Basic Principles and Techniques

Diagnostic neuroangiography is the study of the central nervous blood vessels and related cervicocerebral vasculature using radiographs during the injection of intravascular contrast media. Cerebral angiography was first introduced by Moniz in 1927 and remains a vital tool in the neuroradiological evaluation of cerebrovascular diseases. Although neuroangiography had been historically used to evaluate many types of central nervous system diseases, CT and MRI have largely supplanted diagnostic angiography in the primary evaluation of central nervous system diseases. y State of the art CT and MRI offer advanced vascular imaging capabilities, yielding excellent "angiographic" types of information. Nevertheless, diagnostic neuroangiography continues to remain the gold standard in the evaluation of vascular diseases related to the head, neck, and spine.

The goal of neuroangiography is to define and outline the cerebral vasculature, both for diagnostic and potentially therapeutic purposes. Typical cerebral angiography is performed using the femoral arterial approach to gain access to the cerebrovascular arterial tree. Alternatively, in selected cases, the axillary, brachial, or direct cervical approaches

Figure 23-19 Adhesive arachnoiditis/!, Anteroposterior view of lumbar myelogram. The thecal sac below the level of the L2-3 disc space is narrowed and featureless with central clumping of distal nerve roots giving the appearance of a pseudocord. Note absence of posterior elements at L3 and L4 secondary to prior decompressive laminectomy surgery. A small amount of contrast has inadvertently been injected into L2-3 disc space during lumbar piB, Postmyelogram CT scan through the L3-4 disc space. Central clumping of lumbosacral nerve roots with "pseudocord" appearance is once again noted. Large bilobed pseudomeningocele protruding through laminectomy defect into deep and superficial soft tissues represents postoperative complication secondary to dural tear with continued CSF leak.

may be used as necessary. After access, nonselective catheterization of the aortic arch or selective catheterizations of the cervical arteries (specifically, the carotid or vertebral arteries) can be performed. Contrast medium is injected through the catheter with simultaneous radiographic filming of appropriate vascular territories such that diagnostic images of the cerebral vasculature are obtained. Current microcatheter technology also permits superselective angiographic analysis of smaller branch vessels of the brain, for both diagnosis and management of intracranial diseases.

Conventional film-screen technology in modern cerebral angiography has largely been replaced by digital subtraction technology. State-of-the-art digital suites now image with a 1024y matrix resolution, providing exquisite vascular detail. In addition, digital angiography allows rapid image acquisition, instantaneous review, and pixel shifting capabilities, providing vascular resolution unsurpassed by conventional filming. For these reasons, conventional film screen angiography is rapidly becoming outmoded and most new, dedicated neuroangiographic suites are now constructed solely with digital angiographic capabilities.

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