Neurointerventional procedures have revolutionized the treatment of several cerebrovascular diseases, offering minimally invasive alternatives to traditional open surgery [1]. However, these procedures depend on fluoroscopic guidance, exposing both patients and medical personnel to ionizing radiation. As these procedures grow in complexity and frequency, balancing image quality and radiation safety becomes crucial [2-4]. High-quality imaging is also essential for precise diagnosis and treatment, but minimizing radiation exposure is equally important. Therefore, a comprehensive approach to dose reduction is needed while maintaining procedural effectiveness.

With the release of the new IAEA (International Atomic Energy Agency) Guidance on Quality Assurance and Optimization in Interventional Procedures in March 2025 [5], this review explores key strategies for enhancing image quality and reducing radiation dose in neurointerventional procedures.

Reducing radiation dose in neurointerventional procedures involves several key strategies. Using pulsed fluoroscopy instead of continuous fluoroscopy significantly lowers exposure while maintaining image quality, and adjusting frame rates to match procedural needs further optimizes safety [6]. Proper collimation minimizes unnecessary radiation by limiting the field of view, reducing scatter radiation, and enhancing image contrast [7]. Magnification should be used cautiously, as it increases patient dose; digital magnification is preferable over geometric magnification, since it does not require higher radiation output [8]. Additionally, implementing low-dose acquisition protocols across multiple procedures helps reduce cumulative exposure [3,9,10]. Advanced image processing techniques play a crucial role in optimization. Noise reduction algorithms, such as temporal filtering, can improve image quality in low-dose acquisitions [11]. Proper adjustment of window and level settings can enhance visualization without increasing radiation output.

Utilizing last image hold and road mapping features can minimize live fluoroscopy time, which allows interventionalists to navigate catheters and devices with reference to previously acquired images, reducing the need for continuous live imaging. Changing projection angles during prolonged procedures helps distribute skin dose and avoid prolonged exposure to a single area, reducing the risk of deterministic skin effects [12,13]. Tailoring protocols based on patient size, age, and clinical condition is crucial. Pediatric patients and young adults require special attention to dose reduction due to their increased radiosensitivity and longer life expectancy [14]. To decrease the procedure time, selecting the appropriate device is also important [15].

Comprehensive radiation safety training and real-time dose monitoring are vital for maintaining safety during complex neurointerventional procedures [2]. Dose alerts prompt immediate reassessment, while regular reviews of dose metrics against reference levels identify areas for improvement. Periodic image quality assessments ensure diagnostic accuracy isn’t compromised [5]. Continuous collaboration between radiologists, interventionalists, and medical physicists is crucial for refining imaging protocols, enhancing patient safety, and improving image quality. Interventional neuroradiologists play a significant role in these efforts, combining clinical and technical expertise to drive procedural effectiveness and dose reduction across practices.

As technology continues to advance, new opportunities for optimization emerge. Artificial intelligence and machine learning algorithms show promise in further reducing dose while maintaining or even improving image quality [16]. These technologies could potentially assist in real-time protocol optimization, automated collimation, and enhanced image reconstruction.