Abstract
Background:
Cerebral Digital Subtraction Angiography (DSA) is still the standard method for diagnosing and treating neurovascular disorders, including arteriovenous malformations (AVMs), aneurysm formation, or ischemic stroke. Nevertheless, the high radiation exposure required for these procedures endangers patients and clinicians, especially in low-resource environments. Even with advances in radiation safety, there is a lack of data on DSA-induced radiation exposure from rural tertiary care centers where potentially the most recently introduced dose-reduction technologies may not be as accessible.

Aim:
The present study was designed to evaluate the radiation exposure metrics of cerebral DSA procedures at a rural Indian tertiary care center, compare these with global reference standards, and suggest some strategies for minimizing radiation dose.

Methods:
112 cerebral DSA procedures were performed between January 2020 and March 2022 among adult patients encompassed by the present retrospective observational study. Radiation exposure parameters fluoroscopic time, dose-area product (DAP), cumulative dose (CD), effective dose (EFF.DOSE), and peak skin dose (PSD) were collected. The number of frames was also noted. Descriptive statistics were analyzed, and comparisons were based on the DSA finding type pre-DSA diagnosis.

Results:
112 patients underwent cerebral digital subtraction angiography (DSA) during the study. The mean fluoroscopic time was 17.65 minutes, with a DAP of 45.1 Gy·cm² and a cumulative dose (CD) of 544.62 mGy. The peak skin dose (PSD) averaged 304.99 mGy, and the mean effective dose (EFF.DOSE) was 3.93 mSv. Variation in radiation exposure was observed based on pre-DSA diagnoses and DSA findings. Subarachnoid hemorrhage (SAH) cases exhibited the highest exposure, with a fluoroscopic time of 19.11 minutes, a DAP of 48.91 Gy·cm², and a cumulative dose of 659.6 mGy. Comparatively, arteriovenous malformation (AVM) cases had shorter fluoroscopic times (14.67 minutes) and lower DAP (38.81 Gy·cm²). Aneurysm and vasculitis cases had the most extended fluoroscopic times, while "normal" cases had the highest DAP at 67.63 Gy·cm², resulting in the highest effective dose of 5.88 mSv. These findings underscore the variability in radiation exposure across different diagnosis types, highlighting the need for targeted radiation management strategies.

Conclusion:
Radiation exposure from cerebral DSA using a biplane angiography unit in a rural setting is similar to that published in global literature, although room dose could still be optimized. Practicing in line with the ALARA principles, optimizing fluoroscopic time, and adopting emerging dose-reduction technologies may lower radiation exposure, particularly within resource-sensitive environments. Prompt radiation safety is critically dependent on routine operator training and continuous monitoring of doses in real-time.

Key words: Radiation exposure, Cerebral digital subtraction angiography, Fluoroscopic time, Rural tertiary care center, Peak skin dose