General vs MAC vs no anesthesia
ETT vs natural airway
|Lines and access||
|Primary anesthetic considerations|
Maintain normotension if aneurysm
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.
It can be used to further investigate cerebral hemorrhage, AV malformations, cerebral aneurysms, blood flow to tumor, or other abnormal arterial blood flow.
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.
|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|
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
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.
- 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
Neurologic exam is often obtained upon emergence
- Generally PACU
- ICU if significant neurological intervention is required (for neuro monitoring) or otherwise hemodynamically unstable (e.g. cerebral hemorrhage)
Generally minimal pain management is needed as there is only a small incision for catheter placement.
|Variant 1||Variant 2|