Cerebral angiography

Last revised by Raymond Chieng on 13 Oct 2023

Cerebral angiography is an interventional procedure for the diagnosis and/or treatment of intracranial pathology.

Indications

Cerebral digital subtraction angiography (DSA) is indicated in a variety of settings including:

Projections

Standard projections
  • posteroanterior internal carotid artery

    • projects middle cerebral artery away from bony landmarks, minimizing beam hardening artifacts

    • petrous ridge superimposed on supraorbital margin

    • include the entire skull vault

    • conclusively demonstrates

      • ICA lacerum portion

      • ICA distal bifurcation

      • ACA A1 segment

      • MCA M1 segment (including lenticulostriate vessels)

      • confluence of sinuses

      • transverse sinus

      • sigmoid sinus

      • intracavernous sinus

  • lateral internal carotid artery

    • include the entire skull vault

    • effectively demonstrates

      • ICA cavernous portion

      • ICA communicating segment (PCOM, anterior choroidal artery)

      • ACA A2 segments

      • MCA M3 segments

      • ophthalmic artery

      • superior and Inferior sagittal sinuses

      • internal cerebral veins

      • basal vein of Rosenthal

      • great vein of Galen

      • straight sinus

      • cavernous sinus

      • inferior petrosal sinus

  • transorbital oblique internal carotid

    • petrous ridge positioned on infraorbital margin

    • include the entire skull vault. However, magnification can be employed if the indication is specifically for an intracranial aneurysm

    • ipsilateral obliquity, 30°

    • effectively demonstrates

      • ICA distal bifurcation

      • ACA A1 segment

      • ACA occasionally for ACOM

      • MCA trifurcation of M1/M2 segments

  • reverse transorbital oblique internal carotid

    • petrous ridge positioned on infraorbital margin

    • include the entire skull vault; however, magnification can be employed if the indication is specifically for an intracranial aneurysm

    • contralateral obliquity 30°

    • effectively demonstrates

      • MCA occasionally trifurcation of M1/M2 segments

      • ACA occasionally for ACOM    

  • cross compression projection internal carotid

    • petrous ridge positioned on infraorbital margin

    • no (RAO/LAO) obliquity

    • effectively demonstrates

      • ICA distal bifurcation

      • ACA A1 segment

      • ACOM provides a baseline position for cross compression and visualization of the ACOM

      • MCA M1 segment

  • posteroanterior vertebral artery

    • petrous ridge positioned on supraorbital margin

    • effectively demonstrates

      • vertebral distal portion

      • basilar artery

      • superior cerebellar artery (SCA)

      • anterior inferior cerebellar artery (AICA)

      • superior sagittal sinus

      • confluence of sinuses

      • transverse sinus

      • sigmoid sinus

  • lateral vertebral artery

    • effectively demonstrates

      • vertebral artery distal portion

      • basilar artery (excluding basilar tip)

      • PCOM

      • PCA - posterior choroidal artery

      • superior and inferior sagittal sinuses

      • internal cerebral veins

      • basal vein of Rosenthal

      • great vein of Galen

      • straight sinus

Additional positioning notes for the vertebral artery
  • from the baseline vertebral posteroanterior, the c-arm is angled cranially to demonstrate the PCA best in addition to demonstrating the thalamoperforating vessels

  • basilar artery is foreshortened in Towne's view 2.

  • caudal tilt (Water's projection) will better demonstrate the basilar artery without foreshortening.

  • PICA origins best demonstrated in 45° ipsilateral obliquity

General patient positioning
  • patient supine, head supported in a radiolucent head holder or curved sponge

  • strap across the patient's head to minimize movement

  • head positioned without rotation

  • head tilt (radiographic baseline) determined by patient comfort

    • the patient should not be forced into an uncomfortable head tilt

    • adjustments made for head tilt by craniocaudally c-arm angulation

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