A Patients Guide to a Cerebral Angiogram

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MOST IMPORTANT

If you are allergic to medicines, please tell the nurse or doctor.
If you suspect that you may be pregnant please tell the nurse or doctor.
If you are diabetic and are taking glucophage (metformin) please tell your doctor. This drug can react with the xray dye and can cause serious kidney damage.
Do not eat anything after midnight the day before your procedure.If you take medicines in the morning, please clarify with the nurse or Dr. Song whether to take these medicines the day of the procedure.

A cerebral angiogram or arteriogram is a study of the blood vessels in your head or neck that supply the brain. This test should be discussed with your physician so that you fully understand the reasons for the procedure.

An angiogram is usually done as an out-patient procedure, with the patient being admitted in the morning and then discharged later the same day. Sometimes these studies are performed on patients who have already been admitted to the hospital, in which case patients return to their hospital ward following the procedure.

Special preparation is needed before the test. A brief physical exam is done to evaluate pulses in the groin and legs. If a person has a weak pulse in the groin, a different artery will be used to insert the catheter. The doctor will also review the person's medical and surgical history. He or she may ask whether the person:

1. takes medicines that thin the blood, such as aspirin or warfarin

2. has a bleeding tendency or any blood disorders

3. the person has any problem with or disease that affects the kidneys

4. has had a prior allergic reaction to medicine or contrast agent or dye

Before the test, the person's blood is tested to check for any bleeding tendency and to check kidney function. A woman of childbearing age will be screened for pregnancy, usually with a urine or blood pregnancy test. This is done because the radiation from the test could harm an unborn child.

The person cannot eat or drink anything for 6 to 8 hours before the test. This allows us to provide medication to make you comfortable during the exam. Dentures, eyeglasses, and jewelry, such as a necklace or earrings, should be removed before the exam.

During Your Angiogram

When you arrive to the radiology department, a nurse will have you change into a hospital gown, and direct you to the angiography suite where you will lie on the angiography table. A blood pressure cuff will be placed on your arm to check your blood pressure and a pulse oximeter on your finger to check your oxygen levels. An I.V. will be placed in your arm to allow us to give medication to make you comfortable during the exam. With attention paid to your privacy, we will shave a small amount of hair from the groin, usually on the right side. The area will be washed with a cleansing solution, and covered with a sterile drape. It will be necessary for you to keep your arms and legs relatively still underneath the drapes so that the area is not contaminated. Your head will rest on a cushion so that it does not move during the examination. A strip of tape may be placed across your forehead to remind you to hold your head still. The doctor will then inject some local anesthetic, or numbing medicine, over the artery in the groin. This causes some stinging when first administered, but the stinging should go away within about 15 seconds. Intravenous sedation (pain medicine to be given through your I.V.) composed of Fentanyl (a narcotic) and Versed (Midazolam),a tranquilizer, will be given to make you comfortable and reduce anxiety. Each patient requires differing amounts of these medicines, so please tell Dr. Song or his nurse if you feel uncomfortable so we can give you more medicine. I truly wish for this procedure to be as comfortable and as stress free as possible.

After the local anesthetic is given, a small needle is used to puncture the artery in the groin, allowing the physician to thread a small, soft wire into the artery. Over this wire, the doctor is able to thread a tiny straw called a catheter into the artery. (The "straw" is very small. It is similar in thickeness to a coffee stirrer) During the placement of the tube in the artery, the anesthetic should prevent pain. Occasionally, there is some mild discomfort even if the anesthetic has been placed. If you experience bothersome pain in the groin, you should tell the physician or the nurse so that they can administer additional medication.

Once the catheter is inserted into the artery, it is navigated using x-ray through the body. There are no nerves in these arteries and you will have no sensation of the movement of the catheter. Once the catheter is in the correct artery, a small amount of x-ray contrast dye will be injected and pictures will be taken with the x-ray machine. During the injection of the contrast dye, you may feel the sensation of warmth. Occasionally during a cerebral angiogram you may see flashing lights in one eye, or have other transient sensations. These sensations are normal and are related to the contrast dye. During the injection, which lasts a few seconds, you will be asked to hold your breath, not swallow, and hold perfectly still. This avoids the picture becoming blurry. The physician may then move the x-ray tube into a new position for another injection in the same artery, or move the catheter into another artery that is necessary for your examination.

During the angiogram, feel free to ask the doctor or the technologist questions as they arise. While the x-ray pictures are being taken, it is important to hold very still so that the angiogram images are not fuzzy. The technologists will instruct you exactly when the pictures are being taken so that you can hold your breath, not move your jaw, or swallow. This period of holding still is only for about ten seconds. If you move, cough, or talk while the pictures are being taken, it will not hurt you, but the pictures may become blurry and need to be repeated. While the pictures are not being taken, you may ask the doctor and technologists questions, although occasionally they will ask you to hold still or not talk.

Through out the course of the angiogram, medications may be given to prevent discomfort and help you relax during the procedure. If you feel anxious or experience discomfort, tell a member of the angiography team so they can help you.

Family & Visitors

If your family or friends accompany you to your angiogram, they should come with you from your room to the Radiology Department where the angiogram is being performed. There is a waiting area close to the angiography room and progress reports can be sent out to the family members or friends. The physician will discuss the results of this test with everyone if that is what you desire. Family members must sign-in in the waiting room area, and the physician performing the procedure should be notified that they would like to discuss the results of the study.

Risks of a Cerebral Angiogram

Your doctor has asked us to perform a test because he/she feels there is no alternative test that will provide the needed information to direct your care. The risk of angiography is extremely small. However, when catheters are put in blood vessels there is always some risk.

The risks primarily relate to placing the needle into the artery in the leg. There is a small risk that the artery could be damaged, bleeding could occur, or you will have pain and discomfort with this procedure. Bruises form if there is some bleeding underneath the skin. A small or moderate bruise should not be of concern. Occasionally this bleeding can be quite large, going from the lower part of the belly down into the thigh. If this occurs, it usually resolves within a few weeks.

The x-ray contrast dyes have markedly improved over the last several years, so that allergic complications and the toxicity of the dye have been greatly reduced. Despite these advances, there is still a very small risk of an unpredictable life threatening allergic reaction to the contrast agent. If you have ever had a contrast allergy in the past or have many other allergies, you should let your physician know.? Generally, these types of allergies can be prevented by pre-treating you with steroids and antihistamines. It is important for you to let you physician know these things before the procedure.

Kidney Injury: Sometimes X-ray dye can cause injury to the kidneys. It is rare but can be worrisome is the patient has pre-existing kidney disease. To minimize this risk, we check the kidneys health by getting a blood test for Creatinine. This blood test does not require fasting. If the patient is taking Metformin (Glucophage) for diabetes, they need to stop the metformin 48 hours before the test and can start the metformin 48 hours after the test.

Whenever catheters are placed in blood vessels in the neck leading up into the brain, there is always a small risk of damage to those blood vessels. This damage can lead to a stroke. While your physician does everything possible to reduce the risk of stroke from an angiogram, the risk cannot be eliminated. Strokes can be mild or even unnoticeable, but occasionally they produce more severe effects such as paralysis, blindness, or loss of life. These severe complications are exceedingly rare and your physicians feel that risk of these complications is much less than the risk of not understanding the blood vessels in your head and neck. Other risks include but are not limited to infection, kidney injury, or allergies to the drugs to make you comfortable.

After Your Angiogram

After the examination, the doctor or assistant will usually pull the catheter out of the artery and apply pressure to the insertion site for about 15 minutes to stop any bleeding. The hole in the artery is very small and bleeding is rarely a problem. It is necessary for you to lay flat and keep your leg straight for 6 hours. This allows the small hole in the artery to completely seal. At the end of the six hours, you may stand up and walk around. If you are feeling well, you may go home. Someone else must drive you home.

In some cases, a short introducing catheter called a sheath may be left in position until it is appropriate to remove it from the artery. There are personnel staffing the hospital wards who are trained to perform this task. In other cases, a special stitch device, designed to close the puncture site, will be placed. In these cases you will be allowed walk or move about much sooner (usually 2 hours). This artery-stitching device is not used in all cases because it may result in a slightly higher risk of infection, which is rarely seen, but can require surgical treatment.

Once the procedure is finished and you are back in your room, you can usually eat right away, and are usually encouraged drink plenty of fluids to help flush the x-ray contrast from your system. Your nurse will assist you if you need to visit the restroom. Most people can use either a bedpan or a urinal. Occasionally it is necessary to place a small tube into the bladder in order to aid relief. Please tell the nurse if you notice any weakness, nausea, itchiness, shortness of breath or the leg or foot becomes cold or painful.

Discharge Information

After you are discharged from the hospital,

ACTIVITIES: Avoid lifting/straining, heavy housework for 48 hours. You may walk as much as is comfortable, but you should not engage in any strenuous activities such as running, bicycling, or lifting. You should call your Doctor for any signs of bleeding or if you are experiencing unusual swelling or pain in the groin area.

You have had medications that may alter your ability to react quickly. Do not operate hazardous mechanical equipment for 24 hours. To continue to flush out the contrast from your kidneys, you may need to drink more fluids for a day. Also, avoid alcoholic beverages for a day as they are dehydrating.
MEDICATIONS: Ask your doctor for specific instructions about blood thinners and Metformin (Glucophage)
CARE OF CATHETER PUNCTURE SITE
a. You may shower the next morning, avoid swimming or bathing where the incision is submerged for a long time underwater to avoid infection.

b. Remove the band-aid in the morning

c. You may notice bruising and soreness at the incision site. This bruising may move down your leg or to the knee area. This is normal.

d. Notify your physician if pain or swelling occurs. Even if it occurs several days after your procedure. Notify your physician immediately if coldness, numbness or pain in the foot develops.
MEDICAL FOLLOWUP: Call and arrange an appointment to see your physician to review the results of the angiogram. Dr. Song will tell you the preliminary results to you and your family, as well as fax these preliminary results to your doctor the day you receive the exam if possible. He will then carefully review your angiogram and dictate a formal report. Please do not be upset is the formal report is different from what he told you on the day of exam. An angiogram is like Dr Song watching a movie of your brain and telling you the story of your brain. And like a movie, the more one sees a movie, the more one picks up the dialogue, plot etc. If there are concerns, please contact Dr. Song and he will be glad to talk to you about it.
IF BLEEDING OCCURS: This is rare, stay calm. Lie down wherever you are. Apply continuous direct pressure just around the puncture site at least fifteen (15) minutes. Never use a tourniquet. If bleeding cannot be controlled, call 911 or your local emergency room number for assistance.
You should not drive yourself or take public transportation home.
HEADACHE: To make your test as comfortable as possible, Dr. Song will give medication to reduce your anxiety and discomfort. Usually the medication is fentanyl and/or Versed. As the drugs wear off patients can develop a headache in the evevning. Please take Tylenol (acetaminophen). ( Also, patient's who are regular coffee drinkers may also develop a dull headache due to not drinking coffee in the morning)

*Sometimes after a procedure Dr. Song will use a device to close off the hole in the leg artery used to work inside the body. To read about the care of your leg with an artery closure device, click here.

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