Is it common for an interventionalist to treat an aneurysm during the same session as a diagnostic cerebral angiogram?

Same-Session Treatment During Diagnostic Cerebral Angiography

Yes, it is common and increasingly standard practice for interventionalists to proceed directly to endovascular treatment of aneurysms during the same session as diagnostic cerebral angiography, particularly in the acute setting of ruptured aneurysms. 1

Clinical Context and Current Practice Patterns

The decision to treat during diagnostic angiography depends primarily on whether the aneurysm is ruptured or unruptured:

Ruptured Aneurysms (Acute Subarachnoid Hemorrhage)

• In acute SAH, same-session treatment is the standard approach when endovascular therapy is deemed appropriate, as early aneurysm obliteration reduces rebleeding risk which carries 24% absolute risk reduction in death or disability. 1

• Modern practice increasingly relies on CTA for initial diagnosis and treatment planning, with 61.4% of patients referred directly to endovascular treatment based on CTA findings alone, achieving successful coiling in 92.6% of cases. 1

• When diagnostic angiography is performed in acute SAH, the interventionalist typically proceeds immediately to treatment if the aneurysm anatomy is favorable for endovascular coiling, as any delay increases rebleeding risk. 1

• The combination of 2D and 3D cerebral angiography provides optimal morphological depiction with high spatial resolution and "is, of course, always used in preparation for endovascular therapy." 1

Unruptured Aneurysms

• For elective cases of unruptured aneurysms, same-session treatment is less common but still occurs when:
  • The aneurysm anatomy is clearly favorable for endovascular treatment 1
  • The patient has been appropriately counseled preoperatively about potential same-session treatment 1
  • All necessary equipment and personnel are available 2

Practical Workflow Considerations

The typical modern workflow involves:

• Initial CTA or MRA for aneurysm detection and characterization 1
• Multidisciplinary discussion between neurosurgeons and interventionalists to determine optimal treatment modality 2
• If endovascular treatment is selected, diagnostic angiography transitions seamlessly to therapeutic intervention in the same session 1

Key factors enabling same-session treatment:

• Availability of advanced imaging (3D rotational angiography) in the angiography suite allows real-time treatment planning 1
• Modern endovascular devices (coils, stents, flow diverters) are readily available in neurointerventional suites 1
• Flat-panel volumetric CT can be used intraprocedurally during embolizations for immediate assessment 1

Important Caveats

Situations requiring staged procedures:

• When CTA provides insufficient anatomic detail (occurs in 4.4% of acute SAH cases), diagnostic DSA may be performed first with treatment deferred pending multidisciplinary review 1
• Complex aneurysm anatomy requiring surgical clipping rather than endovascular treatment 1
• Posterior circulation or posterior communicating artery aneurysms more commonly require additional imaging before treatment (67-75% and 62% respectively required preoperative DSA in one series) 3
• Multiple aneurysms where determining the ruptured aneurysm requires careful analysis 3, 2

Radiation exposure concerns:

• The combination of diagnostic CT, CTA, diagnostic angiography, and therapeutic intervention can result in substantial cumulative radiation doses, with risk of scalp erythema and alopecia, requiring judicious use of fluoroscopy time. 1