Cerebral Angiography

Original Editor - Mohit Chand
Top Contributors - Mohit Chand and Stacy Schiurring

Introduction

Cerebral angiography is an invasive clinical procedure in vascular neurology which uses a special iodine based contrast dye and X-ray for diagnosis and treatment of Intracranial Pathology. It is also called intra-arterial digital subtraction angiography (IADSA). In simple terms, cerebral angiography helps to examine the blood vessels in the brain via real time imaging.

Technique

In Cerebral angiography, a thin catheter is inserted though the artery of arm or leg by making a small incision in the skin. Under the guidance of X-ray, it is then moved to the area being examined. Once in place, the contrast material is injected through the catheter and images are captured using ionising radiation (x-rays). Then the images are electronically manipulated so that the overlying skull bone, which normally obscures the vessels, is removed from the image, resulting in the remaining vessels being clearly seen.

Below is a small video demonstrating the procedure:

Purpose

Cerebral angiography is indicated in a variety of settings, including:

Diagnosis and treatment of:

Cerebral Arteriovenous Malformation Under Cerebral Angiogram

Aortic aneurysms. It is defined as a permanent localised dilatation of the vessels. It is a life-threatening condition and requires monitoring or treatment depending on the size of the aneurysm and associated symptoms.

Acute ischemic stroke.

Vascular abnormalities. This can include (1) arteriovenous malformation (AVM) which is an abnormal connection between arterial and venous vessels without intervening capillary structures. Due to absence of capillaries, the arterialised vein experiences high pressure, which can lead to disruption of venous walls and ultimately cause fatal hemorrhage. (2) Arteriovenous fistula (AVF) are a subtype of AVM. AVFs can occur because of a congenital or genetic anomaly, or can be secondary to iatrogenic injury or trauma.

Cerebral vasospasm post subarachnoid hemorrhage.

Meningioma. Meningiomas arise from the meningothelial cells of the arachnoid and are the most common non-glial tumors of the central nervous system (CNS). Meningiomas accounts for between 16 and 20% of all intracranial tumors.

Investigation of:

Reversible cerebral vasoconstriction syndrome. This is a clinical and radiologic syndrome that represents a common presentation of a diverse group of disorders. The syndrome is characterised by thunderclap headache and reversible vasoconstriction of cerebral arteries, which can either be spontaneous or related to an exogenous trigger.

Moyamoya syndrome. Moyamoya syndrome is a rare, chronic condition characterised by progressive narrowing of the internal carotid arteries and their branches, leading to reduced blood flow to the brain. The condition is progressive and can lead to stroke, transient ischemic attacks, or hemorrhage.

Confirming brain death. Cerebral angiogram can visualise and confirm a cessation of blood flow to the brain, which is a key indicator of brain death. Specifically, it shows a lack of perfusion, meaning no blood is reaching the brain tissue, confirming the complete absence of brain function.

Risks

Risks of a cerebral angiogram can include (1) a allergic reaction to the contrast dye, (2) blood clot formation or bleeding where the catheter is inserted, which could partly block blood flow to the leg or hand (rare), (3) damage to an artery or artery wall from the catheter, which can block blood flow and cause a stroke (rare), (4) damage to the kidneys from the IV contrast.

Role of Physiotherapist

Physiotherapy plays an important role in early mobilisation and reducing complications. The key roles of a rehabilitation after cerebral angiography are:

1. Early Functional Assessment: Physiotherapists perform a comprehensive evaluation of the patient’s neurological status, mobility, and functional abilities after the procedure, especially if the angiogram was performed for acute neurological events such as stroke or aneurysm.
2. Promotion of Early Mobilisation: When medically cleared, physiotherapists initiate early mobilization to prevent complications of immobility, such as muscle weakness, joint stiffness, deep vein thrombosis, and pressure ulcers. This includes assisted transfers, bed mobility, and gradual progression to ambulation.
3. Cardiorespiratory Support: For patients with reduced endurance or respiratory compromise, physiotherapists may incorporate breathing exercises and aerobic conditioning to enhance cardiovascular and pulmonary function, which is especially relevant for those with comorbidities or after prolonged hospitalisation.
4. Education and Empowerment: Physiotherapist educated patients and their family about precaution, wound care and personal hygiene post angiography.

Precautions for Rehabilitation Interventions

Immediate Post-Procedure Period (First 4–6 Hours):

1. Bed Rest: Patients are typically on bed rest for at least 4 hours after a femoral approach, with the accessed limb kept straight to prevent bleeding or hematoma.
2. Observation: Frequent neurovascular and neurological checks are performed (every 30 minutes for 4 hours, then every 4 hours until discharge).
3. No Early Mobilisation: Avoid physiotherapy interventions that require movement of the accessed limb or getting out of bed during this period.

Early Recovery (First 24–48 Hours):

1. Gradual Activity: After the initial rest period, gentle mobilisation may be allowed if the puncture site is stable and there are no complications.
2. Avoid Strain: No strenuous activity, heavy lifting, or exercises that stress the puncture site (e.g., hip flexion if femoral access) for at least 48 hours.
3. Monitor for Complications: Check for signs of bleeding, hematoma, limb numbness, coldness, or neurological changes. If any are present, stop physiotherapy and alert the medical team immediately.
4. Hydration: Encourage proper hydration to help clear contrast dye.
5. Educate Patient about wound care and personal hygiene.