Angiography in patients with occlusive cerebrovascular disease: views of a stroke neurologist and neuroradiologist.

Even after four decades of use, cerebral angiography continues to be a focus of controversy and misunderstanding among neurologists , surgeons, and neuroradiologists. Cerebral angiography is, or at least should be, performed solely by neuroradiologists and should be requested solely by neurologists, neurosurgeons, or vascular or cardiac surgeons after neurologic consultation. Most often at issue are the indications for angiography, the timing of the procedure, the need for preliminary investigations, and the extent and sequence of opacifications and filming . Improvements in neuroimaging and sonography have definitely reduced the need for angiography. However, angiography is still critical in the evaluation of patients with suspected aneurysms, vascular malformations, and arteritis. Angiography remains the key investigative device to detect, localize, and quantify occlusive cerebrovascular lesions. Tumor, displacement of brain structures, and abnormalities of the ventricles and CSF pathways are now usually defined satisfactorily by CT and MR imaging. We, a stroke neurologist who works closely with neuroradiologists and an experienced neuroradiologist with a special interest in cerebrovascular disease, thought it might be useful to express our views on angiography in regard to patients with occlusive disease. The discussion for the most part is also relevant to MR angiography (MRA), which eventually may partially or completely replace arterial opacification with contrast material. Since the extracranial and all the intracranial arteries cannot be imaged in a reasonable interval by MRA, technology, personnel , and time considerations will limit the number of patients that can be studied and the time available for each patient. Neuroradiologists and neurologists will need to make decisions about which vessels should be studied in which sequence in which patients. Angiographic decisions will need to be individualized irrespective of whether MRA or arterial opacification angiography is performed.