Cerebral angiogram

Cerebral angiogram

Anesthesia type	General vs MAC vs no anesthesia
Airway	ETT vs natural airway
Lines and access	1 PIV
Monitors	Standard
Primary anesthetic considerations
Preoperative
Intraoperative	Maintain normotension if aneurysm
Postoperative
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A cerebral angiogram (also known as cerebral arteriogram) is a procedure where contrast is injected through an artery and X-Rays are used to visualize the cerebral blood flow. It is performed by neuro-interventional radiology.

Overview

Indications

It can be used to further investigate cerebral hemorrhage, AV malformations, cerebral aneurysms, blood flow to tumor, or other abnormal arterial blood flow.

Surgical procedure

The most common approach is through the femoral artery, though occasionally it can be done through the radial artery (e.g. if patient has history of femoral bypass procedure). Upon access the artery through catheter, contrast is injected with timed X-ray imaging.

Type of anesthesia

This procedure can be done without anesthesia or with MAC anesthesia for most patients who are able to follow commands and lie still, and if the the procedure is purely diagnostic in nature. If a patient is unable to lie still, or will need additional treatment (e.g. embolization, stent placement, etc.), then general anesthesia is used.

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic	Depending on the abnormality being explored, patients may have baseline neuro deficits which should be known preoperatively
Cardiovascular	Patients with aneurysms and history of hypertension should continue antihypertensives to avoid sheer stress
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Coags, BMP (to evaluate kidney function prior to high volume contrast)

Operating room setup

In general, multiple C arms in different planes are used, so the anesthesia machine and monitors are situated far from patient. Multiple extensions are needed for any lines (PIVs, arterial lines, central lines) and long cables for monitors.

For patients with tight blood pressure control required (e.g. cerebral hemorrhage, aneurysm), prepare multiple antihypertensives (nicardipine infusion, nitroglyceride injection) and vasopressors (norepinephrine infusion, phenylephrine injection).

Patient preparation and premedication

If there is high concern for neurologic deficit, medications that may alter mental status exam postoperatively should be used with caution: e.g. midazolam, scopolamine patch.

Regional and neuraxial techniques

N/A

Intraoperative management

Monitoring and access

• Standard ASA monitors
• 1-2 PIV
• Arterial line if patient requires strict blood pressure goals (e.g. cerebral hemorrhage) or is otherwise hemodynamically unstable.
• Patients with elevated ICP may present with external ventricular drain (EVD) requiring ICP monitoring and ICP fluid drainage.

Induction and airway management

Standard induction. Slow cardiac induction if indicated for tight blood pressure management.

Positioning

• Supine
• All lines and monitors must be out of plane with the head and shoulder area to avoid obstructed X-ray imaging. Generally across the chest.
• Consider extensions on PIVs

Maintenance and surgical considerations

• Maintain deep paralysis as imaging of requires breath holding to avoid ventilatory variation.
• If active cerebral hemorrhage

Emergence

Neurologic exam is often obtained upon emergence

Postoperative management

Disposition

• Generally PACU
• ICU if significant neurological intervention is required (for neuro monitoring) or otherwise hemodynamically unstable (e.g. cerebral hemorrhage)

Pain management

Generally minimal pain management is needed as there is only a small incision for catheter placement.

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications