Diagnostic Cerebral Angiography

General: Patients may be symptomatic (due to the lesion, subarachnoid hemorrhage or cerebrovascular vasospasm) or asymptomatic. You should know the location and type of the cerebrovascular malformation, any neurological deficits, if the patient has had a subarachnoid hemorrhage and if the patient is at risk for cerebrovascular vasospasm.
Preop: Start an IV. Premedicate with up to 2 mg of midazolam.
Monitors:Routine monitors. Foley catheter inserted after beginning of sedation. Monitoring devices must be positioned so that they do not hinder radiologic visualization of the cerebral vasculature, or the aortic arch area.
Anesthesia: Goal is to have the patient hold still during angiography. For MAC cases (low likelihood of treatment or unknown pathology) the patient typically receives small doses of fentanyl in addition to midazolam. Consider administering a small propofol bolus before Foley catheter insertion. If the patient is unable to stay still, has a high likelyhood of being treated, or comes intubated from the ICU, general anesthesia will be administered. The goals of general anesthesia are to induce and maintain anesthesia without causing further morbidity (potential aneurysm rupture, avoid hypotension if vasospasm is suspected), prevent patient movement (poor image quality and risk of catheter related complications), and rapid emergence from anesthesia to allow neurologic examination soon after procedure. Induction with propofol. In case of increased ICP, have patient hyperventilate during preoxygenation. Fentanyl 3 µg /kg in divided doses throughout induction, prior to intubation. Verify adequate neuromuscular blockade prior to intubation to avoid coughing/straining. Tape eyes, insert esophageal temperature probe. Maintain anesthesia with oxygen, low dose inhalation agent or propofol infusion. Maintain euvolemia (Lactated Ringer’s) and neuromuscular relaxation (vecuronium or rocuronium). Use of inhalation agents or propofol is usually stopped at the end of procedure. Reverse residual neuromuscular blockade. Consider prophylactic use of labetalol to attenuate emergence hypertension. During the procedure, if requested, administer nitroglycerin ointment (typically one inch of nitropaste applied on the chest) to prevent catheter induced vasospasm. If the patient has an EVD that is draining, be vigilant about the radiologist changing the table height.
Potential complications: Intracranial bleeding. Movement during procedure. Oversedation. Inability of patient to follow commands.
Recovery: For MAC cases, transport patient to the radiology holding area. For general anesthesia cases, wake patient up immediately after the procedure to allow neurologic examination. Use a hemodynamic monitor and supplemental oxygen during patient transport to PACU or ICU. Prevent post procedure hypertension (labetalol) to avoid intracranial bleeding.

Last revised 05/2013 Talke