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  • Diagnosis of primary neurovascular diseases;
  • Planning for neurointerventional procedures;
  • Intra-operative assistance with aneurysm surgery;
  • Follow-up imaging after treatment.


Endovascular diagnostic materials

  • Femoral artery sheath for the rapid exchange of catheters and less potential for trauma to the arteriotomy site (from 4 French up to 8 French);
  • Hydrophilic 0.035 inch guidewire;
  • Diagnostic catheter (made in different shapes) advanced over an hydrophilic wire.


Standard angiographic projections

Biplane angiography is the standard of care for cerebral angiography

  • PA (postero-anterior) projection: the petrous bones are at the lower edge of the orbits;
  • Caldwell projection - The petrous bones are about one third of the way up the orbits;
  • Towne projection - The foramen magnum can be seen through the calvarium;
  • Water projection - The view is from below; the maxillary can be seen clearly;
  • Submentovertex projection - The view is from way below; the vertex of the skull is framed by the mandible;
  • Lateral projection - On a straight lateral view, the floors of the left and right frontal fossas directly overlapping.


Cerebral angiography for intracranial aneurysms

  • Four-vessel angiogram should be done;
  • External carotid artery runs are needed in patients that will be treated with ECA-ICA by-pass, or in patients with non aneurysmal subarachnoid hemorrhage, to exclude an arteriovenous fistula;
  • 3D reconstruction is useful to assess the aneurysm dome, neck, parent vessel, and adjacent vessels.


Anterior communicating artery aneurysm, shown by angiographic series in the right internal carotid artery.


Cerebral angiography for brain artero-venous malformations

  • Internal/external cerebral circulation, vertebrobasilar system angiogram and selective microcatheterization, if needed, to identify all feeding arteries, draining veins, and eventually any compartment of the nidus;
  • High-speed runs (4/6 fps) to clarify anatomy of AVMs;
  • It is mandatory to identify intranidal and perinidal aneurysms and enlarged veins.



b-avm - Cerebral arteriovenous malformation localized on left parietal lobe. It is possible to appreciate afferent arteries from the ipsilateral middle cerebral artery and anterior cerebral artery.


Cerebral angiography for dural arteriovenous fistulas

  • Internal/external cerebral circulation, vertebrobasilar system angiogram and selective catheterization, generally of the external carotid artery, to identify all feeding arteries;
  • Long time runs after each injection, to assess the normal venous drainage and its relation with pathological drainage of the fistula.



Dural arteriovenous fistula - Dural arteriovenous fistula between a branch of the middle meningeal artery and a vein bridge. 


Cerebral angiography for direct carotid-cavernous fistulas

  • High-speed runs (4/6 fps) are useful to identify the entry point into the cavernous sinus;
  • Huber maneuver (injection of contrast into the ipsilateral vertebral artery with manual compression of the carotid artery) is useful to assess reduction of distal perfusion due to the fistula;
  • It is mandatory to assess the venous drainage, determining whether it is retrograde into the ophthalmic vein and whether the ipsilateral or/and controlateral inferior petrosal sinus are visible.


Direct cc fistula - Post-traumatic direct carotid-cavernous fistula on the left. The marked ectasia is on the ipsilateral ophthalmic vein.



Harrigan, M. R., & Deveikis, J. P. (2012). Handbook of Cerebrovascular Disease and Neurointerventional Technique.
Takahashi, S. (2010). Neurovascular Imaging: MRI & Microangiography.




Dr. Simone Peschillo, M.D.

Endovascular Neurosurgeon 
"Policlinico Umberto I" Hospital
"Sapienza" University - Rome (Italy)


Dr. Francesco Diana, M.D.

Interventional Neuroradiology
"Policlinico Umberto I" Hospital
"Sapienza" University - Rome (Italy)