CEREBRAL

ANGIOGRAPHY(DSA)-
TECHNIQUE AND
NORMAL ANATOMY
Dr prashant shringi
Senior resident neurology
NORMAL ANATOMY
• ARTERIAL SUPPLY
• 2 Internal Carotid Artery
• 2 Vertebral Arteries
CIRCLE OF WILLIS
• Grand Vascular Station of the Brain
• Classical –18% to 20%
• Majority circles shows anomaly-52%
• Most frequent anomaly is hypoplasia of ACA-24%
• Accesory vessels in the form of duplication/triplicationsof
ACOM (2 M.C.) -12%
Fetal posterior cerebral artery-10%
CIRCLE OF WILLIS
 COMPONENTS:

• Internal carotid arteries

• Horizontal segments of Anterior cerebrals(A1)
• Anterior communicating artery
• Proximal segments of posterior cerebrals(P1)
• Posterior communicating arteries
• Basilar artery
Branches of ACA
• A1- medial lenticulostriate artery
• ACoA- Perforating branches
• A2- Recurrent artery of Heubner (RAH)
• Orbitofrontal artery
• Frontopolar artery
• A3- Pericallosal and Callosomarginal a.
• A4 & A5- Cortical branches
ACA
MIDDLE CEREBRAL ARTERY

• Larger terminal branch of ICA

• Run laterally in stem of lateral sulcus
• Curves on superolateral surface
• Runs backwards in depth of posterior ramus of lateral
sulcus
• M1 segment =horizontal segment from origin to its
bifurcation (it is in sylvian fissure)
• M2 segment =lacunar segment -in the insula loops over
insula—laterally to exit from sylvian fissure
• M3 segment = opercular branch-from sylvian fissure &
ramify over cerebral cortex
• Anomalies of MCA are uncommon
POSTERIOR CEREBRAL ARTERY

 P1-Peduncular/Precommunicating
 P2-Ambient segment
 P3-Quadrigeminal segment
 P4-Cortical branches
• 2 major terminal br of PCA—
•
• parieto occipital art & calcarine art
POSTERIOR FOSSA
• Vertebral artery
• Basilar artrery

• Vertebral arteries
• Originate from the subclavian arteries
• Left VA is dominant in 60% cases
Branches of vertebral artery
• Extracranial -numerous branches to the meninges,spinal
cord & muscles
• -Posterior meningeal artery

• Intracranial-
-Anterior spinal artery
• -Posterior inferior cerebellar Art.
• Anterior medullary
• Lateral medullary
• Tonsillomedullary
• Telovelotonsillar
• Cortical branches
BASILAR ARTERY
• Right and left VA unite to form basilar artery
• Courses infront of pons (Prepontine cistern)
terminates in the interpeduncular cistern
• 3cm in length,1.5 to 4mm in width
Branches of basilar artery
• Anterior inferior cerebellar artery (AICA)
• Superior cerebellar artery
• Pontine artery
• Labyrinthine artery
Normal VARIANTS
• Fenestrations and duplications
• Variants of the circle of Willis
• Persistent carotid-basilar anastomoses
• Anomalies identified in the skull base
Normal Variants of the Circle of Willis
CEREBRAL ANGIOGRAPHY
• Angiography –

• Radiological study of blood vessel in the body

after the introduction of iodinated contrast
media.
Imaging Techniques
• Vascular structures of brain can be imaged by 4
means:
• 1. DSA: gold standard
• Invasive and risk of nephrotoxic contrast,ionising
radiation

• 2. Vascular ultrasound: least invasive, can be

done bedside, cost effective.
• Best choice for imaging vessels close to skin
surface.
• Drawback: limited anatomic coverage, deep
vessels cant be imaged, operator dependent,
requires skill.
• 3 CT angio: main drawbacks are contrast use and
radiation exposure,
• calcifications are overestimated.
• Preferred for aorta and coronaries

• 4 MRA : non invasive, no radiation exposure.

• Preferred for carotids and intracranial vessels as MRI
brain can also be obtained
• widely used in neurological disorders
• ANGIO?
• ‘ANGIO means blood vessel’

• SUBTRACTION?
• It is simply a technique by which bone
structures images are subtracted or canceled
out from a film of bones plus opacified vessels,
“leaving an unobscured image of the vessels”
DSA
• Acquisition of digital fluoroscopic images
combined with injection of contrast material
and real time subtraction of pre- and post
contrast images to perform angiography is
referred to as digital subtraction angiography
HISTORY
Portuguese neurologist Egas Moniz,( Nobel
Prize winner 1949), in 1927 developed the
technique of contrast x-ray cerebral angiography
to diagnose diseases,
such as tumors and arteriovenous
malformations.
• Idea of subtraction images was first proposed
by the Dutch radiologist Ziedses des Plantes in
the 1935, when he was able to produce
subtracted images using plain films.
HISTORICAL DEVELOPMENT
• CONVENTIONAL SUBTRACTION TECHNIQUE:

• Photographicmethod used to eliminate

unwanted images.

• No addition of information; only purpose to

make diagnostically important information
• Developed in 1970s, University of Wisconsin,
University of Arizona, University of Kiel.
• USA
• Commercial systems introduced in 1980.
• 3 conditions:

• SCOUT FILM
• ANGIOGRAM FILM-CONTRAST
• NO MOTION OF HEAD
PRINCIPAL
• Principles of subtraction are based on the
following:

• Scout film shows the structural details of the

skull and the adjacent soft tissue.
• Angiogram film shows exactly the same
anatomic details, if the patient does not move,
plus the opacified blood vessels.
• If all the information in the scout film could be
subtracted from the angiogram film, only the
opacified vessel pattern would remain visible.
DIGITAL IMAGE PROCESSOR
WHY DSA?
• Digital subtraction angiography (DSA) was developed
to improve vessel contrast.

• Technique that uses a computer to subtract two

images, obtained before and after contrast media is
injected into the vessels of interest.
• Anatomical structures that are the same in the two
images can be removed and the resulting image
shows the vessels only
• Modern DSA systems are based on digital
fluoroscopy/fluorography systems, which are
equipped with special software and display
facilities
• Image before the contrast agent is
administered is called the mask image.
•

• Once the contrast is administered, a sequence

of images are taken by a television camera in
analog form, which is then digitised by
computer
• DSA processor has two separate image
memories, one for the mask and the other for
the images with contrast medium.

• These two image memories are subtracted

from one another arithmetically, and the result
goes to an image processing and display unit.
Indications
• Diagnostic:

• Non traumatic Subarachnoid Hemorrhage

(SAH)
• Arterial dissection
• laceration
• Aneurysm
Indications
• Pseudoaneurysm
• Thrombosis (Extracranial & Intracranial)
• Arterio-venous malformation (AVM).
• Arterio-venous fistula (AVF).
• Tumor vascularity
• Therapeutic:

• Embolisation
• Stenting
• Thrombolysis
• Thrombectomy
Contra indications
• No absolute contraindication.
• Poor renal reserve.
• Deranged coagulogram.
• Allergic to contrast media
Contrast Media
• Blood vessels are not normally seen in an x-ray
image, because of low tissue contrast.

• To increase image contrast, contrast agents,

which are dense fluids with elements of high
atomic numbers, such as iodine, are injected into
a blood vessel during angiography. Because of its
higher density and high atomic number, iodine
absorbs photons more than blood and tissue.
 Creates detailed images of the blood vessels in
real time.

• First contrast media used for intravascular

injection were called high-osmolar contrast
media (HOCM).
• High osmolarity caused adverse effects such as
pain, endothelial damage, thrombosis, and
increased pressure in the pulmonary circulation.

• Low-osmolar contrast media (LOCM) were first

developed in the 1970's reduce side effects.

• Major risks of modern iodine contrast media is an

allergic reaction to iodine
• Non ionic Iso-osmolar contrast media.

• 30-40% dilution with normal saline.

• 50 ml of diluted contrast media is enough to do

a standard cerebral angiogram with total 8
projections.

• Approx. 5-8 ml diluted contrast / injection.

Materials used
• Catheters • Saline
• Arterial sheath • Disposable syringes
• Medicut • Local anesthesia
• Guidewires • Heparin
• Contrast • Surgical gloves
• Connector/100 • Elastoplast
cm.tubing
• Surgical blade
 Picard Pigtail

Sim -1
•
Guide Wires Medicut
PREPARATION
• Should be well
• Nil orally 4-6 hrs. hydrated.
• On trolley • Should void before
• In hospital gown
procedure.
• Peripheral pulses
• Groin shave
marked.
• Records
• I.V line in place.
• Informed consent
PROCEDURE
• Gaining arterial access.
• Selective arterial catheterization.
• Image acquisition.
• Closure of arterial access.
• Post processing
• Hard copy
• Patients may be sedated to reduce anxiety.

• Monitor of vitals

• Local anesthetic is usually used in the area

where the catheter is to be inserted,

• Most common femoral artery

PROCEDURE
• Small incision given, medicut is inserted into the artery,

• Fluoroscopy is used to guide the needle to the proper

position .

• Needle is then removed after placing guide wire in the

artery and vascular sheath is inserted over the guide wire
.
• Catheter is then inserted along the guide wire through the
sheath
• When the catheter is in the correct position, the wire is
pulled out and dye is injected through the catheter.

• Images are acquired during contrast injection.

• Injections can be made directly into the artery of interest

(selective arteriography)
COMPLICATIONS
• 0.16% major complication rate.

• Local complications: hematoma, vessel laceration,

dissection, pseudoaneurysm ,AVfistula.

• Systemic complications: contrast reactions, fever,

sepsis, dehydration, death.

• CNS complication: aggravation of preexisting

complaints, neurological deficit.
POSTPROCEDURAL CARE
• After the catheter is removed compression is applied to
the puncture site

• Bed rest for a minimum of 4 hours

• During rest patient is monitored and vital sign like

peripheral pulse like distal to Puncture are regularly
• Extremity is also checked for warmth, color, numbness to
ensure circulation has not been disrupted.
Cerebro-vascular anatomy as
appreciated in DSA
Diagnostic usage
• Acom aneurysm:
ACA Aneurysm
MCA Aneurysm
Pcom Aneurysm
AV Malformation
Tumour vascularity
Digital subtraction angiography based
advances
• Better visualization and less radiation exposure
are key tenets in the development of digital
subtraction angiography

• Complexity of disease types increases and

more technically challenging, cutting-edge
procedures are performed
• Digital subtraction angiography systems with flat
panel : ADVANTAGES-

• High spatial resolution, wide dynamic range,

square field of view, and real-time imaging
capabilities with no geometric distortion—all of
which may be used for improve image quality,
reduced patient exposure to radiation
• Hatakeyama et al have shown that two-dimensional (2D)
and three-dimensional (3D)digital subtraction angiography
using the flat panel detector system of the direct
conversion type, with low radiation dose, is superior in
image quality for visualizing small intracranial vessels with
significantly decreased radiation exposure compared with
digital subtraction angiography with the conventional
image intensifier television system

• Hatakeyama Y, Kakeda S, Korogi Y, et al. Intracranial 2D and 3DDSA with flat panel detector of the
direct conversion type: initial experience. Eur Radiol 2006;16:2594 –2602.
Digital subtraction techniques

• Mask subtraction
• Dual energy subtraction
• Time interval differencing
• Temporal filtering
• Allura Xper FD20/10 biplane flat detector
system with integrated 3D for intricate
neurovascular procedures.

• 3D- reconstructions
• Xper CT
• SPECTRA BEAM
• 3D Roadmapping
• multi-modality information integration
• Redefines image clarity and captures
information at a resolution four times greater
than conventional X-ray systems.
Xper CT
• With XperCT clinicians can access CT-like imaging right
on the angio system so can assess soft tissue, bone
structure and other body structures before, during or after
an interventional procedure.

• XperCT reconstruction is created from rotational

acquisition performed on the Allura Xper system.

• This reconstruction can be overlaid with the 3D vascular

image.
• 3D soft tissue imaging supports diagnosis
planning, interventions and treatment follow-up

• XperCT can be combined with Allura 3D-RA

images to visualize soft tissue and vascular
anatomy on one image.
Spectra Beam
• Basically a selectable copper beam filtration

• Combination of Spectra Beam with the MRC-

tube allows increased X-ray output with better
filtration of soft radiation.

• Reduces patient X-ray dose for cardiac and

vascular applications, while maintaining the same
image quality.
Disadvantage of DSA
• Limited spatial resolution
• Artifacts
• Small visual field
• Not a good technique for neoplasm
Conclusion
• Despite recent advances in CT angiography and
MR angiography, DSA remains the standard
imaging technique for evaluation of the
cerebral vasculature .

• 3D reconstruction of the dataset acquired

during rotational DSA represents the latest
development in the neurovascular imaging .
• 3D-DSA has taken a prominent role in
treatment planning by enabling better
appreciation of the morphology of complex
vascular lesions before endovascular or surgical
management.

• Superior in the performance of sophisticated

tasks such as aneurysm volume measurement
• On the other hand, inability of 3D-DSA to
simultaneously image osseous and vascular
structures is noted as a weakness of this
technique compared with CT angiography .
Refrences-
• The Principle of Digital Subtraction Angiography and Radiological Protection;
K. OKAMOTO, . IT, K. SAKAI, S. YOSHIMURA ; Interventional
Neuroradiology 6 (Suppl1): 25-31, 2000

• Advances in Interventional Neuroimaging; Vallabh Janardhan and Adnan I.

Qureshi; Vol. 4, 414–419, July 2007 c The American Society for Experimental
NeuroTherapeutics,

• Intracranial Vascular Stenosis and Occlusive Disease: Evaluation with CT

Angiography, MR Angiography, and Digital Subtraction Angiography; Bash et
al; AJNR Am J Neuroradiol 26:1012–1021, May 2005

• Uptodate.com
• Digital substraction Angiography ;John hopkins Medical university
• Gray’s text book of anatomy
• Teachme anatomy .com
• THANK YOU