# Cerebral angiography - please help!!



## iamlou (Jun 30, 2015)

I'm so confused with these. Every time I look at the codes in this category, I come up with something else. Can somebody please help guide me? 
EXAM:  IRS-ANGIO-CAROTID/CEREBRAL BI       
HISTORY: male with subarachnoid hemorrhage.  CT and CTA
demonstrate enlarged calcified right supraclinoid ICA and right P-comm,
with secondary streak artifact that limits evaluation.
PRE-PROCEDURE DIAGNOSIS:
Subarachnoid hemorrhage
POST-PROCEDURE DIAGNOSIS:
Same.

PROCEDURES PERFORMED:
Cerebral angiography.
IMAGING MODALITY UTILIZED:
Ultrasound and fluoroscopy.

ACCESS SITE:
Right common femoral artery.
CATHETER POSITION:
Ascending thoracic aorta, left vertebral artery, left common carotid
artery, left internal carotid artery, right brachiocephalic artery, right
subclavian artery, right common carotid artery, right internal carotid
artery.

TECHNIQUE:  Under ultrasound guidance, after achieving local anesthesia with 1 percent
lidocaine, the right common femoral artery was accessed.  Over a guidewire
a 6 French sheath was inserted.  A saline flush was established to the
sheath.  Heparin was omitted.
Subsequently over a  guidewire, a 5 French pigtail catheter was placed in
the ascending thoracic aorta.  LAO thoracic arch aortography was performed.
Catheter was exchanged over a guidewire for a 5 French Berenstein catheter
which was placed into the left subclavian artery.  Injection performed.
Catheter advanced into the left vertebral artery.    Injections performed
centered on the calvarium with the AP and lateral projections.  Catheter
repositioned over a guidewire into the left common carotid artery.
Injection was performed.  Catheter was advanced over a guidewire into the
left internal carotid artery, and injections were performed to the level of
the neck, as well as at the level of the calvarium in the AP and lateral
projections.  Catheter repositioned over a guidewire into the right
brachiocephalic artery.  Injections performed in the RAO projection.
Catheter advanced into the right common carotid artery.  Injection
performed.  Catheter advanced into the right proximal cervical ICA.  With
the catheter in this position, images were obtained at the level of the
calvarium in the AP and lateral projections.  Additional right transorbital
images were obtained.  Catheter was repositioned over a guidewire into the
right subclavian artery.  Injection performed to evaluate the origin of the
right vertebral artery.  Right vertebral artery was not selected, due to
CTA demonstrating patent right vertebral artery, and patent right PICA.
Catheter removed.  Assess site closed using StarClose.
FINDINGS:
Arch: There is a type I transverse thoracic aortic arch.
Right vessel branching anatomy conventional.  Mild atheromatous plaque in
the transverse arch.  No thoracic arch dissection.
Right innominate: Patent.
Right subclavian artery: Patent.
Left subclavian artery: Patent.
Left carotid: The left common carotid, internal carotid, external carotid
arteries are patent.  No dissection or significant stenosis.
Right carotid: The right common carotid, internal carotid, external carotid
arteries are patent.  No stenosis or dissection.
Vertebral arteries: The right and left vertebral arteries are patent, right
is dominant.  The left vertebral artery is selected and left PICA patent.
The right vertebral artery is not selected, and there is not left to right
reflux of the distal right vertebral artery to facilitate assessment of the
right PICA.  The right PICA however, is widely with patent CTA.
Circle of Willis: The right and left supraclinoid ICAs are patent.  The
right supraclinoid ICA is calcified, and in continuity with a calcified
prominent right P-comm.  Proximal to the junction of the right P-comm, the
right posterior cerebral artery, there is aneurysmal change of the vessel
measured at 5.2 mm.  Distal to the aneurysmal segment, there is a tapered
stenosis at the level the proximal right PCA.  The right P2 PCA segment is
fed solely from the enlarged calcified ectatic P-comm.  The left anterior
and middle cerebral arteries are patent.  No left P-comm is visualized.
The right anterior and middle cerebral arteries are patent.
The basilar artery is patent.  The Left P1, P2, PCA are patent.  There is
atresia/occlusion of the right P1, PCA.  Right P2, PCA derives supply from
the ectatic, calcified,  aneurysmal right P-comm.  The right P-comm is a
likely site of hemorrhage.
The right and left internal jugular veins are patent.
COMPLICATIONS:  None.
IMPRESSION:
CEREBRAL ARTERIOGRAPHY DOCUMENTS CALCIFIED RIGHT SUPRACLINOID ICA IN
CONTINUITY WITH AN IRREGULAR CALCIFIED, ECTATIC ANEURYSMAL RIGHT P-COMM.
RIGHT P-COMM DEMONSTRATES APPROXIMATELY A 5.2 MM ANEURYSM, WITH STENOSIS
AND ASSOCIATED IRREGULARITY.  THERE IS ATRESIA/OCCLUSION OF THE RIGHT P1,
WITH RIGHT P2 PCA IS SUPPLIED ENTIRELY FROM THE RIGHT P-COMM WHICH IS
DISEASED, AND LIKELY THE SITE OF HEMORRHAGE.
NO OTHER ANEURYSM EVIDENT.
LEFT AND RIGHT EXTRACRANIAL CAROTID ARTERIES PATENT WITHOUT DISSECTION OR
SIGNIFICANT STENOSIS/OCCLUSIVE DISEASE.
LEFT AND RIGHT EXTRACRANIAL VERTEBRAL ARTERIES PATENT.
The last codes I came up with were: 36224-50, 36225-50, and 36226. 
Thank you in advance for any advice!


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## Prasanna Subbulakshmi (Jun 30, 2015)

codes are 36224-50,36225-RT,36226-LT


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## Amy Pritchett (Oct 5, 2015)

Your codes are:
36224-50
36225-RT
36226-LT

Hope this helps


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