Pioneering a Neurosurgical Digital Subtraction Angiography (DSA) Program: Lessons From 100 Cases Using 3D C-arm Technology

Introduction: Digital subtraction angiography (DSA) remains the gold standard for diagnosing and managing cerebrovascular diseases, despite the increasing use of noninvasive imaging modalities. Traditionally performed in catheterization labs by interventional radiologists, the integration of DSA into neurosurgery operating theaters (OT) using 3D C-arm technology offers neurosurgeons greater control over diagnosis and treatment planning, reducing dependency on external specialists. Objective: This study aims to describe the initiation and implementation of a DSA program in a neurosurgery OT using 3D C-arm technology, detailing the technique, procedural nuances, and associated benefits. By sharing our institutional experience, we seek to provide a valuable resource for neurosurgeons interested in establishing similar programs. Methods: Between October 2023 and January 2025, 100 diagnostic DSA procedures were performed in our neurosurgery OT utilizing a multi-axis 3D C-arm (Ziehm Vision RFD 3D, Ziehm Imaging, Germany). Patient selection criteria, procedural protocol, radiation safety measures, and complication management strategies were meticulously developed. Arterial access was obtained via the right femoral artery, and angiographic views were optimized to ensure comprehensive cerebrovascular evaluation. Post-procedural care included hemostasis, neurological monitoring, and complication prevention. Results: Among the 100 DSA procedures performed, the most common indication was spontaneous subarachnoid hemorrhage (SAH) in 88 cases (88%). Two patients underwent intra-arterial nimodipine injection for vasospasm management post-aneurysm clipping. No major complications, including stroke or mortality, were encountered. Challenges such as radiation safety, staff training, and equipment acquisition were successfully addressed, leading to improved efficiency and procedural safety over time. Conclusions: The successful implementation of a DSA program in the neurosurgery OT using 3D C-arm technology underscores its feasibility and benefits. Neurosurgeons, with their deep understanding of cerebrovascular anatomy and pathology, are well-positioned to perform DSA, manage complications, and advance endovascular capabilities. This initiative highlights the potential for hybrid neurosurgical practice, bridging the gap between open microsurgery and endovascular interventions, ultimately improving patient outcomes and advancing neurovascular care.