The development of non-ionic contrast mediums, e.g. iohexol, iopamidol, has considerably reduced the risk of complications during or following angiography. Cerebral ischaemia: caused by emboli from an arteriosclerotic plaque broken off by the catheter tip, hypotension or vessel spasm following contrast injection. The reduced amount of contrast used for intra-arterial DSA carries less risk. In the hands of experienced radiologists, permanent neurological deficit occurs in only one in every 5,000 investigations.

Contrast sensitivity: mild sensitivity to the contrast occasionally develops, but this rarely causes severe problems.

Magnetic Resonance Angiography (MRA) (see page 41) INTERVENTIONAL ANGIOGRAPHY

With recent advances, endovascular techniques now play an important role in neurosurgical management.

Embolisation: Particles (e.g. Ivalon sponge) injected through the arterial catheter will occlude small vessels; e.g. those feeding meningioma or glomus jugulare tumours, thus minimising operative haemorrhage.

'Glue' (isobutyl-2-cyanocrylate) can be injected into both high and low flow arteriovenous malformations. Operative excision is greatly facilitated; if the lesion is completely obliterated, this may even serve as a definitive treatment.

Platinum coils inserted into the aneurysm fundus through the angiographic catheter can induce thrombosis and complete or partial obliteration. Whether this permanently protects against rebleeding awaits long-term follow-up (see page 283).

Balloons inflated, then detached from the catheter tip will occlude high flow systems involving large vessels, e.g. carotico-cavernous fĂ­stula, high flow arteriovenous malformations.

All techniques carry some risk of cerebral (or spinal) infarction from inadvertent distal embolisation when used in the internal carotid or spinal systems.

Angioplasty: Inflation of an intravascular balloon within a vasospastic segment of a major vessel may reverse cerebral ischaemia, but the technique is not without risk and experience is still limited in most centres. Trials are currently addressing its role in the management of carotid stenosis and vasospasm after subarachnoid haemorrhage.

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