Diagnostic cerebral angiography: A report of the SNIS Standards and Guidelines Committee, endorsed by ANZSNR and ESMINT

BACKGROUND: Diagnostic cerebral angiography (DCA) remains the gold standard for evaluating cerebrovascular pathology despite advances in non-invasive imaging. This guideline provides evidence-based recommendations for the contemporary practice of DCA from a patient-centered perspective. METHODS: A structured literature review was performed searching MEDLINE from January 2019 to July 2024 with regard to the concept of DCA. The strength and quality of evidence were graded according to established criteria. Recommendations were developed by consensus of the writing committee with input from the SNIS Standards and Guidelines Committee and Board of Directors. RESULTS: The management of DCA continues to evolve with advances in technology and technique. The expert panel agreed on the following recommendations:Recommendation 1: DCA should be employed as the reference standard imaging modality for problem-solving ambiguous findings from non-invasive imaging and for guiding endovascular interventions (Class 1, Level B-NR).Recommendation 2: We recommend consultation of the American College of Radiology Manual on Contrast Media for guidelines on the management of contrast reactions.Recommendation 3: A biplane angiographic system should be used for the acquisition of diagnostic cerebral angiograms in order to minimize patient contrast dose (Class 1, Level C-LD).Recommendation 4: Physicians trained and credentialed in performing and interpreting cerebral angiography, including complication avoidance and management, should perform DCA following established safety protocols (Class 1, Level C-EO).Recommendation 5: For conscious sedation during DCA we support the Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists developed by the American Society of Anesthesiologists Task Force.Recommendation 6: The choice of access site should consider anatomic factors, comorbidities, propensity for access site bleeding, patient preference, and individual operator experience (Class 1, Level C-EO).Recommendation 7: Continuous catheter flushing or double flushing and meticulous injection techniques should be employed to minimize the risk of embolic complications during DCA (Class 2a, Level B-NR).Recommendation 8: Normative exposure data should be collected by practitioners using x-ray fluoroscopy in order to adhere to neuroangiography practice guidelines and minimize potential harm to patients (Class 1, Level C-LD).Recommendation 9: It is incumbent on the practitioner to tailor the examination to the clinical question being answered (Class 1, Level C-EO).Recommendation 10: Prompt identification and management of intraoperative complications, including but not limited to the use of emergent thrombectomy for large emboli and treatment for flow-limiting dissections, are crucial to patient safety (Class 1, Level B-NR).Recommendation 11: It is reasonable to use a standardized reporting framework to ensure completeness of reporting with common elements of history, indication, technique, findings, and impression (Class 1, Level C-EO).Recommendation 12: It is reasonable to use arterial closure devices in patients who are at high risk for access site bleeding or who would benefit from a shorter recumbency duration (Class 2a, Level B-NR).Recommendation 13: It is recommended to discuss the study findings with the patient and/or family in a setting that enables processing and retention of the information presented (Class 1, Level C-EO).Recommendation 14: We affirm the practice recommendations of the SNIS Pediatric Committee pertinent to pediatric DCA. CONCLUSIONS: DCA continues to evolve as both a diagnostic and therapeutic guidance tool. These guidelines provide evidence-based recommendations for the safe and effective performance of DCA in the contemporary era.