Angiography
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Angiography in Gliomas.

Cerebral angiography was once an important diagnostic modality that provided preoperative diagnosis and localization of an intracranial tumor. In the case of deep tumors, angiography also provided a map of the superficial cortical veins, enabling the surgeon to determine where to incise the brain to reach the tumor. This is no longer necessary. Today, CT and MRI provide preoperative tumor evaluation, and intraoperative ultrasound is used at the time of surgery for accurate localization of deep masses and for determining the best surgical approach through the brain. In addition, intraoperative ultrasound can also help the neurosurgeon monitor the extent of resection during surgery.

Despite modern neuroimaging techniques, a few indications remain for preoperative cerebral angiography in evaluating cerebral tumors. A well-localized, rounded, enhancing tumor mass may require differentiation from a giant aneurysm. In the overwhelming majority of instances, this distinction can be made using appropriate MR techniques to demonstrate the presence of hemosiderin-laden clot within the mass and, with MR angiography, to demonstrate flow within the patent portion of the aneurysm cavity. However, in some cases the MRI and MRA findings are equivocal, and angiography is necessary. A giant aneurysm at angiography appears as a small aneurysm that projects into the large mass and only partially fills it.

Occasionally, cerebral angiography is needed to distinguish between a superficial intra-axial cerebral mass and an extra-axial tumor such as a meningioma. Differentiation between intra-axial and extra-axial tumors is almost always positively established using MRI. However, it happens, that a handful of cases in which this distinction was not possible using the MRI studies alone. In these cases, angiography can determine the compartmental localization of the tumor mass by demonstrating the blood supply. Meningiomas are fed by dural arteries. Within the tumor, a characteristic "sunburst" or "spoke-wheel­like" pattern of feeding vessels is seen. The tumor stain is intense, appears late in the arterial phase, and persists well into the venous phase. No early draining veins are seen. Intra-axial masses, on the other hand, will show a pial blood supply and the cortical vessels will be stretched around the lateral aspect of the mass rather than displaced inward from the inner table of the skull.

Angiography of gliomas is nonspecific. Many gliomas, especially those of lower grade, are hypovascular and are only seen as avascular or hypovascular areas surrounded by displaced normal vessels. Higher-grade gliomas may show intense tumor neovascularity in a disorganized pattern, a prominent tumor blush in the mid-arterial phase, arteriovenous shunting with early draining veins, and hypovascular areas representing necrosis or cysts. These characteristics do not permit differentiation of a primary glioblastoma from a metastasis and do not provide information on the tumor histology, grade, or extent. These determinations are all made much more easily and more accurately by CT or MR imaging.

The distinction between an arteriovenous malformation and a tumor is unequivocal with MRI. The flow within the abnormal vessels of an arteriovenous malformation together with the prominent arterial feeders and the large draining veins are well shown on MRI and MRA, making angiography unnecessary.

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