CEREBRAL ANGIOGRAPHY

Posterior Cerebral Circulation

ROSALIE T. DE GUZMAN
CHRYSTALY JOY CAFIRMA
RT32A
INTERVENTIONAL RADIOLOGY
CEREBRAL ANGIOGRAPHY

Cerebral angiography is a procedure that uses a

special dye (contrast material) and x-rays to see how
blood flows through the brain.

ALTERNATIVE NAME

Cerebral angiogram
Cerebral arteriogram
Digital Subtraction Angiography [DSA]
INDICATION

Physicians use the procedure to detect or confirm

abnormalities within the blood vessels in the brain,
including:

•an aneurysm.
•arteriovenous malformation.
•vasculitis.
•a tumor.
•a blood clot.
•a tear in the lining of the artery.
•atherosclerosis, a narrowing of the arteries.
INDICATION

A cerebral angiogram may be performed:

•to evaluate arteries of the head and neck before surgery.

•to provide additional information on abnormalities seen on MRI
or CT of the head.
•to prepare for other medical treatment.
•in preparation for minimally invasive (endovascular) treatment.

The procedure is also used to help diagnose the cause of

symptoms such as:

•severe headaches •blurred or double vision

•memory loss •weakness or numbness
•slurred speech •loss of coordination or balance.
•dizziness
PATIENT PREPARATION 

• Your physician will explain the procedure to you and offer you
the opportunity to ask any questions that you might have about
the procedure.

•You will be asked to sign a consent form that gives permission

to do the procedure. Read the form carefully and ask questions if
something is not clear.

Before an angiogram, tell your doctor if you:

•Are or might be pregnant.

•Are breast-feeding.
PATIENT PREPARATION 
•Are allergic to iodine dye used in the test.

•Have ever had a serious allergic reaction (anaphylaxis) from any

substance, such as the venom from a bee sting or from eating
shellfish.

•Have asthma.

•Are allergic to any medicines.

•Have any bleeding problems or are taking blood-thinning medicines.

•Have a history of kidney problems or diabetes

PATIENT PREPARATION 

•Do not eat or drink for 4 to 8 hours before the angiogram. You may
be asked to not take aspirin, aspirin products, or blood thinners for
several days before the test and for 1 day after the test. If you take
these medicines, talk with your doctor.

•An angiogram can be done as an inpatient or outpatient. If you are

an outpatient, you will stay in a recovery room for several hours
before you go home. If you stay overnight in the hospital, you will
likely go home the next day.

•The test may take several hours, so you will empty your bladder just
before it begins.

•Also before the angiogram you may have other blood tests, such
as blood clotting (coagulation) studies, blood urea nitrogen (BUN),
and creatinine.
HOW AN ANGIOGRAM IS DONE
HOW IT IS DONE
Cerebral angiography is done in the hospital or large radiology
center. You will be asked to lie on an x-ray table. Your head is
positioned and held still using a strap, tape, or sandbags, so you do
not move during the procedure. The health care provider will attach 
electrocardiogram (ECG) leads to your arms and legs, which monitor
your heart activity during the test.

Before the test starts, you will be given a mild sedative to help you
relax.

An area of your body, usually the groin, is cleaned and numbed with
a local numbing medicine (anesthetic). A thin, hollow tube called a
catheter is placed through an artery and carefully moved up through
the main blood vessels in the belly area and chest and into an
artery in the neck. Moving x-ray images help the doctor position the
catheter.
HOW IT IS DONE
Once the catheter is in place, a special dye (contrast material) is
injected into catheter. X-ray images are taken to see how the dye
moves through the artery and blood vessels of the brain. The dye
helps highlight any blockages in blood flow.

After the x-rays are taken, the needle and catheter are withdrawn.
Pressure is immediately applied on the leg at the site of insertion for
10 - 15 minutes to stop the bleeding. After that time, the area is
checked and a tight bandage is applied. Your leg should be kept
straight for 4 - 6 hours after the procedure. Watch the area for
bleeding for at least the next 12 hours.

Digital subtraction angiography (DSI) uses a computer to "subtract"

or take out the bones and tissues in the area viewed, so that only
the blood vessels filled with the contrast dye are seen.
CATHETER PLACEMENT
POSTERIOR CEREBRAL CIRCULATION 
is the blood supply to the posterior portion of the brain, including
the occipital lobes,  cerebellum and  brainstem.
The posterior circulation is supplied by the vertebral arteries that
combine to form the basilar artery which then divides into the 
posterior cerebral arteries.
POSTERIOR
CEREBRAL
CIRCULATION 
CEREBRAL ARTERIAL SUPPLY TO THE BRAIN
 CEREBRAL ANGIOGRAPHY
DSA (ANGIOGRAPHY)

Injection in the left vertebral

artery, with retrograde flow
in the contralateral vertebral
artery, the basilar artery and
the posterior communicating
artery. The posterior
cerebral circulation can be
seen, including the posterior
part of the arterial circle of
Willis. 

Cerebral

Diagram of the basilar artery

and circle of willis.
AFTER THE PROCEDURE
While the patient is in the observation area, nurses check vital
signs, the incision site, and attend to all of the patient's needs. It is
necessary for the patient to lie still with his or her head flat for six to
eight hours. Gradually the patient is allowed to get out of bed with
assistance; lightheadedness and dizziness may occur if the patient
gets out of bed too quickly.
When the patient is released home, he or she is given discharge
instructions. These ‘at home' instructions include:

•No heavy lifting, exercise, and driving for 48 hours. Do not operate
machinery for at least 24 hours. It is important not to stress the
incision/puncture site.
•During the next 24 hours, drink plenty of fluids to flush the contrast
dye from the kidneys. Avoid beverages that dehydrate the body,
such as alcohol or coffee.
•Resume a regular diet.
WHAT ARE THE BENEFITS VS. RISKS?

BENEFITS

•Angiography may eliminate the need for surgery. If surgery

remains necessary, it can be performed more accurately.
•Cerebral angiography presents a very detailed, clear and
accurate picture of blood vessels in the brain. This is especially
helpful when a surgical procedure or other treatment is being
considered.
•Results from cerebral angiography are more accurate than those
produced by carotidDoppler ultrasound.
•Use of a catheter makes it possible to combine diagnosis and
treatment in a single procedure.
•The degree of detail displayed by cerebral angiography may not
be available with any other noninvasive procedure.
•No radiation remains in a patient's body after an x-ray
examination.
•X-rays usually have no side effects in the diagnostic range.
AFTER THE PROCEDURE

CALL YOUR DOCTOR IF:

•There is bleeding, bruising, redness, warmth, or loss of

feeling at the incision site.
•Numbness, tingling or weakness occurs in the
extremities (arms, legs) or face.
•Urination is difficult.
•A change or loss of vision occurs.
•Swallowing or talking is difficult.
•Mental confusion or comprehension difficulties occur.
•An allergic reaction develops, such as hives, itching,
rapid heart beats, dizziness, chest pain, or shortness of
breath.
RISKS
In general, risks may include:

•Allergic reaction to the dye used

•Bleeding, infection, and pain at the injection site
•Blood clots
•Damage to blood vessels
•Damage to the kidneys from the dye used (higher risk in those with
diabetes)

Let your health care provider know immediately if you have:

•Facial weakness
•Slurred speech
•Visual trouble
•Numbness in your leg during or after the procedure
SAMPLE CASE

CEREBRAL ANEURYSM

A cerebral aneurysm occurs when a weak spot in a

brain blood vessel balloons. Engorged with blood,
the aneurysm either causes pressure on
surrounding brain tissue or it ruptures. Aneurysms
develop for a variety of reasons, including age,
genetic predisposition, and less commonly from
injury or infection. Saccular, or “berry,” aneurysms
—resembling a small sac— are the most common
type and often require intervention. 
COMMON LOCATIONS OF CEREBRAL SACCULAR ANEURYSMS
 Three-dimensional rotational
digital subtraction angiogram,
carotid injection, reveals a
small anterior communicating
artery aneurysm (arrow).

3-D angiography picture of a

brain aneurysm. The aneurysm
is the bulge on the vessel in the
middle of the picture. 3-D
angiography is used to
determine the dimensions and
shape of aneurysms.
 Endovascular coiling
of cerebral aneurysm.
Transfemoral
approach to gain
access to the
aneurysm via a small
microcatheter (A) and
final occlusion of the
aneurysm with coils
(B)
TREATMENT OF BRAIN ANEURYSMS
Coil Embolization or Endovascular Coiling

Tiny platinum coils are threaded The aneurysm is filled in with coils,
through a microcatheter and obstructing the flow of blood into
pushed into the aneurysm. The the aneurysm. Once properly
coils are flexible enough to positioned within the aneurysm,
conform to the aneurysm shape. the coil is detached from the
delivery wire using an electrolytic
detachment process (electrical
charge)
 Novel treatment strategies for
treatment of wide-necked
aneurysms include balloon-
assisted (above) and stent-
assisted (below) techniques.

eec
 Angiogram of an aneurysm
Angiogram of an aneurysm
after endovascular coiling
before treatment. The
treatment. The aneurysm has
aneurysm is the dark bulge
been filled in with coils, so
on the vessel.
blood can no longer flow into
the aneurysm. The aneurysm
now appears as a silver
bulge on the angiogram
OUTCOME OF THE PROCEDURE

Endovascular Coiling v. Surgical Clipping

The study found that, in patients equally suited for

both treatment options, endovascular coiling
treatment produces substantially better patient
outcomes than surgery in terms of survival free of
disability at one year. The relative risk of death or
significant disability at one year for patients treated
with coils was 22.6 percent lower than in surgically-
treated patients.
THE END