The Many Faces of Cerebral Developmental Venous Anomaly and Its Mimicks: Spectrum of Imaging Findings

Cerebellar cavernoma excision with a preserved venous anomaly: A case report in girl 28-year-old

INTRODUCTION AND IMPORTANCE

Cavernous malformations are congenital or acquired vascular abnormalities. They are uncommon entities with an incidence of 0.5 % of the general population and usually are unnoticed until a hemorrhagic event occurs. Cerebellar cavernomas (CCMs) account for 1.2 to 11.8 % of all intracranial cases and 9.3 to 52.9 % of all infratentorial cases. Cavernomas can be concurrently seen with developmental venous anomalies (DVAs) in 20 % (range 20 %-40 %) of cases, in which case they are known as mixed vascular malformations.

PRESENTATION OF CASE

We report a case of a healthy young adult who presented with acute onset of headache, with characteristics of chronic headache that gets progressively worse. The patient complains of frequent dizziness when sitting and standing for a long time. Complaints have been felt for two years and have worsened for the past two weeks. Additional complaints are dizziness and nausea with intermittent episodes of vomiting for four days. Magnetic resonance imaging (MRI) revealed an underlying cavernoma that had bled and a coexisting DVA. The patient was discharged home with no deficits. Outpatient follow-up two months later showed no symptoms or neurologic deficits.

CLINICAL DISCUSSION

Cavernous malformations are congenital or acquired vascular anomalies that occur in approximately 0.5 % of the general population. Our patient likely had dizziness due to localization of the bleeding of the cavernoma on the left side of the cerebellum. In our patient, brain imaging revealed numerous abnormal blood vessels radiating from the cerebellar lesion, a highly suggestive of DVAs associated with cavernoma.

CONCLUSION

A cavernous malformation is an uncommon entity that might coexist with deep venous anomalies, making management more challenging.

Symptomatic Developmental Venous Anomaly: State-of-the-Art Review on Genetics, Pathophysiology, and Imaging Approach to Diagnosis

Developmental venous anomalies (DVAs) are the most common slow-flow venous malformation in the brain. Most DVAs are benign. Uncommonly, DVAs can become symptomatic, leading to a variety of different pathologies. DVAs can vary significantly in size, location, and angioarchitecture, and imaging evaluation of symptomatic developmental venous anomalies requires a systematic approach. In this review, we aimed to provide neuroradiologists with a succinct overview of the genetics and categorization of symptomatic DVAs based on the pathogenesis, which forms the foundation for a tailored neuroimaging approach to assist in diagnosis and management.

Conventional and advanced MRI evaluation of brain vascular malformations

Vascular malformations (VMs) of the central nervous system (CNS) include a wide range of pathological conditions related to intra and extracranial vessel abnormalities. Although some VMs show typical neuroimaging features, other VMs share and overlap pathological and neuroimaging features that hinder an accurate differentiation between them. Hence, it is not uncommon to misclassify different types of VMs under the general heading of arteriovenous malformations. Thorough knowledge of the imaging findings of each type of VM is mandatory to avoid these inaccuracies. Conventional MRI sequences, including MR angiography, have allowed the evaluation of CNS VMs without using ionizing radiation. Newer MRI techniques, such as susceptibility-weighted imaging, black blood sequences, arterial spin labeling, and 4D flow imaging, have an added value of providing physiopathological data in real time regarding the hemodynamics of VMs. Beyond MR images, new insights using 3D printed models are being incorporated as part of the armamentarium for a noninvasive evaluation of VMs. In this paper, we briefly review the pathophysiology of CNS VMs, focusing on the MRI findings that may be helpful to differentiate them. We discuss the role of each conventional and advanced MRI sequence for VMs assessment and provide some insights about the value of structured reports of 3D printing to evaluate VMs.

Anatomical Variations, Mimics, and Pitfalls in Imaging of Patients with Epilepsy

Epilepsy is among one of the most common neurologic disorders. The role of magnetic resonance imaging (MRI) in the diagnosis and management of patients with epilepsy is well established, and most patients with epilepsy are likely to undergo at least one or more MRI examinations in the course of their disease. Recent advances in high-field MRI have enabled high resolution in vivo visualization of small and intricate anatomic structures that are of great importance in the assessment of seizure disorders. Familiarity with normal anatomic variations is essential in the accurate diagnosis and image interpretation, as these variations may be mistaken for epileptogenic foci, leading to unnecessary follow-up imaging, or worse, unnecessary treatment. After a brief overview of normal imaging anatomy of the mesial temporal lobe, this article will review a few important common and uncommon anatomic variations, mimics, and pitfalls that may be encountered in the imaging evaluation of patients with epilepsy.

Cerebral Cavernous Malformations, Developmental Venous Anomaly, and Its Coexistence: A Review

BACKGROUND

Cerebral cavernous malformations (CCMs) are intracranial vascular malformations that can exist as a single lesion or mixed vascular lesions. The most common mixed form is the coexistence of CCM with an associated developmental venous anomaly (DVA). In this paper, we aim to give a comprehensive review of CCM, DVA, and their coexistence as mixed lesions. A PubMed search using the keywords "Cerebral cavernous malformations, Developmental venous anomaly, Mixed Cerebral cavernous malformations with Developmental venous anomaly" was done. All studies in the English language in the past 10 years were analyzed descriptively for this review.

SUMMARY

The search yielded 1,249 results for "Cerebral cavernous malformations," 271 results for "Developmental venous anomaly," and 5 results for "Mixed Cerebral cavernous malformations with Developmental venous anomaly." DVA is the most common intracranial vascular malformation, followed by CCM. CCM can have a wide array of clinical presentations like hemorrhage, seizures, or focal neurological deficits or can also be an incidental finding on brain imaging. DVAs are benign lesions by nature; however, venous infarction can occur in a few patients due to acute thrombosis. Mixed CCM with DVA has a higher risk of hemorrhage. CCMs are angiographically occult lesion, and cerebral digital subtraction angiography is the gold standard for the diagnosis of DVA. Mixed lesions, on the other hand, are best diagnosed with magnetic resonance imaging, which has also been effective in detecting specific abnormalities. Asymptomatic lesions are treated through a conservative approach, while clinically symptomatic lesions need surgical management.

CONCLUSION

Individual CCM or DVA lesions have a benign course; however, when they coexist in the same individual, the hemorrhagic risk is increased, which prompts for rapid diagnosis and treatment.

Developmental venous anomaly (DVA) mimicking thrombosed cerebral vein

Venous angiomas are relatively common lesions that occur in up to 3% of the general population. It is usually asymptomatic and discovered incidentally. We present a case of developmental venous anomaly mimicking thrombosed cerebral vein on nonenhanced computed tomography scan of the brain. A 48-year-old male patient medically free referred to our center for further management of high blood pressure. Because of the concern of thrombosed cerebral vein on computed tomography, further investigation with magnetic resonance venogram revealed a small network of veins in the region of the left internal cerebral vein with a picture of venous angioma. This case highlights such findings for the junior radiologist to consider additional investigations and avoid subsequent inadvertent treatment with anticoagulation.

Cerebral Venous Malformations in a Chinese Population: Clinical Manifestations, Radiological Characteristics, and Long-Term Prognosis

OBJECTIVE

We elucidated the clinical and radiological characteristics and analyzed the risk factors for hemorrhage and poor outcomes of cerebral venous malformations (CVMs) in a northern Chinese population.

METHODS

We included 60 consecutive patients with CVM patients in Beijing Tiantan Hospital from January 2011 to February 2018. The clinical manifestations, radiological characteristics, management, and outcomes were elucidated and analyzed. The patients were followed up for 5-64 months (median, 26). Poor outcomes included repeat bleeding, secondary infarction, severe disability (modified Rankin scale score ≥3), and death.

RESULTS

Infratentorial CVMs were more prone to intracranial hemorrhage (75% vs. 28.6%; P < 0.001), dizziness (37.5% vs. 10.7%; P = 0.017), and focal neurological deficits (65.6% vs. 25%; P = 0.002) than were supratentorial CVMs. Supratentorial CVMs were more prone to seizure (32.1% vs. 0%; P = 0.001) than were infratentorial CVMs. Multivariate logistic regression revealed that the major risk factors for intracranial hemorrhage in CVMs were infratentorial lesions (P = 0.003) and complicated cavernous angiomas (P = 0.016). Compared with conservative treatment, resection of hematoma or cavernous angiomas with CVM preservation did not increase the risk of poor outcomes (P = 0.646). However, CVM resection significantly increased that risk (odds ratio, 44.0; P = 0.003).

CONCLUSIONS

Our results have shown that conservative treatment of CVMs results in a relatively good prognosis. For those complicated by hemorrhage or cavernous angiomas requiring surgical interventions, the integrity of the CVM should be preserved, irrespective of the treatment. In exceptional cases, before CVM resection, the CVM drainage should be comprehensively evaluated.