Cerebral angiography

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
  • PA internal carotid artery
    • projects middle cerebral artery away from bony landmarks, minimising beam hardening artifacts
    • petrous ridge superimposed on supraorbital margin
    • include 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 entire skull vault
    • effectively demonstrates
      • ICA  cavernous portion
      • ICA  communicating segment (PCOM, anterior choidal 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 entire skull vault. However, magnification can be employed if 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 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 baseline position for cross compression and visualisation of the ACOM
      • MCA M1 segment
  • PA 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 PA, the c-arm is angled cranially to demonstrate the PCA best in addition for demonstrating the thalamoperforating vessels
  • 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 patient's head to minimise movement
  • head positioned without rotation
  • head tilt (radiographic baseline) determined by patient comfort
    • patient should not be forced into an uncomfortable head tilt
    • adjustments made for head tilt by craniocaudally c-arm angulation
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Cases and Figures

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    Petrous ridge pos...
    Figure 1: PA ICA
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    Full skull lateral
    Figure 2: lateral ICA
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    Full skull transo...
    Figure 3: transorbital oblique ICA
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    Magnified transor...
    Figure 4: transorbital oblique (magnified) ICA
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    Magnified reverse...
    Figure 5: reverse transorbital oblique ICA
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    Right ICA injecti...
    Figure 6: cross compression ICA
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    Superior border o...
    Figure 7: PA vertebral
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    Inferior border o...
    Figure 8: lateral vertebral
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