arterial system, then a second series as it reaches the venous system. For some applications cerebral angiography may yield better images than less invasive methods such as
computed tomography angiography Computed tomography angiography (also called CT angiography or CTA) is a computed tomography technique used for angiography—the visualization of arteries and veins—throughout the human body. Using contrast injected into the blood vessels, im ...
and
magnetic resonance angiography Magnetic resonance angiography (MRA) is a group of techniques based on magnetic resonance imaging (MRI) to image blood vessels. Magnetic resonance angiography is used to generate images of arteries (and less commonly veins) in order to evaluate t ...
. In addition, cerebral angiography allows certain treatments to be performed immediately, based on its findings. In recent decades, cerebral angiography has so assumed a therapeutic connotation thanks to the elaboration of endovascular therapeutic techniques. Embolization (a minimally invasive surgical technique) over time has played an increasingly significant role in the multimodal treatment of cerebral MAVs, facilitating subsequent microsurgical or radiosurgical treatment. Another type of treatment possible by angiography (if the images reveal an
aneurysm An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus ( ...
) is the introduction of metal coils through the catheter already in place and maneuvered to the site of aneurysm; over time these coils encourage formation of
connective tissue Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...
at the site, strengthening the vessel walls. In some jurisdictions, cerebral angiography is required to confirm
brain death Brain death is the permanent, irreversible, and complete loss of brain function which may include cessation of involuntary activity necessary to sustain life. It differs from persistent vegetative state, in which the person is alive and some au ...
. Prior to the advent of modern neuroimaging techniques such as
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
and CT in the mid-1970s, cerebral angiographies were frequently employed as a tool to infer the existence and location of certain kinds of lesions and hematomas by looking for secondary vascular displacement caused by the
mass effect ''Mass Effect'' is a military science fiction media franchise created by Casey Hudson, Drew Karpyshyn and Preston Watamaniuk. The franchise depicts a distant future where humanity and several alien civilizations have colonized the known unive ...
related to these medical conditions. This use of angiography as an ''indirect'' assessment tool is nowadays obsolete as modern non-invasive diagnostic methods are available to image many kinds of primary intracranial abnormalities directly. It is still widely used however for evaluating various types of vascular pathologies within the skull.


Uses

Cerebral angiography is used for diagnosis but may be followed by treatment procedures in the same setting. Cerebral angiography is used to image various intracranial (within the head) or extracranial (outside the head) diseases. Intracranial diseases are: non-traumatic subarachnoid haemorrhage, non-traumatic intracerebral haemorrhage,
intracranial aneurysm An intracranial aneurysm, also known as a brain aneurysm, is a cerebrovascular disorder in which weakness in the wall of a cerebral artery or vein causes a localized dilation or ballooning of the blood vessel. Aneurysms in the posterior circu ...
,
stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop funct ...
, cerebral vasospasm,
cerebral arteriovenous malformation A cerebral arteriovenous malformation (cerebral AVM, CAVM, cAVM) is an abnormal connection between the arteries and veins in the brain—specifically, an arteriovenous malformation in the cerebrum. Signs and symptoms The most frequently observed ...
(for Seltzer-Martin grading and plan for intervention), dural arteriovenous fistula, embolisation of brain tumours such as
meningioma Meningioma, also known as meningeal tumor, is typically a slow-growing tumor that forms from the meninges, the membranous layers surrounding the brain and spinal cord. Symptoms depend on the location and occur as a result of the tumor pressing o ...
, cavernous sinus haemangioma, for Wada test, and to obtain haemodynamics of cerebral blood flow such as cross flow, circulation time, and collateral flow. Extracranial diseases are: Subclavian steal syndrome, rupture of the carotid artery,
carotid artery stenosis Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis. Signs and symptoms The common carotid artery is the large artery whose pulse can be felt on both sides of the neck unde ...
, cervical spine trauma,
epistaxis A nosebleed, also known as epistaxis, is bleeding from the nose. Blood can flow down into the stomach, and cause nausea and vomiting. In more severe cases, blood may come out of both nostrils. Rarely, bleeding may be so significant that low bl ...
(nose bleeding) and plan for embolisation of juvenile nasopharyngeal angiofibroma before operation. Although
computed tomography angiography Computed tomography angiography (also called CT angiography or CTA) is a computed tomography technique used for angiography—the visualization of arteries and veins—throughout the human body. Using contrast injected into the blood vessels, im ...
(CTA) and
Magnetic resonance angiography Magnetic resonance angiography (MRA) is a group of techniques based on magnetic resonance imaging (MRI) to image blood vessels. Magnetic resonance angiography is used to generate images of arteries (and less commonly veins) in order to evaluate t ...
(MRA) has been used widely in evaluation of intracranial disease, cerebral angiography provides higher resolution on the conditions of blood vessel lumens and vasculature. Cerebral angiography is also the standard of detecting intracranial aneurysm and evaluating the feasibility of
endovascular coiling Endovascular coiling is an endovascular treatment for intracranial aneurysms and bleeding throughout the body. The procedure reduces blood circulation to the aneurysm through the use of microsurgical detachable platinum wires, with the clinician i ...
. Certain conditions such as contrast allergy, renal insufficiency, and coagulation disorders are contraindicated in this procedure.


Technique

Before the procedure, focused history and neurological examination is performed, available imaging, and blood parameters are reviewed. When reviewing imaging, arch anatomy and variants are evaluated to select suitable catheters to assess the vessels.
Complete blood count A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and p ...
is reviewed to ensure adequate amount of
haemoglobin Hemoglobin (haemoglobin BrE) (from the Greek word αἷμα, ''haîma'' 'blood' + Latin ''globus'' 'ball, sphere' + ''-in'') (), abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein present in red blood cells (erythrocyt ...
in subject's body, and to rule out the presence of
sepsis Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
. Serum
creatinine Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass). Biological relevance Serum creatinine (a blood measurement) is an impor ...
is assessed to rule out renal dysfunction. Meanwhile,
prothrombin time The prothrombin time (PT) – along with its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) – is an assay for evaluating the ''extrinsic'' pathway and common pathway of coagulation. This blood test is als ...
is assessed to rule out
coagulopathy Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis), which may occur sp ...
. Informed consent regarding the risks of the procedure is taken. Anticoagulants are withheld if possible. Fasting is required 6 hours before the procedure and insulin requirement is reduced by half for those diabetics who are fasting. Bilateral
groin In human anatomy, the groin (the adjective is ''inguinal'', as in inguinal canal) is the junctional area (also known as the inguinal region) between the abdomen and the thigh on either side of the pubic bone. This is also known as the medial com ...
s (for
femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the fe ...
access) and left arm/forearm (for
brachial artery The brachial artery is the major blood vessel of the (upper) arm. It is the continuation of the axillary artery beyond the lower margin of teres major muscle. It continues down the ventral surface of the arm until it reaches the cubital foss ...
/
radial artery In human anatomy, the radial artery is the main artery of the lateral aspect of the forearm. Structure The radial artery arises from the bifurcation of the brachial artery in the antecubital fossa. It runs distally on the anterior part of the ...
access) are prepared. Neurological status of the patient before
sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
or
anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...
is recorded. Sedation drug such as
intravenous Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
midazolam Midazolam, sold under the brand name Versed among others, is a benzodiazepine medication used for anesthesia and procedural sedation, and to treat severe agitation. It works by inducing sleepiness, decreasing anxiety, and causing a loss of ...
and painkiller such as
fentanyl Fentanyl, also spelled fentanil, is a very potent synthetic opioid used as a pain medication. Together with other drugs, fentanyl is used for anesthesia. It is also used illicitly as a recreational drug, sometimes mixed with heroin, cocaine, ...
can be used if the subject is restless or painful. The subject is then lie down on supine position with arm at the sides. Uncooperative subjects may have their forehead tapped to reduce motion. The subject is advised to stay as still as possible especially when
fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and function ...
images are taken. The subject is also advised to avoid swallowing when images of neck are taken. These measures are taken to reduce motion artifact in the images. Right common
femoral artery The femoral artery is a large artery in the thigh and the main arterial supply to the thigh and leg. The femoral artery gives off the deep femoral artery or profunda femoris artery and descends along the anteromedial part of the thigh in the fe ...
(RFA) is the preferred site of access. If RFA access is not optimal, then brachial artery access is chosen. Either a micropuncture system or an 18G access needle can be used with or without ultrasound guidance. There are four types of catheters that can be used: angled vertebral catheter for usual cases, Judkins right coronary catheter (Terumo) for tourtous vessels, Simmons's catheter and Mani's head hunter catheter (Terumo) for extremely tortous vessels. A 5Fr sheath is also placed within and flushed with heparinised saline to prevent clotting around the sheath. In terms of guidewire, Terumo hydrophilic Glidewire 0.035 inches can be used. To prevent
embolism An embolism is the lodging of an embolus, a blockage-causing piece of material, inside a blood vessel. The embolus may be a blood clot (thrombus), a fat globule (fat embolism), a bubble of air or other gas (gas embolism), amniotic fluid (amni ...
(either due to blood clot or
air embolism An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion ...
, "double flush" and "wet connect" techniques are used. In "double flush" technique, a saline syringe is used to aspirate blood from the catheter. Then, a second heparinised saline syringe is used to flush the catheter. "Wet connect" is the technique that connects syringe to a sheath without air bubbles within.
Digital subtraction angiography Digital subtraction angiography (DSA) is a fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment. Images are produced using contrast medium by subtracting a "pre-contra ...
is the main technique of imaging the cerebral blood vessels. Catheter should be advanced over the guidewire. Rotating the catheter during advancement is also helpful. Roadmap (superimposing previous image on live fluoroscopic image) is used to advance catheters or guidewires before any vessel bifurcation can help to prevent vessel
dissection Dissection (from Latin ' "to cut to pieces"; also called anatomization) is the dismembering of the body of a deceased animal or plant to study its anatomical structure. Autopsy is used in pathology and forensic medicine to determine the cause o ...
. After the catheter is in position, guidewire is removed slowly with heparinised saline dripping into the catheter at the same time to prevent air embolism. Prior to contrast injection, backflow of the catheter should be established to ensure there is no wedging, dissection, or intracatheter clotting. During the catheterisation of
vertebral artery The vertebral arteries are major arteries of the neck. Typically, the vertebral arteries originate from the subclavian arteries. Each vessel courses superiorly along each side of the neck, merging within the skull to form the single, midline ...
, extra care should be taken to prevent vessel dissection or vasospasm. Delayed or incomplete contrast washout may indicate vasospasm or dissection.


Radiographic views

Cervical arch angiogram is taken if there is any suspicion of
aortic arch The aortic arch, arch of the aorta, or transverse aortic arch () is the part of the aorta between the ascending and descending aorta. The arch travels backward, so that it ultimately runs to the left of the trachea. Structure The aorta begins a ...
narrowing, or any anatomical variants such as bovine arch ( brachiocephalic trunk shares a common origin with left
common carotid artery In anatomy, the left and right common carotid arteries (carotids) (Entry "carotid"
in
cannula A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
tion of the main branches of the aortic arch. The catheter of choice to cannulate this area is pigtail catheter with multiple side holes. Contrast injection rate of 20 to 25ml/sec is given with total volume of 40 to 50 ml of contrast. The frame rate of fluoroscopy is 4 to 6 frames per second. The image is taken in with the x-ray tube in left anterior oblique position. To image the vessels of the neck such as common carotid, internal and external carotid arteries, AP, lateral, and 45 degrees bilateral oblique positions are taken. Contrast injection rate is 3 to 4 ml/sec with total volume of 7 to 9 ml. The frame rate of fluoroscopy is 3 to 4 frames/sec. To image the anterior cerebral circulation such as internal and external carotid arteries and its branches, AP, Towne's and lateral views are taken. The petrous part of the
temporal bone The temporal bones are situated at the sides and base of the skull, and lateral to the temporal lobes of the cerebral cortex. The temporal bones are overlaid by the sides of the head known as the temples, and house the structures of the ears. T ...
should be superimposed at the mid or lower orbits when taking the AP/Towne's view. Contrast injection rate is 6 to 7 ml/sec with total volume of contrast at 10 ml. The frame rate of fluoroscopy is 2 to 4 frames/sec. Neck extension can help to navigate into tortous cerival part of the
internal carotid artery The internal carotid artery (Latin: arteria carotis interna) is an artery in the neck which supplies the anterior circulation of the brain. In human anatomy, the internal and external carotids arise from the common carotid arteries, where these ...
. At the level of carotid bifurcation, AP and oblique images are taken. At the cavernous (C4) and ophthalmic segments (C6) of the internal carotid artery, Caldwell and lateral views are taken. At the supraclinoid segment (C5-clinoid, C6-ophthalmic, and C7-bifurcation to
posterior communicating artery In human anatomy, the left and right posterior communicating arteries are arteries at the base of the brain that form part of the circle of Willis. Each posterior communicating artery connects the three cerebral arteries of the same side. Anteri ...
(PCOM) segments), AP view is used to access the terminal branches such as
anterior cerebral artery The anterior cerebral artery (ACA) is one of a pair of cerebral arteries that supplies oxygenated blood to most midline portions of the frontal lobes and superior medial parietal lobes of the brain. The two anterior cerebral arteries arise from ...
(ACA),
middle cerebral artery The middle cerebral artery (MCA) is one of the three major paired cerebral arteries that supply blood to the cerebrum. The MCA arises from the internal carotid artery and continues into the lateral sulcus where it then branches and projects to ...
(MCA) while oblique view (25 to 35 degrees) is used to access the ACA,
anterior communicating artery In human anatomy, the anterior communicating artery is a blood vessel of the brain that connects the left and right anterior cerebral arteries. Anatomy The anterior communicating artery connects the two anterior cerebral arteries across the com ...
(ACOM), and MCA bifurcations. Lateral view is useful to visualise the PCOM while submentovertical view is useful to project ACOM above the nasal cavity, thus making it easier to access the anatomy of ACOM. Transorbital oblique view is useful to access the MCA anatomy. The anatomy of external carotid artery is access via AP and lateral views. To image the posterior circulation, such as vertebral and basilar arteries, AP, Towne's view, lateral projections near the back of the head and upper part of the neck is taken. In this case, petrous bone should be projected at the bottom or below the orbits to visualise the
basilar artery The basilar artery () is one of the arteries that supplies the brain with oxygen-rich blood. The two vertebral arteries and the basilar artery are known as the vertebral basilar system, which supplies blood to the posterior part of the circle of W ...
and its branches in AP/Towne's view. The rate of injection is 3 to 5 ml/sec, for a total of 8ml. The fluoroscope will be catching images at a rate of 2 to 4 frames per second.
Posterior cerebral artery The posterior cerebral artery (PCA) is one of a pair of cerebral arteries that supply oxygenated blood to the occipital lobe, part of the back of the human brain. The two arteries originate from the distal end of the basilar artery, where it b ...
(PCA) can be seen in AP view. Any activation of primary collateral system (ACOM and PCOM arteries) or secondary collateral system (pial-pial and leptomeningeal-dural) in case of occlusion of internal carotid artery should also be documented. Leptomeningeal collaterals or pial collaterals are the small arterial connections that join the terminal branches of ACAs, MCAs, and PCAs on the surface of the brain.


Post-procedural care

Manual compression or percutaneous closure device can be used to stop the bleeding from common femoral artery. Groin
haematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is ...
should be monitored during
intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
(ICU) monitoring. The puncture should be immobilised (to prevent movement) for 24 hours post puncture. Neurological examination should be performed and new neurological deficit should be documented. Significant neurological changes should be evaluated with MRI scan or a repeat cerebral angiography to rule out acute stroke or vessel dissection. Painkiller should be administered if there is any puncture site pain.


Complications

The most common complication is groin haematoma which occurs in 4% of those affected. Neurologic complications such as
transient ischemic attack A transient ischemic attack (TIA), commonly known as a mini-stroke, is a minor stroke whose noticeable symptoms usually end in less than an hour. TIA causes the same symptoms associated with strokes, such as weakness or numbness on one side of ...
in 2.5% of the cases. There is also the risk of stroke with permanent neurological defect in 0.1% of the cases and may lead to death in 0.06%. Rarely, 0.3 to 1% of the cases experience cortical blindness from 3 minutes to 12 hours after the procedure. It is a condition where those affected experienced loss of vision with normal
pupillary light reflex The pupillary light reflex (PLR) or photopupillary reflex is a reflex that controls the diameter of the pupil, in response to the intensity (luminance) of light that falls on the retinal ganglion cells of the retina in the back of the eye, there ...
, and normal
extraocular muscles The extraocular muscles (extrinsic ocular muscles), are the seven extrinsic muscles of the human eye. Six of the extraocular muscles, the four recti muscles, and the superior and inferior oblique muscles, control movement of the eye and the ...
movement. The condition can sometimes be accompanied by headaches, mental state changes, and memory losses. Some risk factors of complications are if the subject is having subarachnoid haemorrhage, atherosclerotic cerebrovascular disease, frequent transient ischemic attacks, age more than 55 years, and poorly controlled diabetes. Besides, longer procedures, increased in number of catheter exchanges, and the use of larger size of catheters also increases the risk of complications.


History

Cerebral angiography was first described by Antonio Caetano de Abreu Freire, Portuguese physician and politician in 1927. He performed this procedure on six patients. Two developed
Horner's syndrome Horner's syndrome, also known as oculosympathetic paresis, is a combination of symptoms that arises when a group of nerves known as the sympathetic trunk is damaged. The signs and symptoms occur on the same side (ipsilateral) as it is a lesion ...
due to leaking of contrast material around the carotid artery, one developed temporary
aphasia Aphasia is an inability to comprehend or formulate language because of damage to specific brain regions. The major causes are stroke and head trauma; prevalence is hard to determine but aphasia due to stroke is estimated to be 0.1–0.4% in th ...
, and another died due to thromboembolism to the anterior circulation of the brain. Prior to the 1970s the typical technique involved a needle puncture directly into the carotid artery, as depicted in the 1973 horror film ''
The Exorcist ''The Exorcist'' is a 1973 American supernatural horror film directed by William Friedkin and written for the screen by William Peter Blatty, based on his 1971 The Exorcist (novel), novel of the same name. It stars Ellen Burstyn, Max von Sydow, ...
'', which was replaced by the current method of threading a catheter from a distant artery due to common complications caused by trauma to the artery at the puncture site in the neck (particularly hematomas of the neck, with possible compromission of the airway).


References


External links


Cerebral Angiography
{{DEFAULTSORT:Cerebral Angiography Projectional radiography Neurosurgery Neuroimaging Portuguese inventions