Interventional Neuroradiology

  • Ravi Bhoja
  • Meghan Michael
  • Jia W. Romito
  • David L. McDonaghEmail author


Interventional neuroradiology (INR) has remarkably evolved over recent years and serves as an alternative to many open neurovascular procedures. Endovascular therapy is less invasive and allows for some interventions that simply cannot be performed with open surgery, making it a primary approach for treating a host of thrombo-occlusive and hemorrhagic neurovascular conditions. To that end, INR also poses many challenges for the anesthesiologist from caring for fragile or critically ill patients in an off-site location to having to navigate through various physical obstacles within the interventional suite.

This chapter will (1) explore the challenges met with working in an angiography suite, (2) discuss a basic approach to the anesthetic regimen and management of common INR procedures, (3) review the uses of endovascular therapy in the treatment of various neurological conditions (both elective and emergent), and (4) discuss some of the common complications encountered in INR.


Interventional neuroradiology Endovascular neurosurgery Neuroanesthesia Anesthesia Cerebrovascular disease Stroke thrombectomy Aneurysm coiling Cerebral vasospasm Arteriovenous malformation treatment 


  1. 1.
    Young WL, Pile-Spellman J. Anesthetic considerations for interventional neuroradiology. Anesthesiology. 1994;80(2):427–56.PubMedCrossRefGoogle Scholar
  2. 2.
    Tonnessen BH, Pounds L. Radiation physics. J Vasc Surg. 2011;53(1 Suppl):6S–8S.PubMedCrossRefGoogle Scholar
  3. 3.
    United States Department of Labor Occupational Safety and Health Administration. Radiology OSHA safety and health topics. Washington, DC: United States Department of Labor Occupational Safety and Health Administration; 2018.Google Scholar
  4. 4.
    Varma MK, Price K, Jayakrishnan V, Manickam B, Kessell G. Anaesthetic considerations for interventional neuroradiology. Br J Anaesth. 2007;99(1):75–85.PubMedCrossRefGoogle Scholar
  5. 5.
    Eskioglu E, Burry MV, Mericle RA. Transradial approach for neuroendovascular surgery of intracranial vascular lesions. J Neurosurg. 2004;101(5):767–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Ross IB, Luzardo GD. Direct access to the carotid circulation by cut down for endovascular neuro-interventions. Surg Neurol. 2006;65(2):207–11.. discussion 211PubMedCrossRefGoogle Scholar
  7. 7.
    Ruijters D, Homan R, Mielekamp P, van de Haar P, Babic D. Validation of 3D multimodality roadmapping in interventional neuroradiology. Phys Med Biol. 2011;56(16):5335–54.PubMedCrossRefGoogle Scholar
  8. 8.
    Schwartz BG, Burstein S, Economides C, Kloner RA, Shavelle DM, Mayeda GS. Review of vascular closure devices. J Invasive Cardiol. 2010;22(12):599–607.PubMedGoogle Scholar
  9. 9.
    Barrett BJ, Parfrey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006;354(4):379–86.PubMedCrossRefGoogle Scholar
  10. 10.
    McDonagh DL, Olson DM, Kalia JS, Gupta R, Abou-Chebl A, Zaidat OO. Anesthesia and sedation practices among neurointerventionalists during acute ischemic stroke endovascular therapy. Front Neurol. 2010;1:118.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Luginbuhl M, Remonda L. Interventional neuroradiology. Recent developments and anaesthesiologic aspects. Minerva Anestesiol. 1999;65(6):445–54.PubMedGoogle Scholar
  12. 12.
    Wang LP, Wolff J. Anesthetic management of severe chronic cardiopulmonary failure during endovascular embolization of a PICA aneurysm: a case report. J Neurosurg Anesthesiol. 2000;12(2):120–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110.PubMedCrossRefGoogle Scholar
  14. 14.
    Steiner T, Juvela S, Unterberg A, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis. 2013;35(2):93–112.PubMedCrossRefGoogle Scholar
  15. 15.
    Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery. 2002;51(5):1101–5.. discussion 1105–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009;8(7):635–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74.PubMedCrossRefGoogle Scholar
  18. 18.
    Li H, Pan R, Wang H, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke. 2013;44(1):29–37.PubMedCrossRefGoogle Scholar
  19. 19.
    Otani T, Nakamura M, Fujinaka T, et al. Computational fluid dynamics of blood flow in coil-embolized aneurysms: effect of packing density on flow stagnation in an idealized geometry. Med Biol Eng Comput. 2013;51(8):901–10.PubMedCrossRefGoogle Scholar
  20. 20.
    Osborn IP. Anesthetic considerations for interventional neuroradiology. Int Anesthesiol Clin. 2003;41(2):69–77.PubMedCrossRefGoogle Scholar
  21. 21.
    Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol. 2011;32(1):34–40.PubMedCrossRefGoogle Scholar
  22. 22.
    Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke. 2001;32(9):1998–2004.PubMedCrossRefGoogle Scholar
  23. 23.
    Lee KH, Lukovits T, Friedman JA. “Triple-H” therapy for cerebral vasospasm following subarachnoid hemorrhage. Neurocrit Care. 2006;4(1):68–76.PubMedCrossRefGoogle Scholar
  24. 24.
    Katsaridis V, Papagiannaki C, Aimar E. Curative embolization of cerebral arteriovenous malformations (AVMs) with Onyx in 101 patients. Neuroradiology. 2008;50(7):589–97.PubMedCrossRefGoogle Scholar
  25. 25.
    Jafar JJ, Davis AJ, Berenstein A, Choi IS, Kupersmith MJ. The effect of embolization with N-butyl cyanoacrylate prior to surgical resection of cerebral arteriovenous malformations. J Neurosurg. 1993;78(1):60–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Ahmed AMC, Fistulas A. In: Michael J, RBD A, editors. Encyclopedia of the neurological sciences. 2nd ed. San Diego: Elsevier; 2014. p. 277–80.CrossRefGoogle Scholar
  27. 27.
    Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.PubMedCrossRefGoogle Scholar
  28. 28.
    Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.PubMedCrossRefGoogle Scholar
  29. 29.
    Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.PubMedCrossRefGoogle Scholar
  30. 30.
    Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.PubMedCrossRefGoogle Scholar
  31. 31.
    Abou-Chebl A, Lin R, Hussain MS, et al. Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter study. Stroke. 2010;41(6):1175–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Jumaa MA, Zhang F, Ruiz-Ares G, et al. Comparison of safety and clinical and radiographic outcomes in endovascular acute stroke therapy for proximal middle cerebral artery occlusion with intubation and general anesthesia versus the nonintubated state. Stroke. 2010;41(6):1180–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Nichols C, Carrozzella J, Yeatts S, Tomsick T, Broderick J, Khatri P. Is periprocedural sedation during acute stroke therapy associated with poorer functional outcomes? J Neurointerv Surg. 2010;2(1):67–70.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Schonenberger S, Uhlmann L, Hacke W, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. JAMA. 2016;316(19):1986–96.PubMedCrossRefGoogle Scholar
  35. 35.
    Lowhagen Henden P, Rentzos A, Karlsson JE, et al. General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke: the anstroke trial (anesthesia during stroke). Stroke. 2017;48(6):1601–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.PubMedCrossRefGoogle Scholar
  37. 37.
    Simonsen CZ, Yoo AJ, Sørensen LH, Juul N, Johnsen SP, Andersen G, Rasmussen M. Effect of general anesthesia and conscious sedation during endovascular therapy on infarct growth and clinical outcomes in acute ischemic stroke: a randomized clinical trial. JAMA Neurol. 2018;75(4):470–7. Scholar
  38. 38.
    Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378:11–21.PubMedCrossRefGoogle Scholar
  39. 39.
    Namasivayam S, Kalra MK, Torres WE, Small WC. Adverse reactions to intravenous iodinated contrast media: a primer for radiologists. Emerg Radiol. 2006;12(5):210–5.PubMedCrossRefGoogle Scholar
  40. 40.
    Trytko BE, Bennett MH. Arterial gas embolism: a review of cases at Prince of Wales Hospital, Sydney, 1996 to 2006. Anaesth Intensive Care. 2008;36(1):60–4.PubMedCrossRefGoogle Scholar
  41. 41.
    Moon REGD. The physiology and medicine of diving. New York: Elsevier Science; 2003.Google Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Ravi Bhoja
    • 1
  • Meghan Michael
    • 1
  • Jia W. Romito
    • 1
  • David L. McDonagh
    • 1
    Email author
  1. 1.Department of Anesthesiology and Pain ManagementUniversity of Texas Southwestern Medical CenterDallasUSA

Personalised recommendations