Study guide
Conventional Angiography & Cranial–Spinal Shunts
ABPN Neurocritical Care Study Guide Exam
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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU
Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU
2 Chapter 2: Cerebral Physiology & Intracranial Dynamics
Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes
3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management
Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions
4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management
Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy
5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management
Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury
6 Chapter 6: Neuropharmacology, Analgesia & Sedation
ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU
7 Bleeding, Thrombosis & Hematologic Emergencies
Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity
8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine
Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention
9 Systemic Trauma & Environmental Injury
Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging
10 Cardiac Emergencies & Mechanical Support
IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies
11 Kidney Injury, Acid–Base & Renal Replacement
Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement
12 Systemic Infection & Endocrine Emergencies
Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies
13 Gastrointestinal & Hepatic Emergencies
Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects
14 Chapter 9: Neuroimaging in the Neuro-ICU
Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness
15 Chapter 10: Electrophysiology & Neuromonitoring
Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler
16 Angiography, Electrodiagnosis & CSF Analysis
Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage
17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria
Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria
18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies
Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction
19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage
Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH
20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia
Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations
21 Venous, Spinal & Traumatic Vascular Disease
Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury
22 Chapter 15: Traumatic Brain & Spinal Cord Injury
Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes
23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies
Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure
24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis
Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies
25 Neuroinflammation & Neurooncology
Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies
26 Pregnancy, Transplantation & Pediatric Care
Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care
27 Chapter 18: Neurosurgical & Perioperative Emergencies
Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies
28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU
Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor
Conventional Angiography & Cranial–Spinal Shunts
Key Takeaways Explain This Topic AI
DSA depicts arterial, capillary, and venous phases and can characterize aneurysms, AVMs, fistulas, or selected vasculopathies.
A symptomatic unruptured aneurysm, such as one producing a new third-nerve palsy, needs urgent neurovascular assessment.
Spinal dural AV fistula can cause progressive congestive myelopathy and may be mistaken for inflammatory disease.
Angiography can cause embolic stroke, dissection, access complications, and contrast-related problems.
Last updated: October 2026
Ask a Question That Angiography Can Answer
Digital subtraction angiography (DSA) removes background structures from contrast images to show vessels with high spatial and temporal detail. It can display arterial filling, capillary transit, early venous drainage, collateral routes, and lesion anatomy. CT and MR angiography are less invasive and often appropriate first studies, but DSA may resolve a specific unanswered question or support treatment in the same session.
The blueprint includes conventional cerebral angiography, vascular anomalies, symptomatic unruptured aneurysms, and cranial and spinal dural fistulas. Do not order DSA reflexively for every abnormal noncontrast scan. Define whether the question is an occult aneurysm, a high-flow shunt, venous drainage architecture, vasospasm, dissection, or an intervention plan. The expected benefit must justify procedural risk.
Read the Temporal Phases
- Phase or finding What to assess
- Arterial phase Vessel caliber, occlusion, aneurysm shape, feeding arteries
- Capillary phase Tissue perfusion and abnormal vascular blush
- Venous phase Drainage routes, stenosis, reflux, delayed emptying
- Premature venous filling Arteriovenous shunting
- Collateral filling Alternate supply and its timing
For an aneurysm , define location, neck, dome, relation to branches, irregularity, and features relevant to treatment. A new pupil-involving third-nerve palsy with a compatible aneurysm raises concern for symptomatic compression and possible instability. Even without subarachnoid blood on CT, urgent neurovascular evaluation is needed. Management of an unruptured lesion depends on symptoms, anatomy, patient factors, rupture risk, and treatment risk rather than a single size threshold.
After an angiogram-negative SAH, further investigation depends on the blood pattern, quality and completeness of the first studies, clinical findings, and the specialist plan. A diffuse aneurysmal pattern raises greater concern for an occult lesion than a strictly perimesencephalic pattern. Do not represent one fixed repeat-imaging day as a universal rule for every patient.
AVMs and Cranial Dural Fistulas
A brain AVM has a nidus connecting feeding arteries to draining veins without an ordinary intervening capillary network. DSA helps define feeders, associated aneurysms, and superficial or deep drainage. The Spetzler–Martin scale estimates microsurgical risk and is not itself a universal directive to operate. Prior rupture, symptoms, location, age, and treatment options all influence decisions.
A dural arteriovenous fistula is a shunt between dural arterial supply and venous structures. Venous drainage is central to risk: cortical venous reflux or direct cortical drainage can cause venous congestion, hemorrhage, and neurologic deterioration. A lesion draining without cortical reflux may have a different natural history and symptom burden. The angiographic study must identify the shunt and drainage sufficiently to plan safe disconnection while preserving necessary normal venous pathways.
Classification systems describe different aspects of this anatomy. Avoid treating every Borden and Cognard category as an exact one-to-one correspondence. Cognard type V includes spinal perimedullary venous drainage, a reminder that a cranial shunt may have spinal manifestations. Clinical urgency is determined by drainage, symptoms, hemorrhage, and the specialist assessment.
Spinal Dural AV Fistula
Spinal dural AV fistula can cause progressive venous congestive myelopathy, often with gait difficulty, leg weakness, sensory change, and bladder dysfunction. Symptoms may fluctuate before becoming steadily worse. MRI can show longitudinal cord edema and abnormal perimedullary vessels, but findings are not always obvious. The syndrome can be misdiagnosed as inflammatory myelitis or degenerative spine disease.
Catheter spinal angiography is the definitive anatomic investigation when the suspicion is sufficient. It can require evaluation of multiple segmental vessels by an experienced team. An incomplete negative study does not provide the same reassurance as an appropriately complete investigation. Treatment aims to disconnect the abnormal shunt and venous drainage through selected endovascular or surgical methods. Delay can permit ongoing cord injury, so progressive unexplained myelopathy with vascular clues warrants reassessment.
Procedural Safety and Post-Procedure Deterioration
Before DSA, assess access, hemostasis, antithrombotic exposure, renal function, contrast-reaction history, airway and transport risks, and intracranial stability. Sedation must permit safe imaging while preserving systemic perfusion. Document a baseline neurologic and limb examination when feasible. A blood-pressure fall during the procedure can harm collateral-dependent tissue even when the catheter images are technically satisfactory.
Afterward, evaluate new focal deficits promptly for thromboembolism, dissection, hemorrhage, or contrast-related encephalopathy rather than dismissing them as routine sedation. Inspect the access site and distal perfusion. Groin or flank pain, falling pressure, or an unexplained hemoglobin decline can suggest access bleeding or retroperitoneal hemorrhage. Contrast-associated kidney risk deserves assessment, but it should not automatically delay a life-saving procedure.
A useful vignette combines progressive leg dysfunction, cord edema, and perimedullary flow voids. Recognizing a possible spinal fistula changes the investigation and treatment path. Another combines a new third-nerve palsy and an unruptured aneurysm; the absence of visible SAH does not make the finding an elective reassurance problem.
Sources checked October 17, 2026: ABPN detailed outline and AHA/ASA aSAH guideline .