Neuroangiography: Review of Anatomy, Periprocedural Management, Technique, and Tips

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 pseudotumor 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 diagnosis and potential subsequent endovascular treatment. A thorough understanding of normal and variant cervical/cranial vascular anatomy is required. In addition, periprocedural management, catheter technique, equipment needed, and underlying disease pathology are paramount to successful and safe outcomes. This article will review basic neurovascular anatomy, periprocedural management, NA technique, and tips for safe and successful outcomes.

Keywords: anatomy; angiography; interventional radiology; vascular anatomy.

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.

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 vertebral artery.

Fig. 3

Lateral digital subtraction angiography of the right external carotid artery depicting a ruptured dural arteriovenous fistula with supply emanating 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.

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.

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.

Fig. 6

Lateral digital subtraction angiography of the left internal carotid artery. A2, ACA A2 segment; A3, ACA A3 segment; A4, ACA A4 segment; C1, cervical ICA; C2, petrous ICA; C3, laceral ICA; C4, cavernous ICA; ID, MCA inferior division; OA, ophthalmic artery; M3, MCA M3 segment; M4, MCA M4 segment; black arrow head, posterior communicating artery; small black arrow, anterior choroidal artery; white arrow, MCA bifurcation.

Fig. 7

Anteroposterior digital subtraction angiography of the left vertebral artery with reflux into the contralateral vertebral artery. BA, basilar artery; CPT, contralateral posterior temporal artery; CVA, contralateral vertebral artery; P1, PCA P1 segment; P2, PCA P2 segment; P3, PCA P3 segment; P4, PCA P4 segment; V2, vertebral artery V2 segment; V3, vertebral artery V3 segment; V4, vertebral artery V4 segment; arrow, contralateral PICA; arrow tip, left AICA/PICA complex; small arrow, left SCA.