ANGIOGRAPHY

Refers to the radiographic examination of vessels after injection of contrast media.

-A general term that describes the radiologic examination of vascular structures within the body after the
introduction of an iodinated contrast medium or gas.

- Angiographic procedure is performed in a specialized imaging suite under sterile condition.

INDICATIONS:

Mass lesion
Intracerebral vessels
Aneurysm
Vascular occlusion
Tumors

CONTRAINDICATIONS:

Contrast media allergy

Impaired renal function
Blood clothing disorders
Anticoagulant medication
Unstable cardio pulmonary
Neurologic status

PREPARATION OF PATIENT:

Before the initiation of an angiographic procedure, It is appropriate to explain the process and
potential complications to the patient.
Written consent is obtained, after explanation.
The patients legs should be elevated, and IVFs may be administered to help restore blood
pressure.
Patients are usually restricted to clear liquid intake and routine medications before undergoing
angiography.
Solid food intake is restricted to reduce the risk of aspiration related to nausea.
The CIT or physician should warn the patients about sensations caused by CM, and the noise
produced by the imaging equipment.
Medical history should be obtained before the procedure is begun.
PREPARATION OF EXAMINING ROOM
Check the angiographic equipment and all working parts of the equipment, and adjust the controls
for the exposure technique to be employed.
Have restraining bands available for application in combative patients.
Ensure patients information is entered correctly on acquisition equipment.
 Sterile and non-sterile items required for introduction of the contrast media vary according to the
method of injection.
VESSELS ACCESS FOR CM.

Four vessels are typically considered for catheterization.

1. Femoral-is the preferred site for an arterial puncture because of its size and easily accessible
location.
2. Axillary
3. Brachial
4. Radial

CONTRAST MEDIA USED:

Water soluble non-ionic iodinated substance

Opaque contrast media
Case report

Patient profile:

Name: unknown

Age: 55 years old

Gender: Female

Medical history:

A history of chest pain that radiated to the left arm at mild exertion. she reported fibromyalgia and a history
of allergy to iodinated CM (anaphylactic shock), sulpha drugs, dipyrene, and non-steroidal anti-
inflammatory drugs.

Diagnosis: sinus rhythm with isolated ventricular extra systoles and left ventricular overload.

Procedure/ Examination underwent:

Because of history of anaphylaxis to iodinated contrast, no allergy test to iodinated contrast agents were
performed. The patient was treated prior to the coronary angiography with 180mg/day of fexofenadine
orally, 25mg of hydroxyzine, and 20mg of prednisone orally every 8 hrs. beginning 25 hrs before the
procedure.

Result and findings:

A coronary angiography was performed via femoral artery access (5 F introducer and catheter); it showed
coronary arteries with parietal irregularities.

A total of 30 ml of godobutrol was used, and the procedure was uneventful the patient was discharge the
next day.

Other pertinent examination done:

Trans thoracic echocardiogram showed left ventricular ejection fraction of 43%, systolic segment
dysfunction (septal akinesia), and left ventricular relaxation alteration.

CEREBRAL ANGIOGRAPHY

-Is the radiologic and angiographic examination of the blood vessel of the brain.

INDICATIONS:

Intracranial lesion
Anuerysm
Arteriovenous malformation
Tumors
Arterosclerotic or stenotic lesions

CONTRAINDICATIONS:

Patients are too ill to receive contrast, or patients that have a history of allergy to contrast.
Elderly patients- increased age increased risk.
Marked hypertension
Severe subarachnoid or intracerebral hemorrhaging.
Coagulopathy
Compromised renal failure
PREPARATION OF PATIENT:

1. Adults patients are examined under local anesthesia in conjunction with the sedation. Adequate
sedation minimizes the intensity of the burning pain felt along the course of injected vessels.

-the sedative has an advantage of lessening the possibility of a reaction resulting in reflex movement
during initial arterial filming at or before the end of each injection.

2. Conscious patient should receive a careful explanation of what to expect during the examination or
what is expected of him.
PROJECTIONS:

Simultaneous biplane oblique projections

Position of patients: supine

Position of parts: place the IR in a 35 degrees RPO position this positions opens the aortic arch and the
origin of the great vessels

For the AP oblique projection which frees the carotid and vertebral arteries from superimposition.

Raise the patients chin to superimposed the inferior margin of the mandible onto the occiput so that as
much of the neck as possible is exposed in the frontal image.

Central ray

Direct perpendicular to the center of the image receptor to enter the patient at a level 1 inch superior to
the sternal angle.

LATERAL PROJECTION

Patient position: supine

Part position: center the patients head to the vertically placed IR.

Extend the patients head enough to place the IOML perpendicular to the horizontal

Adjust the patients head to place the MSP vertical and parallel with the plane of the IR.

CR: directed horizontally to a point horizontally to a point slightly cranial the auricle and

Forehead and the occiput.

AP AXIAL PROJECTION

(SUPRAORBITAL)

Patient position: supine

Part position: adjust the patients head so that the MSP is centered over and perpendicular to the midline of
the grid and so that it is extended enough to place the IOML vertically

CR: directed to the central ray 20 degrees caudally.

CASE REPORT
Patient profile:

Name: x

Age: 55 years old

Gender: female

Medical history:

Presented with onset of headache, dizziness progressive ataxia, with a history of non- hodgkin lymphoma.

Diagnosis:

Aneurysm of the left PICA with hemorrhage in the left cerebellum, also, there were multiple segments of
abnormally dilated branches of the arteries of the posterior fossa as well as the left posterior cerebral
artery. w/c suggest the diagnosis of vasculitis.

Procedure /examination underwent:

She underwent cerebral angiography showing an aneurysm of the left posterior cerebral artery. That was
thought to be the source of hemorrhage.

Result and findings:

A repeat angiogram was performed 3 weeks after the initial hemorrhage and showed an aneurysm of the
left PICA with hemorrhage in the left cerebellum.

Other pertinent examination done:

She underwent MR imaging of the brain and revealed the left cerebellar hemorrhage w/ mildly increased T2
signal intensity in the periventricular white matter.

Cardiac catheterization

Is performed to identify the anatomic and physiologic condition of the heart

-The data gathered during catheterization provide the physician with information to develop management
strategies for patient who has cardiovascular disorder.

INDICATIONS:

Suspected or known coronary artery disease

Myocardial infarction
 Sudden cardiovascular death
Valvular heart disease
Congenital heart disease
Aortic dissection
Pericardial constriction
Cardiomyopathy
Initial and follow up assessment for heart transplant.

CONTRAINDICATIONS:

Active gastrointestinal bleeding

Acute renal failure
Recent stroke
Fever from infection or the presence of active infection
Severe electrolyte imbalance
Severe anemia
Severe uncontrolled hypertension
Coagulopathy or bleeding disorder
Aortic valve endocarditis

PREPARATION OF PATIENTS:

Before the catheterization is performed, the procedure is explained and informed consent is
obtained.
Various medications are frequently administered for sedation and control of nausea.
Patient is not allowed to eat or drink for 4-6 hours before the procedure or after midnight.
During all catheterizations, a protocol of the procedure is maintained.

The records include:

Hemodynamic data, fluoroscopy time, medications administered, supplies used and other pertinent
information.

CATHETERIZATION STUDIES AND PROCEDURES:

The catheter may be introduced through the radial, brachial or femoral artery and advanced over a guide
wire to the ascending aorta. When in the ascending aorta, the guide wire is removed, and the catheter
is aspirated and flushed to prevents backward flow of CM. into the left ventricle during injection,
whereas an insufficient valve does not.

Arterial oximetry and blood pressure measurements within the aorta are taken using the manifold system,

After these the catheter is passed through the aortic valve into the left ventricle.
Case report

Patient profile:

Name: Y

Age: 66 years old

Gender: male

Medical history:

He had a positive nuclear stress test that showed reduced blood flow to the left ventricle.

Diagnosis:

High grade triple vessel disease (narrowing)

Examination /Procedure done:

He was referred for cardiac catheterization

The approach was planned through the radial artery (in the arm) this approach is associated w/ reduced
bleeding during and after the procedure. The total blood loss during the cardiac catheterization
procedure was 50ml 1% of total blood volume.

-coronary artery bypass surgery was recommended.

Result and findings:

The Dr. decided that the patient would be best served by performing an off-pump cardiac surgery
associated with bypass machine, since w/ traditional bypass a substantial amount of the patients
blood is left behind in the circuit of the machine and is unrecoverable.

A special octopus retractor was used to stabilize the heart because during surgery the heart continues to
beat. 3 days later the patient was discharge and looks and felt as good as ever.

RENAL ARTERIOGRAPHY
A way to see the blood vessels of the kidneys
This procedure allows seeing your veins.
They will be able to see the blockages, clots, narrowing and other problems

Indications:

Blood clots
Blockages
Abnormal structural issues
Spasms in the vessels
Tumors
High blood in the vessels
Widened blood vessels

Contraindications:

Allergic reaction to the contrast media

Arterial occlusion from dissection
Damage to the artery or artery wall which can lead to blood clots
Kidney damage from the damage to the artery or from the dye.

Preparation of patient:

Do not eat or drink for 6-8 hours before the test.

You will be given a hospital gown to wear and asked to remove all jewellery
Maybe required to take pain pill (sedative) before the procedure.
AORTOGRAPHY

Radiographic visualization of the aorta and its branches by injection of a radiopaque substance and
involves placement of a catheter in the aorta while taking x-rays of the aorta.

Indications:

Aneurysm
Aortic dissection
Aortic regurgitation or aortic stenosis, when blood returns back to the ventricle
Congenital heart defects
Inflammation of the aorta
Injury to the aorta from trauma or other problems
Peripheral artery disease
Recurring chest pain

Contraindications:

Allergic reaction to the dye

Blockage of the artery
 Blood clots
Bruising
Heart attack
Infection
Injury to the aorta
Irregular heart rhythms
Kidney damage
Stroke
Tear in the artery

Preparation of patients:

Before the test, your doctor will give you full physical examinations. This will include checking your blood
pressure and other vital signs. Tell your doctor about all medications or supplements youre taking
including non-prescription and over the counter drugs.

Fasting for 12 hours before the procedure, limiting liquids and stopping any medications that affect blood
clothing

Your doctor will give you a sedatives and possibly anaesthesia via an IV.

Contrast medium used:

Radiopaque contrast media

DACREOCYSTOGRAPHY

Allows visualization of the lacrimal system by direct injection of contrast into the cannalinus of the eyelid.
It may be combined with CT imaging performed immediately after lacrimal system contrast injection.

Indications:

To determine the potency of the lacrimal drainage system

Epiphora- to demonstrate the site and degree of obstruction

Contrast Medium used:

Low osmolar contrast media

Preparation of patients:

0.5% of bupivacaine eye drop

Procedure:
 Explain the procedure to the patient and gain consent

Wash your hands, put on gloves

Place patient in supine position

Instill a drop of tropical anesthetic into palpebral apparatus of both eyes

A control film is taken after intubation of both lower punction wilt portex intravenous canulae size 27
gauge.

VENOGRAPHY

Radiographic visualization of the vessels using contrast media.

Types of venography:

1. Ascending venography-allows your doctor to see the location of deep vein thrombosis or blood
clots in your legs.
2. Descending venography- allows your doctor to measure the function of the valves in the deep
veins
3. Upper extremity venography-visualization of vascular abnormalities in the veins in your neck and
arms.
4. Venocavography-asses the function of your inferior vena cava.
Assess the status of a veinor systems of veins
Find blood clots within the veins
Assess varicose veins before surgery
Find a vein in good condition to use for a bypass procedure or dialysis access
Help physician place an IV or a medical device, such as stent in a vein
Guide treatment of disease veins.

Contraindications:

In rare cases a venogram can cause thrombosis

Not recommended for pregnant patient

Not recommended for patients who are diabetic

Kidney problems

Allergic reaction to the dye

Infection at the site of an injection

CONTRAST MEDIUM USED:

 Iodine or barium contrast

CENTRAL NERVOUS SYSTEM

Divided into two parts:

Brain

Occupies the cranial cavity

Composed of an outer matter called the cortex, and the inner portion of white matter.
Consist of the cerebellum, cerebrum and the brainstem which continuous the spinal cord
Brainstem consists of the midbrain, pons and medulla oblongata.
Cerebrum the largest portion of the brain.

Spinal cord

Slender elongated structure, extend from the brain where it is connected to the medulla oblongata
at the level of foramen magnum to the approximate level of the space between the first and second
lumbar.

Meninges

Three continuous protective membranes enclose the brain and the spinal cord.

Ventricular system

Consist of four irregular, fluid containing cavities that communicate with one another through
connecting channels.

VENTRICULOGRAPHY

General term applied to the radiologic examination of the brain by means of the introduction of a
gaseous medium into the ventricular system.
It is employed to demonstrate space occupying intracranial lesions as shown by filling outline of the
gas filled ventricular system or the subarachnoid cisternae and channels.

CONTRAST MEDIUM USED:

Air
Gas
Carbon dioxide

Indications:
 Brain tumors
Brain abscess
Brain lesions
Memory problems

Contraindications:

Contrast allergy
Vomiting
Headache

Some cases will show the value of positive contrast ventriculography.

1. With the midline tumor detected by CT scan one has to consider what kind of tumor it might be and
obtain information about its operability.
2. Cause of hydrocephalus this is of importance in deciding what particular neurosurgical procedure
may be necessary.
3. Decompression of cystic tumors during ventriculography.
PNEUMOENCEPHALOGRAPHY

Was a common procedure in which most of the CSF was drained from around the brain by means of a
lumbar puncture and replace by air, oxygen or helium to allow the structure of the brain to show up
more clearly on an x-ray image.

Indications:

Brain tumors

Brain lesions

Contraindications:

Allergy to the CM

Severe vomiting

Headache

Procedure:

1. The air or gas is introduced, in small increments by exchange with CSF into the lower back, with
the patient in sitting position.
2. The patients entire body would be rotated into different positions in order to allow air to displace
the CSF in different areas of the ventricular system and around the brain.

Purpose:
 1. Radiographic visualization of the cerebral ventricles, basal cestern and subarachnoid space after
the injection of air or gas.
2. Radiographic visualization of the fluid containing structure of the brain.
MYELOGRAPHY
Is the radiographic examination of the spinal cord by used of contrast medium injected into the intracranial space.
Also useful in identifying narrowing of the subarachnoid space

Indications:

Intraspinal abnormalities

Nerve root abnormalities

Disk prolapse, herniation

Spondylosis

Spinal stenosis

Tumors

Metastases

Contraindications:

Cerebral aneurysm, arteriovenous malformations

Recent lumbar puncture
Previous reaction to the same contrast medium.

Contrast media:

Omnipaque-nonionic, water soluble contrast that is less neurotoxic than contrast media previously used in
myelography.

Isovist-another non-ionic, water soluble contrast agent that test have shown to be even toxic than
omnipaque.

Patient preparation:
The patient should be well hydrated before the procedure.
Informed consent should be signed.
The patient should remove all clothing and done a patient gown.
If body hair is present in the area of injection, the area may need to be shaved
The procedure should be fully explained to the patient and an adequate history should be taken.
Vital signs are taken from commencement of the procedure to serve as a baseline.
Discography

-Radiologic examination of individual intervertebral disk by means of injection of a small quantity of the
water soluble, iodinated media into the center of the disk by double-needle entry.

Indications:

If surgical management is a viable option.

Pain is not responding to conservative treatment measures.
Pain persists for an extended period of time.
Failed back surgery
Back and neck pain

Contraindications:

Patient with a known bleeding disorder and those on anticoagulation therapy.

Pregnancy
Systemic infection or skin infection over the puncture site.
Allergy to contrast procedure testing with omnipaque contrast, the test can be performed by
gadolinium contrast.
Solid bone fusion that does not allow access to the disc.
Severe spinal canal compromise at disk level to be investigated.
Preparation of patients:

For patients with severe iodine contrast allergy includes gadolinium contrast and saline.patients might take
fluids, but should not eat for 2 hour before the procedure.

Warfarin is stopped 5 days prior to the procedure.

Pain medicines, anti-inflammatory medicines, sedatives and any medicines that alter the patients
perception to pain should not be used the day of the procedure.

LUMBAR RADICULOGRAPHY
This is performed by injection of contrast medium into the lumbar thecal sac.it is possible to introduce the CM from
above by cervical injection.

Indications:

Suspected cauda equina compression

Spinal stenosis
Conus medullaris lesions

Contraindications:

Raised intracranial pressure

 Recent lumbar pucture
Preliminary film:
1. AP and Lateral projections of the region under study.

Preliminary examination of plain films is helpful to assess the anatomy of the spine in order to facilitate the
lumbar puncture, and to assist in interpretation of the images. It is important to draw the surgeons
attention to any question of anbiguous segmentation, either lumbarization or sacralization.

Refference: Merrils radiographic positioning