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Vascular Malformations
Arteriovenous malformation (AVM) Shunt Mixed Malformation Developmental venous anomaly = Combo (DVA) No Cavernous malformation Shunt Capillary telangiectasia
Classic Dural arteriovenous fistula (dAVF) Vein of Galen Malformation (VOG)
Alice Boyd Smith, MD Chief, Neuroradiology Department of Radiologic Pathology Armed Forces Institute of Pathology Washington, DC & Assistant Professor of Radiology & Radiological Sciences Uniformed Services University of the Health Sciences Bethesda, MD
Classic AVM
Arteriovenous shunting & no intervening capillary bed
Enlarged feeding artery Nidus Early draining vein/ varix
AVM
T2
Congenital
Usually neural tissue in between
AVM
Dysregulated angiogenesis continued vascular remodeling Peak age: 20-40 year old Risk of hemorrhage: 24%/year
~50% present with symptoms of hemorrhage NECT
AVM Imaging: CT
Variable Hemorrhage Calcification: 25-30% Enhance postcontrast CTA: Enlarged arteries & draining veins
CECT
AVM
NECT NECT
Calcification
Hemorrhage
AVM
Objectives
Recognize imaging findings in orbits & paranasal sinuses that will change patient management. Be able to develop checklist for imaging findings within orbits & paranasal sinuses that decreases likelihood of overlooking pertinent associated findings.
Alice Boyd Smith, Lt. Col., USAF MC Chief, Neuroradiology Department of Radiologic Pathology Armed Forces Institute of Pathology Washington, DC & Assistant Professor of Radiology & Radiological Sciences Uniformed Services University of the Health Sciences Bethesda, MD
Orbit: Infectious
Pre - or post-septal
Most often secondary to underlying paranasal sinusitis
Maxillary & ethmoid most common
Other etiologies:
Trauma Bacteremia Skin infections Dental infections CECT
Panophthalmitis
Orbit: Infectious
Subperiosteal abscess
Spread from sinus to orbit
Transmission via valveless venous plexus
Direct extension:
Lamina papyracea dehiscence
MR
Post contrast: Rim enhancement; intra- & periorbital enhancement Fat suppression optimal
Visual disturbance:15-30%
Optic neuritis Ischemia: intraorbital pressure Retinal ischemia: Central artery occlusion or thrombophlebitis
Arterial
Pedicle aneurysm Intranidal aneurysm
Difficult to detect by MR
NECT
Venous
Central venous drainage Obstruction of venous outflow Varix
Small nidus
AVM: Treatment
Embolization Radiation: Stereotaxic radiosurgery
Eloquent
Arteriovenous Fistulas
Distinguished from AVMs by presence of direct, high flow fistula between artery & vein
Dural AVF (dAVF) Cavernous carotid fistula (CCF) Vein of Galen malformation
Combination
Surgery
dAVF
Arteriovenous shunts within dura 10-15% of intracranial vascular malformations 2 types:
Adult: Tiny vessels in wall of thrombosed dural venous sinus typically middle aged & older patients
Usually acquired - trauma T1 SSFSE SSFSE
dAVF
T1
Fetal MRI
Type I
Type II
Type III
Type IV
dAVF
Most common near skull base
Transverse sinus most common
dAVF Imaging: CT
NECT: May be normal CECT: May see tortuous dural feeders & enlarged dural sinus
CECT
dAVF
T1 T1
!!!
dAVF
Involved dural sinus frequently thrombosed Flow reversal in dural sinus/cortical veins progressive symptoms, risk of hemorrhage Tortuous engorged pial veins pseudophlebitic pattern
Pseudophlebitic pattern
Venous Drainage
SOV
Superficial Middle Cerebral V.
Uncal v. Cerebellar
Ca Sin verno us us
SPS IPS
CCF: Imaging
T1
CCF
CT:
Marked dilation & enhancement of cavernous sinus May see prominent SOV
MRI:
Abnormal flow voids in cavernous sinus Enlargement of cavernous sinus
Non-Contrast
CCF
T1+Gd T2
dAVF: Treatment
Endovascular Surgical resection Stereotaxic radiosurgery Observation:
Indirect CCF
VOGM
Newborns: Most common extracardiac cause of high-output congestive heart failure < 1% of cerebral vascular malformations
CECT
Classification:
Choroidal: Multiple feeders from pericallosal, choroidal, & thalmoperforating arteries Mural: Few feeders from collicular or posterior choroidal arteries
T1
Falcine Sinus
Venous Pouch
VOGM: CT Findings
Venous pouch May have hydrocephalus Parenchymal atrophy Intraventricular hemorrhage: Rare Post contrast: Avid enhancement of feeding arteries and vein
CECT NCCT
VOGM
VOGM: MR Imaging
T2
VOGM: Angiography
Choroidal or mural Dural venous sinus anomalies
T1
Choroidal VOGM
VOGM: Treatment
Choroidal
Medical therapy for congestive heart failure until 5 or 6 mo 5-6 mo: Transcatheter embolization
Mural
Transcatheter embolization performed later
VOGM
CECT
Cavernous Malformation
AKA: Angioma, cavernoma, cavernous hemangioma Variable size intercapillary vascular spaces, sinusoids, & larger cavernous spaces
No intervening brain 2 types: Inherited: Multiple & bilateral Sporadic
Cavernous Malformation
T2
Cavernous Malformation
NECT
Cavernous Malformation
MRI NECT
-Variable -Popcorn ball - Surrounding edema in acute hemorrhage -Post contrast: minimal/ no enhance look for DVA!
T2 T1
CT Findings T1+Gd -Negative : 30-50% -40-60% Ca++ -No mass effect -Surrounding brain normal -Little or no enhance -CTA usually negative
Cavernous Malformation
Risk of hemorrhage: 0.250.7%/year
More common in posterior fossa lesions In patients with prior hemorrhage annual rate of rehemorrhage 4.5% T2
Cavernous Malformation
T2
Treatment:
Observation: Asymptomatic or inaccessible lesions Surgical excision Radiosurgery: Progressively symptomatic but surgically inaccessible
MPGR
Enlarged medullary veins Drain into dural sinus or deep ependymal vein Usually solitary Medusa head or palm tree
DVA Imaging: CT
Calcification & ischemia may occur in the region drained most likely due to chronic venous obstructive disease
Rare NECT CECT CECT
DVA
T1+Gd
DVA: Treatment
NONE!
Removal may cause venous infarction
T1+Gd
Capillary Telangiectasia
Dilated capillaries interspersed within normal brain Usually small, asymptomatic incidental findings
Rare reports of hemorrhage exist
Capillary Telangiectasia
T2: Increased signal T2*: Low signal Ill defined enhancement after contrast administration: Stippled/brush stroke Occult on angiography Treatment: None T1 T1+Gd T2
Capillary Telangiectasia
T1+Gd
Sinus Pericranii
Communication between extracranial venous system & dural venous sinus Rare May be congenital or acquired
E
Sinus Pericranii
CECT
Sinus Pericranii
MRV T1+Gd
CT: Single/multiple bone defects Vascular enhancement Conventional angiogram: Seen during venous phase
Sinus Pericranii
Spontaneous regression rare Risk of hemorrhage Treatment
Surgery Endovascular
T1+Gd
Vascular Malformations
Arteriovenous malformation (AVM)
Classic Dural arteriovenous fistula (dAVF) Vein of Galen Malformation (VOG)
T1+Gd
Developmental venous anomaly (DVA) Cavernous malformation Capillary telangiectasia Cavernous Malformations
The End
Thank you!