CHAPTER 57

Effect of masses on cerebral vessels

Joseph P. Lin and Irvin l. Kricheff

Types of vascular changes the mass receive forces from one direction only. They
Stretching and spreading of vessels are displaced away from the mass, curving around its
Obliteration, narrowing, or invasion circumference (Fig. 57-1). An artery that passes over
Changes in pattem of local circulation
Localized arterial dilatation the axis (middle) of a mass receives equal forces from
Distortion of gyral pattern opposite directions so that it appears straightened (Fig.
Modification of displacements by dural folds with masses in 57-1). When viewed in aplane at right angles, how-
different locations ever, the artery may appear curved and circumferen-
Modification by falx cerebri tial, with its concavity toward the center of the mass.
Modification by tentorium The arteries situated between the periphery and the
Features of specific masses
axis of the tumor receive unequal forces from both
Cystic or solid masses versus infiltrating tumor
Tumor versus edema directions. Consequendy they are less bowed than those
Intra-axial versus extra-axial masses at the periphery but are not straight as is the axis
artery (Fig. 57-1). These changes are illustrated in Figs.
57-2 and 57-3. The stretched artery describing the arc
of shortest diameter (circumferential artery) delineates
The detection of intracranial space-occupying lesions
the margin of the mass; the straight (axis) artery indi-
by cerebral angiography depends mainly on the displace-
cates the center of the mass. Less acutely arched arteries
ment of cerebral vessels, abnormal vascularity (either
increased or decreasedL and alterations in the rate of
local circulation. Occasionally neoplasms may direcdy
involve arterial walls or compress the surface veins. The
arteries on the cerebral convexity are loosely covered by
the pia mater and at various points are fixed by small
perforating arteries. Because these arteries, whose courses
are undulant and wavy, usually lie in a sulcus between the
gyri, they are easily displaced or stretched by space-
occupying lesions. Space-occupying masses at a distance
cause a diffuse arterial displacement whereas superficial
masses acutely displace and stretch the adjacent arteries.
The superficial veins lie on the surface of the gyri rather
than in the sulci and are therefore affected only by
superficially situated masses.
TYPES OF V ASCULAR CHANGES
Fig. 57.1. Suprasylvian tumor. Carotid arteriogram, lateral
Stretching and spreading of vessels projection. The eireumferential arteries (solid blaek arrows)
The location and extent of a mass may be accurately outline the periphery of the mass. These vessels reeeive forees
from one direetion to form a sharp eoneave eurve. The axis
oudined by the displacement and bowing of the con- artery (open arrows) is straightened by equal forees eoming
vexity arteries and veins. Brain tumors tend to be spheri- from opposite direetions. Intermediate arteries (white arrows)
calor ovoid and are accompanied by variable degrees reeeive unequal forees from both direetions and are therefore
of cerebral edema. The arteries near the periphery of less eurved than the cireumferential arteries.

1164
 Effect 01 masses on cerebral vessels 1165

A B

Fig. 57-2. Circumferential arteries, in A, receive forces from
one direction only and are therefore more sharply curved
than the artery in B, which is subject to forces from either
side. (From Kricheff, 1. l., and Taveras, J. M.: Radiology
82:602-614, 1964.)
Fig. 57-3. Diagram iIIustrating the appearance of the axis
artery. A, An axis artery has equal forces acting on it from
both sides. Although stretched, it is not curved. B, When
this vessel is seen in aplane at right angles to A, the artery
now appears circumferential. (From Kricheff, 1. l., and
Taveras, J. 1"1.:Radiology 82:602-614, 1964.)

B
A

----

--

Fig. 57-4. Balloon model to iIIustrate the effects of an expanding mass on the superficial
arteries. A, Redundant ruhher hands have heen fixed at intervals to provide a model of the
convexity arteries. B, The balloon has been slightly inflated. The "arteries" show slight
straightening. C, With further inflation of the balloon, the "arteries" are now straightened.
(From Lehrer, H.: Acta Radiol. [Diagn.] 6:233-240, 1967.)
1166 Arteries
---
(i.e., arcs of large diameter) may be observed beyond
the circumferential artery. These arteries are respond-
ing to edema of the cerebral tissues around the tumor
or the general effect of increased volume of the space-
occupying mass.
l
Masses deep to the convexity produce similar but less
dramatic changes in the convexity arteries. The arteries A
are separated and somewhat straightened. In these in-
stances the arterial curvatures tend to conform to the
axis-circumferential pattern, but the overall increase of
volume also affects these vessels. For this reason, when
edema surrounds a mass, the size of the mass may be
difficult or impossible to estimate. Nevertheless, the
analysis of arterial curvatures accurately identifies the L
r -
center of the lesiono

Taveras and Wood (1964) used balloons to simulate

the cerebral gyri and to explain the mechanism oí the
displacement oí these arteries. When the balloons were
inflated to the same degree oí tension, the "artery" be-
tween these two balloons was straightened in a manner
similar to that oí an artery coursing over the axis of a
mass. Unequal tension of the balloons produced unequal
curva ture of the artery.
Lehrer (1967) disagreed with this explanation and
pointed out that the convexity arteries do not lie com-
pletc1y deep in the su1ci but also pass over the gyri with
some points fixed by perforating arteries. He postulated
that in the presence of an underlying mass surrounded
by edema, "the c1astic vessels would be caused to take
the shortest possible path between these points of fixa-
tion." This course would represent a curve characteristic
for that' particular surface (the geodesic line). To iIIus-
trate this concept, Lehrer employed a balloon with rubber
bands (representing the convexity arteries) taped on its
surface (Fig. 57-4). With gradual inflation of the bal-
loon, the rubber bands lost their wavy appearance and
became straight when viewed from the front, conforming
to the surface of the balloon. When viewed from the
side, these rubber bands described wide, smooth curves.
When a mass compresses the adjacent normal brain
tissues, especially in the high convexity area, the arteries
forro parallel curves (Fig. 57-5). This appearance has
been call,:d "onion peeling." The first artery to show a
concave curve is usually at the border of the mass.
Obliteration, narrowing, or invasion
The cerebral arteries may be compressed or invaded
by intracranial neoplasms. Meningiomas at the base of
the skull characteristically engulf the adjacent arterics
and cause variable narrowing of the arteriallumen (Fig.
57-6). Direct involvement of the vascular system by
tumor was observed as early as 1907 by Goldmann.
Russell and Rubinstein (1971) described vascular en-
dothelial proliferation in patients with glioblastoma
multiforme. Direct invasion of the cerebral arteries by
various intracranial neoplasms was demonstrated angio-
liI
B
I
,
L ___
Fig. 57-5. Posterior falx meningioma. Carotid arteriogram,
lateral projection. A, Arterial phase. The parietal and pos-
terior temporal branches of the middle cerebral artery are
stretched around the large parietal mass. Compression of the
adjacent brain resuIts in stretching and "onion-peeling" of
the arteries adjacent to the tumor (arrows). B, Capillary
phase. The meningioma is now outlined by a diffuse homog-
eneous area of contrast medium accumulation. The compres-
sion of the adjacent gyral pattern with "onion-peeling" is
again noted (arrows).
graphically by Taveras and Wood (1964), Cowen and
associates (1970), Leeds and associ¡¡tes (1971), Lin and
Siew (1971), and Leeds and Rosenblatt (1972). The
angiographic features consist of irregularities of the wall
of the involved cerebral artery (Fig. 57-7). Occasionally
a tumor may occlude small arterial branches and there-
fore may simula te intracranial atherosclerosis or vasculi-
tis (Lin and Siew, 1971) (Fig. 57-8). Arterial irregular-
ity or occlusion by tumors is observed more frequently
when direct geometric magnification angiography is
used.
Changes in pattern of local circulation
The arterial circulation may be slowed locally and
venous filling delayed in the region of a mass because
 Effect 01 masses on cerebral vessels 1167

Fig. 57-6. Cavernous sinus meningioma. Internal carotid arte-

riogram, lateral projection. The cavernous portion of the
internal carotid artery is narrowed by the tumor. Note the
enlargement of the meningohypophyseal trunk and the faint
tumor stain (arrows).

Fig. 57.7. Glioblastoma multiforme. Carotid arteriogram, lat- 1

...
eral projection. The axis artery (solid arrows) has been in- l'
vaded by the tumor, causing irregularity in its lumen (shaggy ..,
vessel). Circumferential arteries (open arrows) outline the ,
boundaries of the mass. (From Leeds, N. E., and Rosenblatt,
R.: Radiology 103:121-124, 1972.)

Distortion of gyral pattem

of locally increased pressure (Leeds and Taveras, 1963).
Masses situated close to the surface of the brain often
compress the adjacent veins before arterial slowing is
recognized. Extreme elevation of the intracranial pres-
sure may be associated with nonfilIing of the intracranial
branches of the internal carotid artery (Davies and
Sutton, 1967). The internal carotid artery in these pa-
tients usualIy filIs slowly to the siphon, but opacifica-
tion more distalIy is not evident. This phenomenon is
seen most frequently after severe head trauma or intra-
cerebral hemorrhage and the outcome is usualIy fatal.
Localized arterial dilatation
Displacement of cerebral vessels is an indirect sign of
an intracerebral mass. Abnormal vascularity within the
mass is direct evidence of such a lesion. The specific
character of the abnormal vascularity often indicatcs
the histologic diagnosis (Chapter 77).
The capillary phase is often helpful in localizing
masses that may not be clearIy apparent on either the
arterial or the venous phase (Liliequist, 1967). In the
normal capillary phase, subtraction techniques outline
the normal gyral pattern of the brain. Masses tend to
distort the gyral pattern, a finding often clearIy evident
at angiography (Figs. 57-9 and 57-10).
MODIFICATION OF DISPLACEMENTS BY
DURAL FOLDS WITH MASSES IN
DIFFERENT LOCA TIONS
Modification by falx cerebri
The falx cerebri is a rigid dural fold that extends from
the superior to the inferior sagittal sinus. It is attached
to the crista galli anteriorly and to the internal occipital
protuberance posteriorIy. Its posterior portion is deeper
than its anterior portion. The pericalIosal artery lies
1168 Arteries

beneath the free margin of the falx throughout most

of the artery's course. Except for the most proximal seg-
ment, the callosomarginal artery lies above the lower
edge of the falx. The rigid falx is difficult to displace
from the midline. Therefore only the most proximal part
of the callosomarginal artery can be displaced across the
midline. The falx modifies the amplitude and shape of
midline arterial and venous displacements by diffusing
the vector forces that are produced by masses against
its rigid, unyielding structures. The exact configuration
of displaced midline vessels depends not only' on the
position and size of the mass but also on the relation of
those vessels to the falcine incisura (Chapter 62).

Modification by tentorium
A
The tentorium is a rigid dural fold attached anteriorly
to the anterior clinoid processes, posterosuperiorly to the
straight sinus, and posterolaterally to the lateral sinus.
Displacements of vessels related to the tentorial incisura
are modified by the rigid unyielding tentorium. The

--,

Fig. 57-9. Parietal glioma. Carotid arteriogram, capillary

phase. Distortion of the normal gyral pattern (arrows) indi-
cates the location of the tumor.

Fig. 57-8. Glioblastoma multiforme with partial obstruction

of the cortical arteries. A, Carotid arteriogram, early arterial
phase. The irregularity in the walls of the pericallosal and
callosomarginal arteries (arrows) is noted. The avascular
e area in the frontal region is caused by occlusion of branches
of the anterior and middle cerebral arteries. B, Carotid ar-
teriogram, early venous phase. Retrograde filling of the distal
branches of the pericallosal and middle cerebral arteries is now
seen. C, Internal carotid arteriogram performed 3 months
later. The irregularities of the pericallosal and callosomar-
ginal arteries are no longer present (arrows). Many abnormal
vessels are, however, noted in the frontal and parietal regions.
(From Lin, J. P., and Siew, F. P.: Radiology 101:353-354,
1971.)

effect of herniation of cerebral vessels through the ten-
torial notch is discussed in detail in Chapter 86.
FEATURES OF SPECIFIC MASSES
Cystic or solid masses versus infiltrating tumor
Well-defined solid or cystic masses affect the convexity
arteries more acutely than do infiltrating lesions. The
boundary of an infiltrating lesion usually is not distinct
and the mass involves the brain tissue diffusely and more
insidiously (Fig. 57-11). Except for hemangioblastomas,
in which a small vascular mural nodule often exists
within a large avascular cyst, differentiation of a cystic
lesion from a solid lesion is usually impossible angio-
graphically. Occasionally a cyst wall may be outlined
by accumulation of contrast medium within it (Chap-
ter 77) .
A collateral circulation, or intra-axial neoplasms involve
B "
Fig. 57-10. Frontal lobe abscess. Carotid arteriogram, lateral
projection. A, Arterial phase. B, Capillary phase. The proxi-
mal pericallosal artery is displaced posteriorly and its frontal
branches are stretched. The large mass is best shown in the
capillary phase, in which marked compression and distortion
of the adjacent gyri can be appreciated.
Effect 01 masses on cerebral uessels 1169
Tumor versus edema
A zone of edema may surround specific intracranial
tumors (Chapter 77). The differentiation, however, of a
solid or cystic avascular lesion from localized edema may
be impossible. A well-localized mass may be differen-
tiated from cerebral edema by an analysis of the arterial
curvatures. A localized mass is usually outlined by cir-
cumferential and axis arteries whereas generalized
edema more subtly stretches the vessels of a larger por-
tion of the hemisphere. Sometimes the entire hemisphere
is affected by edema or tumor without definite circum-
ferential arteries being visible. When generalized edema
involves both cerebral hemispheres, no midline shift is
noted. The angiographic features of poorly loca1ized in-
filtrative tumors are similar to those of cerebral edema.
Intra-axial versus extra-axial masses
Meningeal blood supply. Meningiomas characteris-
tically receive contributions from the meningeal arteries.
Meningeal branches also often richly supply other extra-
axial tumors such as neurinomas, chemodectomas, and
tumors of the calvarium. In these instances the dural
vessels are usually cnlarged and tortuous. Meningeal
arterial contribution, however, is not pathognomonic for
an extra-axial lesion. When arteriovenous malformations,
the dura, meningeal vessels may be similarly involved
(Chapters 60 and 77).
Displacement of vessels. Intra-axial masses tend to
displace vessels toward bony structures such as the floor
..,
,.
t
/
.".
A
j;<."- ;
,
Fig. 57-11. Infiltrating frontal lobe glioma. The branches of
the callosomarginal artery are diffusely stretched. Faint ac-
cumulation of contrast medium (arrows) is noted within the
tumor.
1170 Arteries

masses increase the volume of the temporal lobe. The

arteries on the surface of this lobe thereby become

f7
r
Fig. 57-12. Subfrontal meningioma. Carotid arteriogram, lat-
eral projection. The proximal pericallosal artery and its
branches are lifted upward in a curvilinear fashion (arrows),
away from the floor of the anterior fossa.
---,
Fig. 57-13. Temporal lo be hematoma. The main trunk of the
middle cerebral artery is displaced upward. Its temporal
branches are elongated and stretched (draping sign), indicat-
ing the presence of a mass within the temporal lobe.
of the cranial fossa or thc inner table of thc skull. Extra-
axial masses, in contrast, tend to displace vessels away
from bony structures or dural surfaces. Intra-axial
tumors, which are often infiltrating, commonly cause
less stretching of the adjacent vessels. Conversely, extra-
axial tumors, which compress and bulge into the adja-
cent cerebral structures, cause a greater stretching and
displacement of the surface vessels (Figs. 57-5 and 57-
12).
The differentiation of intra-axial masses from extra-
axial masses in the temporal region has been dcscribed
by Chase and Taveras (1963). Intra-axial temporal
stretched and elongated whereas the insular arteries are
displaced almost en masse-the so-called draping sign
(Fig. 57-13). Extra-axial masses that arise from the
floor of the middle fossa also displace the insular arteries
upward. In contrast to the changes resulting from intra-
axial masses, however, the temporal branches of thc
middle cerebral artery are displaced upward away from
the floor of the middle cranial fossa or the tentorium
and therefore become crowded and shortened. Extra-
axial masses with origin in the medial aspect of the
middle fossa produce changes in the insular and tem-
poral convexity arteries. These changes may resemble
those of intratemporal masses when the temporal lobe
is displaced upward and laterally (Chapter 63). Pro-
nounced elevation and lateral displacement of the an-
terior choroidal artery, however, especially when asso-
ciated with me dial displacement of the posterior cerebral
artery, are diagnostic of an extra-axial mass.
REFERENCES
Chase, N. E., and Taveras, J. M.: Temporal tumors studied by
serial angiography. A review of 150 cases, Acta Radiol.
[Diagn.] 1:225-235, 1963.
Cowen, R. L., Sigueira, E. B., and George, E.: Angiographic
demonstration of a glioma involving the wall of the anterior
cerebral artery; report of a case, Radiology 97:577-578,1970.
Davies, E. R., and Sutton, D.: Pseudo-occlusion of the internal
carotid artery in raised intracranial pressure, Clin. Radiol.
18:245-252, 1967.
Goldmann, E.: The growth of malignant disease in man and
the lower animals, with special reference to the vascular sys-
tem, Proc. R. Soco Med. (Surg. Sect.) 1:1-13, 1907-1908.
Kricheff, 1. l., and Taveras, J. M.: The angiographic 10caliza-
tion of suprasylvian space-occupying lesions, Radiology 82:
602-614, 1964.
Leeds, N. E., and Rosenblatt, R.: Arterial wall irregularities
in intracranial neoplasms; the shaggy vesse\ brought into
focus, Radiology 103:121-124, 1972.
Leeds, N. E., Rosenblatt, R., and Zimmerman, H. M.: Focal
angiographic changes of cerebral lymphoma with pathologic
correlation, Radiology 99:595-599, 1971.
Leeds, N. E., and Taveras, J. M.: Changes in local circulation
time in frontal and parietal tumors studied by rapid serial
angiography, Acta Radiol. [Diagn.] 1:332-342, 1963.
Lehrer, H.: Mechanism in indirect arterial displacements over
cerebral convexities accompanying cerebral mass lesions, Acta
Radiol. [Diagn.] 6:233-240, 1967.
Liliequist, B.: Capillary phase in cerebral angiography, Acta
Radiol. [Diagn.] 6:113-125, 1967.
Lin, J. P., and Sicw, F. P.: Glioblastoma multiforme presenting
angiographically as intracranial atherosclerotic vascular dis-
case, Radiology 101:353-354, 1971
Russcll, D. S., and Rubinstein, L. J.: Pathology of tumours of
the nervous system, ed. 3, Baltimore, 1971, The Williams
& Wilkins Co.
Tavcras, J. M., and Wood, E. H.: Diagnostic neuroradiology,
Baltimorc, 1964, Thc Williams & Wilkins Co.