The Presentation and Clinical Course of Intracranial Developmental Venous Anomalies in Adults

Developmental Venous Anomaly: Its Impact on Brain Parenchymal Function as Revealed by FDG PET

ABSTRACT

Developmental venous anomaly (DVA) is a common benign brain vascular malformation, typically asymptomatic, with intervention required when complications arise. We present the case of a 63-year-old man with mild cognitive decline whose brain FDG PET showed decreased uptake not only at the site of DVA, but in the extended surrounding parenchyma where MRI showed no parenchymal abnormalities. DVAs arise from developmental irregularities in the embryonic venous system, but likely affecting a greater extent of the surrounding parenchymal functions. These findings highlight the clinical significance of DVAs and their effects on the parenchymal function seen on FDG PET albeit normal parenchyma on structural imaging.

Idiopathic cerebellar hemorrhage in a patient with isolated developmental venous anomaly: A case report

Background

Developmental venous anomalies (DVAs) are benign anatomical variations in venous angioarchitecture. They are considered low-flow malformations and are often incidental and clinically insignificant. Hemorrhagic complications from isolated DVAs are extremely rare, typically occurring due to coexisting cavernous malformation.

Case Description

A 33-year-old female presented with severe headaches and vertigo, progressing from balance issues and dizziness. Misdiagnosed initially as Meniere's disease, her symptoms included left oculomotor nerve palsy, left-sided hemidysmetria, dysdiadochokinesis, and positive Romberg's sign. Cranial computed tomography revealed an acute hemorrhage in the cerebellar vermis. Contrast-enhanced magnetic resonance imaging and angiography identified an isolated DVA. The absence of substantial mass effect or obstructive hydrocephalus prompted conservative management with steroids and analgesics, leading to full recovery.

Conclusion

This case underscores the importance of considering isolated DVA in cerebellar hemorrhage etiology in young adults and conservative treatment is recommended to prevent secondary complications, given the DVA's role in normal venous drainage.

Intracranial Vascular Malformations in Children

Intracranial vascular malformations (IVMs) represent a significant challenge in pediatric medicine due to their diagnostic and therapeutic complexity. Despite their rarity, the severity of potential neurologic outcomes necessitates a comprehensive understanding and approach to management. This article aims to provide an overview of pediatric IVMs, specifically nidal arteriovenous malformations, cavernous malformations, capillary telangiectasias, and developmental venous anomalies, and highlight the importance of advanced diagnostic imaging and therapeutic strategies in improving outcomes. Vein of Galen malformations, pial arteriovenous fistulas, dural sinus malformations, and intracranial venous malformations will be addressed in other articles. Following a discussion of imaging and clinical considerations within the field, novel imaging techniques will be discussed.

Developmental Venous Anomalies

Developmental venous anomalies (DVAs) are the most common vascular malformation detected on intracranial cross-sectional imaging. They are generally benign lesions thought to drain normal parenchyma. Spontaneous hemorrhages attributed to DVAs are rare and should be ascribed to associated cerebral cavernous malformations, flow-related shunts, or venous outflow obstruction. Contrast-enhanced MRI, susceptibility-weighted imaging, and high-field MRI are ideal tools for visualizing vessel connectivity and associated lesions. DVAs are not generally considered targets for treatment. Preservation of DVAs is an established practice in the microsurgical or radiosurgical treatment of associated lesions.

I saw Medusa's head sign and turned to stone

Developmental venous anomalies (DVAs) are characterized by many radially oriented medullary veins surrounding a central draining vessel. When the imaging plane is perpendicular to the central vessel, these medullary veins resemble Medusa's head of snakes. Medusa's head sign, or caput medusae, can be appreciated on contrast enhanced CT scans and MRIs of the brain and is highly indicative of a DVA.

Venous Pathologies and Interventions of the Head

Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.

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.

Cerebellar hemorrhage in a healthy young adult: a case report

Background

Cavernous venous malformation is an uncommon entity that occurs in around 0.5% of the general population. Cerebellar cavernous venous malformation accounts for 1.2–11.8% of intracranial cavernous venous malformation cases. Patients are commonly asymptomatic until a hemorrhage occurs. In approximately 20% of the cases, cavernous venous malformation and developmental venous anomalies occur together, called mixed vascular malformation. Our case report reveals the imaging features of the mixed vascular malformation and highlights the appropriate imaging modality and sequence to detect the abnormalities.

Case presentation

We report the case of a 15-year-old Malay male, a healthy young male who presented with dizziness, vomiting, and mild headache for 1 month. Computed tomography brain imaging at presentation revealed cerebellar hemorrhage with multiple cavernous venous malformation and coexisting developmental venous anomalies, which was then confirmed by magnetic resonance imaging. The patient was started on dexamethasone 4 mg four times a day, observed in the ward, and discharged well without neurological sequelae.

Conclusion

A cavernous malformation with concurrent developmental venous anomalies requires accurate diagnosis. Our case report contributes to the literature on the imaging diagnosis of this disease, which is beneficial for current and future reference.

Intracerebral Hemorrhage Caused by Thrombosis of a Developmental Venous Anomaly with an Unusual Structure: A Case Report

Developmental venous anomalies (DVAs) are common intracranial vascular malformations and they are generally do not cause clinical complications. In cases showing DVA and hemorrhage, the hemorrhage is usually associated with adjacent cavernous malformations. Very few cases of intracerebral hemorrhage (ICH) caused by thrombosis in DVA have been reported in the literature. In this case report, we present an interesting case of a large ICH caused by thrombosis within a DVA with an unusual structure that may have potentiated the thrombosis.

Central nervous system vascular malformations: A clinical review

CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.

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.

Neonatal Developmental Venous Anomalies: Clinicoradiologic Characterization and Follow-Up

BACKGROUND AND PURPOSE

Although developmental venous anomalies have been frequently studied in adults and occasionally in children, data regarding these entities are scarce in neonates. We aimed to characterize clinical and neuroimaging features of neonatal developmental venous anomalies and to evaluate any association between MR imaging abnormalities in their drainage territory and corresponding angioarchitectural features.

MATERIALS AND METHODS

We reviewed parenchymal abnormalities and angioarchitectural features of 41 neonates with developmental venous anomalies (20 males; mean corrected age, 39.9 weeks) selected through a radiology report text search from 2135 neonates who underwent brain MR imaging between 2008 and 2019. Fetal and longitudinal MR images were also reviewed. Neurologic outcomes were collected. Statistics were performed using χ², Fisher exact, Mann-Whitney U, or t tests corrected for multiple comparisons.

RESULTS

Developmental venous anomalies were detected in 1.9% of neonatal scans. These were complicated by parenchymal/ventricular abnormalities in 15/41 cases (36.6%), improving at last follow-up in 8/10 (80%), with normal neurologic outcome in 9/14 (64.2%). Multiple collectors (P = .008) and larger collector caliber (P < .001) were significantly more frequent in complicated developmental venous anomalies. At a patient level, multiplicity (P = .002) was significantly associated with the presence of ≥1 complicated developmental venous anomaly. Retrospective fetal detection was possible in 3/11 subjects (27.2%).

CONCLUSIONS

One-third of neonatal developmental venous anomalies may be complicated by parenchymal abnormalities, especially with multiple and larger collectors. Neuroimaging and neurologic outcomes were favorable in most cases, suggesting a benign, self-limited nature of these vascular anomalies. A congenital origin could be confirmed in one-quarter of cases with available fetal MR imaging.

Recurrence of cavernous malformations after surgery in childhood

OBJECTIVE

Cavernous malformations (CMs) are commonly treated cerebrovascular anomalies in the pediatric population; however, the data on radiographic recurrence of pediatric CMs after surgery are limited. The authors aimed to study the clinical presentation, outcomes, and recurrence rate following surgery for a large cohort of CMs in children.

METHODS

Pediatric patients (≤ 18 years old) who had a CM resected at a single institution were identified and retrospectively reviewed. Fisher's exact test of independence was used to assess differences in categorical variables. Survival curves were evaluated using the Mantel-Cox method.

RESULTS

Fifty-three patients aged 3 months to 18 years underwent resection of 74 symptomatic CMs between 1996 and 2018 at a single institution. The median length of follow-up was 5.65 years. Patients most commonly presented with seizures (45.3%, n = 24) and the majority of CMs were cortical (58.0%, n = 43). Acute radiographic hemorrhage was common at presentation (64.2%, n = 34). Forty-two percent (n = 22) of patients presented with multiple CMs, and they were more likely to develop de novo lesions (71%) compared to patients presenting with a single CM (3.4%). Both radiographic hemorrhage and multiple CMs were independently prognostic for a higher risk of the patient requiring subsequent surgery. Fifty percent (n = 6) of the 12 patients with both risk factors required additional surgery within 2.5 years of initial surgery compared to none of the patients with neither risk factor (n = 9).

CONCLUSIONS

Patients with either acute radiographic hemorrhage or multiple CMs are at higher risk for subsequent surgery and require long-term MRI surveillance. In contrast, patients with a single CM are unlikely to require additional surgery and may require less frequent routine imaging.

Paediatric developmental venous anomalies (DVAs): how often do they bleed and where?

INTRODUCTION

Developmental venous anomalies (DVAs) are anomalies of venous drainage and considered a low-flow malformation. Studies evaluating natural history and risk factors for intracranial haemorrhage in the paediatric population are rare. We evaluate clinical and radiological features, risk factors and outcomes of paediatric DVAs.

METHODS

A retrospective study was conducted over a 10-year period between 2004 and 2014. Medical records, imaging and prospective databases were reviewed. Three-hundred-and-three radiological studies in total were evaluated.

RESULTS

Fifty-two children (20 boys and 32 girls [median age: 6 years] were identified with DVAs. Their age distribution was as follows: 1.9% neonates (< 1 month), 11.5% infants (1 month to 1 year), 30.8% 1-5 years, 30.8% 5-12 years and 25% 12-16 years. The majority (92.3%) presented with asymptomatic DVAs identified incidentally. Overall, anatomical distribution revealed predilection for frontal region (42.3%) with other common sites being posterior fossa (17.3%) and basal ganglia (13.5%). Temporal (11.5%), parietal (9.6%) and occipital (5.8%) were the remainder. Associated cavernous malformations (CMs) were present in 3/52 (5.8%), and no DVAs were associated with aneurysms or arteriovenous malformations (AVMs). Three patients had more than one DVA. There were three deaths unrelated to DVAs over median follow-up of 3.8 years. Four patients (7.7%) suffered DVA-related intracranial haemorrhage presenting with neurological deficits. The ages of the children with DVA-related haemorrhages were 21 days, 2 years and 6 months, 7 years and 1 month and 11 years and 7 months. Left-sided DVA haemorrhages predominated (3/4, 75%). The relative risk of a cerebellar DVA haemorrhage compared to its supratentorial counterpart was 5.35 (OR 6.8, 95% CI 0.8-58).

DISCUSSION

DVA-related haemorrhage is sevenfold greater in our paediatric cohort compared to adults and is significantly associated with cerebellar location and cavernous malformations. There were no haemorrhages over a median period of 3.8 years of prospective follow-up.

Vascular Malformations of the Brain and Its Coverings

Vascular malformations of the brain and its coverings encompass several different vascular pathologies of the brain and its coverings, which substantially differ in morphology, clinical presentation, and prognosis, reaching from incidental, asymptomatic vascular abnormalities to life-threatening diseases with high risks of morbidity, most frequently caused by intracranial hemorrhage. In this article, the most common vascular malformations of the brain with and without arteriovenous shunting of blood (e.g., arteriovenous malformations [AVMs], dural arteriovenous fistulas [DAVFs], and cavernous malformations) are explained with a focus on definition, diagnosis, classification, and management.

Isolated hemorrhagic arterialized DVAs: revisiting symptomatic DVAs

We aim to present here a small case series of symptomatic isolated hemorrhagic arterialized developmental venous anomalies (sDVAs) with a larger goal of revisiting the classification based on patho-mechanisms plus emphasizing angiographic features coupled with CT and MRI. Typically, DVA is an incidental and silent abnormality on neuroimaging. Understanding its morphology in terms of arterialization and relationship with other entities is crucial for management. One adult and two pediatric cases presented with acute or sub-acute hemorrhage in the cerebellum or thalamus. Morphologic characterization on cross-sectional imaging and catheter angiography confirmed the integrated diagnosis of "symptomatic isolated hemorrhagic arterialized DVAs with deeper or superficial venous drainage". Conservative management was adopted in all cases. We emphasize the following classification and approach for symptomatic DVAs: (1) congestive isolated arterialized sDVAs, (2) congestive isolated resistive sDVAs, (3) coexisting sDVAs (with AVM or cavernous malformation), (4) compressive sDVAs (compressive effects), and (5) idiopathic DVAs. Like our three cases, ganglionic and infratentorial DVAs have higher propensity of hemorrhage, compressive effects, and usually harbor deeper venous drainage. Typical "caput medusae" as dominant collector vein on cross-sectional imaging is crucial to complement and even confirm the diagnosis of DVA before catheter angiography in sDVAs. Capillary stain or early opacification of DVAs is a marker of arteriovenous shunting in arterialized sDVAs. Recognition of this entity is crucial as treatment is usually conservative.

Imaging of PTEN-related abnormalities in the central nervous system

The phosphatase and tensin homolog (PTEN) located at 10q23.31 is a tumor suppressor gene expressed ubiquitously, and loss of function mutations lead to aberrant growth, angiogenesis, and an increased risk for a variety of tumors. PTEN mutations have been associated with multiple abnormalities in the central nervous system, and a number of clinical phenotypes are now attributed to germline PTEN mutations, collectively referred to as PTEN hamartoma tumor syndrome (PHTS). Most notably, these include Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome (BRRS), and autism spectrum disorders with macrocephaly. It is important to recognize the neuroimaging features associated with PTEN mutations to not only avoid misdiagnosis in cases of known PHTS but also to guide genetic testing in patients who do not yet have an established diagnosis. In this review, the central nervous system imaging features of PTEN-related disorders are discussed.

Cerebellar Cavernous Malformation (Cavernoma): A Case Report

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. 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. We report a case of a healthy young adult, who presented with acute onset of headache, dizziness, and nausea with intermittent episodes of vomiting for four days. Brain tomography imaging at presentation revealed likely multiple foci of intracranial hemorrhage; however, magnetic resonance imaging (MRI) showed findings suggestive of an underlying cavernoma that had bled, in addition to a coexisting DVA. The patient was discharged home with no deficits. Outpatient follow-up five months later revealed no symptoms or neurologic deficits.

Metabolic Changes of Brain Developmental Venous Anomalies on 18F-FDG-PET

RATIONALE AND OBJECTIVES

To determine the metabolic effects of developmental venous anomalies (DVAs) and to correlate those effects with conventional magnetic resonance imaging (MRI) findings.

MATERIALS AND METHODS

We conducted a retrospective review of MRI and brain 18F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) examinations in subjects with DVAs. Conventional MRI was used to determine DVA number, location, size, and associated parenchymal findings such as atrophy, hemorrhage, cavernoma, capillary telangiectasia, cortical dysplasia/polymicrogyria, and white matter signal abnormality. Qualitative and quantitative measures of relative metabolism in the drainage territory of the DVA were measured on ¹⁸F-FDG-PET.

RESULTS

Fifty-four subjects with 57 DVAs were included in the analysis. 38% were associated with qualitative and quantitative metabolic abnormalities on ¹⁸F-FDG-PET, with decreased metabolism in the parenchyma surrounding all but one of these DVAs. DVAs draining gray matter were significantly more likely to be hypometabolic than those draining only white matter, suggesting that the metabolic effects of DVAs may be underestimated on ¹⁸F-FDG-PET.

CONCLUSION

Altered metabolism is seen in the drainage territory of a significant proportion of DVAs, suggesting that these anomalies are vascular lesions with abnormal physiologic features.

[Intracranial vascular malformations]

Intracranial vascular malformations range from incidental asymptomatic vascular alterations up to life-threatening vascular disorders. Arteriovenous malformations and dural arteriovenous fistulas are cerebral vascular malformations with arteriovenous shunting of blood. In the majority of cases they are accompanied by an elevated risk of intracerebral hemorrhage and can cause severe symptoms. They can be treated conservatively or interventionally via microneurosurgery, endovascular embolization and radiation therapy. Cavernous malformations, developmental venous anomalies (DVA) and capillary telangiectasia are cerebral vascular malformations without arteriovenous shunting. Cavernous malformations are rarely symptomatic in the form of cerebral hemorrhage, headache or seizures and in such cases an operative treatment can be indicated. The DVA and capillary telangiectasia are usually asymptomatic and do not require treatment.

Neuroimaging abnormalities in patients with Cowden syndrome: Retrospective single-center study

Background

We retrospectively reviewed the neuroimaging findings of patients with Cowden syndrome and determined their frequency in a single cohort.

Methods

Electronic medical records were queried from January 1999 to January 2017 to identify patients who fit the clinical criteria for diagnosis of Cowden syndrome with or without a documented PTEN mutation. Patients with brain MRI examinations were then identified.

Results

We retrospectively identified 44 patients with Cowden syndrome, 22 of whom had neuroimaging for review. Eleven (50%) had Lhermitte-Duclos disease, 4 (18.1%) had meningiomas, 13 (59.1%) had at least one developmental venous anomaly, 3 had cavernous malformations, 2 had evidence of dural arteriovenous fistula, 7 had increased white matter signal abnormalities relative to age (31.8%), 4 had prominent perivascular spaces, cerebellar tonsillar ectopia was present in 7 of 21 (33.3%), and 1 had cortical malformation.

Conclusions

It is important to recognize that in addition to Lhermitte-Duclos disease, other intracranial findings such as multiple venous anomalies, meningiomas, greater than expected white matter signal abnormality, prominent perivascular spaces, and cortical malformations may warrant a thorough evaluation for Cowden syndrome in the appropriate clinical setting. We further recommend that this broader spectrum of intracranial abnormalities be considered for addition to the Cowden syndrome diagnostic criteria at the time of next revision.

Can developmental venous anomalies cause seizures?

Developmental venous anomalies (DVAs) are congenital anatomical variants of normal venous drainage of normal brain. Although DVAs are often discovered on the occasion of a seizure, their involvement in epilepsy is poorly studied. Our objective was to determine whether DVA can cause seizures, in the cases where there is no associated lesion, including no cavernoma or dysplasia. Based on clinical history, cerebral MRI, EEG recording, and ¹⁸F-FDG PET, we report 4 patients with DVA revealed by seizures. The first patient had a convulsive seizure caused by a hemorrhagic infarction due to thrombosis of her DVA. The second patient had a left temporo-parietal DVA next to a nonspecific lesion, possibly a sequelae of a venous infarction. The last two patients disclosed an isolated and uncomplicated DVA with a concordant epileptic focus confirmed on ictal video EEG recording. We reviewed literature and identified 21 other published cases of seizures caused by complications of a DVA and 9 patients that may have a direct link between epilepsy and an isolated and uncomplicated DVA. Seizures are linked to a DVA in two main situations: presence of an associated epileptogenic lesion, such as cavernoma or dysplasia, and occurrence of a complication of the DVA. Before concluding that a seizure is caused by a DVA, it is essential to perform full MRI protocols to search them. It remains rare and uncertain that isolated and uncomplicated DVA can cause seizures. In this last situation, physiopathological processes are probably different in each patient.

The Management of Symptomatic Cerebral Developmental Venous Anomalies: A Clinical Experience of 43 Cases

Background

Developmental venous anomalies (DVAs) are rare vascular diseases becoming more frequently diagnosed. Most patients with DVAs have no clinical symptoms with the exception of a few patients with epilepsy, intracranial hemorrhage, or neuro-function deficit. There is still controversy with respect to treatment strategies for symptomatic DVAs.

Material/Methods

Forty-three cases of symptomatic DVAs from January 2006 to October 2015 were retrospectively reviewed and the imaging characteristics of DVAs by CT, MRI, and DSA and the treatment modalities for DVAs were studied.

Results

Typical imaging characteristics of symptomatic DVAs were wedge or umbrella-shaped collections of dilated medullary veins converging in an enlarged subependymal or transcortical collecting vein, draining to the superficial or deep vein system. Based on location and draining vein features, symptomatic DVAs were tentatively classified into six different subtypes. Of the 43 cases, 19 were treated by surgical methods and 24 were treated conservatively.

Conclusions

We concluded that the rate of accompanying abnormalities in cases of symptomatic DVAs was high. Intracerebral hemorrhage was usually attributed to associated CMs or AVMs. The associated lesions and the branches responsible for bleeding could be resected while preserving the collecting vein as far as possible.

The relation between angioarchitectural factors of developmental venous anomaly and concomitant sporadic cavernous malformation

Background

Past studies found that cerebral developmental venous anomaly (DVA) is often concurrent with cavernous malformation (CM). But the reason of the concurrency remains unknown. The purpose of this study was to confirm whether angioarchitectural factors relate to the concurrence and which angioarchitectural factors can induce the concurrency.

Methods

DVA cases were selected from the records of the same 3.0 T MR. The DVA cases was divided into two group which are DVA group and DVA concurrent with CM group. 8 angioarchitectural factors of the DVAs were selected and measured. Statistical analysis was performed by the Pearson chi-square statistic,analysis of variance (ANOVA) and multi-factor logistic regression analysis.

Results

Five hundred three DVA lesions were found and 76 CM lesions coexisting with DVA. In the single factor analysis, all the 8 angioarchitectural factors of DVA were related to the concurrency. In the multivariate analysis, 6 angioarchitectural factors. Result of multi-factor logistic regression analysis is Logit(P) = -4.858-0.932(Location) + 1.616(Direction) + 1.757(Torsion) + 0.237(Number) + 2.119(Stenosis rate of medullary vein)-0.015(Angle), goodness of fit is 90.1 %.

Conclusions

The angioarchitectural factors of DVA are related to the concurrency of DVA and CM. 6 angioarchitectural factors may induce the concurrency.

Quantitative Analysis of Metabolic Abnormality Associated with Brain Developmental Venous Anomalies

Background and Purpose: Abnormal hypometabolism is common in the brain parenchyma surrounding developmental venous anomalies (DVAs), although the degree of DVA-associated hypometabolism (DVAAh) has not been quantitatively analyzed. In this study, we demonstrate a simple method for the measurement of DVAAh and test the hypothesis that DVAs are associated with a quantifiable decrement in metabolic activity.

Materials and Methods: Measurements of DVAAh using ratios of standardized uptake values (SUVs) and comparison to a normal database were performed on a cohort of 25 patients (12 male, 13 female), 14 to 76 years old, with a total of 28 DVAs (20 with DVAAh, seven with isometabolic activity, and one with hypermetabolic activity).

Results: Qualitative classification of none, mild, moderate, and severe DVAAh corresponded to quantitative measurements of DVAAh of 1 ± 3%, 12 ± 7%, 18 ± 6%, and 37 ± 6%, respectively. A statistically significant linear correlation between DVAAh and age was observed (P = 0.003), with a 3% reduction in metabolic activity per decade. A statistically significant linear correlation between DVAAh and DVA size was observed (P = 0.01), with a 4% reduction in metabolic activity per each 1 cm in the longest dimension. The SUV_DVA-based measures of DVAAh correlated (P = 0.001) with measures derived from comparison with a standardized database.

Conclusion: We present a simple method for the quantitative measurement of DVAAh using ratios of SUVs, and find that this quantitative analysis is consistent with a qualitative classification. We find that 54% (15 of 28) of DVAs are associated with a greater than 10% decrease in metabolic activity.

Developmental venous anomalies of the brain in children -- imaging spectrum and update

Developmental venous anomalies (DVAs) are the most common vascular malformation of the brain and are commonly identified on routine imaging of the brain. They are typically considered incidental findings, usually with no clinical significance. However the increasing identification of DVAs as a result of improved imaging technology has led to recognition of their association with a variety of abnormal imaging findings and clinically important conditions. This pictorial essay explores the suspected embryological origin, associated imaging features, and proposed pathophysiological mechanisms of DVAs in the pediatric population. This paper emphasizes newer physiological imaging data, which suggest that DVA drainage has less physiological flexibility than otherwise normal venous drainage development.

Brain metabolic abnormalities associated with developmental venous anomalies

BACKGROUND AND PURPOSE

Developmental venous anomalies are the most common intracranial vascular malformation and are typically regarded as inconsequential, especially when small. While there are data regarding the prevalence of MR imaging findings associated with developmental venous anomalies, FDG-PET findings have not been well-characterized.

MATERIALS AND METHODS

Clinical information systems were used to retrospectively identify patients with developmental venous anomalies depicted on MR imaging examinations who had also undergone FDG-PET. Both the MR imaging and FDG-PET scans were analyzed to characterize the developmental venous anomalies and associated findings on the structural and functional scans. Qualitative and quantitative assessments were performed, including evaluation of the size of the developmental venous anomaly, associated MR imaging findings, and characterization of the FDG uptake in the region of the developmental venous anomaly.

RESULTS

Twenty-five developmental venous anomalies in 22 patients were identified that had been characterized with both MR imaging and FDG-PET, of which 76% (19/25) were associated with significant metabolic abnormality in the adjacent brain parenchyma, most commonly hypometabolism. Patients with moderate and severe hypometabolism were significantly older (moderate: mean age, 65 ± 7.4 years, P = .001; severe: mean age, 61 ± 8.9 years, P = .008) than patients with developmental venous aberrancies that did not have abnormal metabolic activity (none: mean age, 29 ± 14 years).

CONCLUSIONS

Most (more than three-quarters) developmental venous anomalies in our series of 25 cases were associated with metabolic abnormality in the adjacent brain parenchyma, often in the absence of any other structural abnormality. Consequently, we suggest that developmental venous anomalies may be better regarded as developmental venous aberrancies.

Neuroimaging of epilepsy: a review of MRI findings in uncommon etiologies and atypical presentations of seizures

ABSTRACT: 

Imaging patients with seizures presents a challenge to both clinician and radiologist, especially when symptoms or EEG features are atypical, not conforming to established epilepsy syndromes or EEG patterns. Appropriate, directed use of MRI enhances the detection of underlying epileptogenic foci and can evaluate both common and unusual etiologies. This review examines imaging evaluation of epilepsies due to uncommon presentations of common conditions, unusual conditions and atypical seizure presentations. Understanding these uncommon presentations of seizures ensures optimal clinical management and can guide appropriate intervention. Advances in newer imaging methods including diffusion tensor imaging, functional connectivity MRI, magnetic source imaging and magnetic resonance spectroscopic imaging can further increase sensitivity to detect subtle structural abnormalities causing epilepsy and can also be used to plan more successful epilepsy surgery.

The association between cerebral developmental venous anomaly and concomitant cavernous malformation: an observational study using magnetic resonance imaging

Background

Some studies reported that cerebral developmental venous anomaly (DVA) is often concurrent with cavernous malformation (CM). But there is lack of statistical evidence and study of bulk cases. The factors associated with concurrency are still unknown. The purpose of this study was to determine the prevalence of concomitant DVA and CM using observational data on Chinese patients and analyze the factors associated with the concurrency.

Methods

The records of all cranial magnetic resonance imaging (MRI) performed between January 2001 and December 2012 in Beijing Tiantan Hospital were reviewed retrospectively. The DVA and CM cases were selected according to imaging reports that met diagnostic criteria. Statistical analysis was performed using the Pearson chi-square statistic for binary variables and multivariable logistic regression analysis for predictors associated with the concurrent CM.

Results

We reviewed a total of 165,230 cranial MR images performed during the previous 12 year period, and identified 1,839 cases that met DVA radiographic criteria. There were 205 patients who presented concomitant CM among the 1,839 DVAs. The CM prevalence in DVA cases (11.1%) was significantly higher than that in the non-DVA cases (2.3%) (P<0.01). In the multivariate analysis, we found that DVAs with three or more medullary veins in the same MRI section (adjusted OR = 2.37, 95% CI: 1.73-3.24), infratentorial DVAs (adjusted OR = 1.71, 95% CI: 1.26-2.33) and multiple DVAs (adjusted OR = 2.08, 95% CI: 1.04-4.16) have a higher likelihood of being concomitant with CM.

Conclusions

CM are prone to coexisting with DVA. There is a higher chance of concurrent CM with DVA when the DVA has three or more medullary veins in the same MRI scanning section, when the DVA is infratentorial, and when there are multiple DVAs. When diagnosing DVA cases, physicians should be alerted to the possibility of concurrent CM.

Epileptogenic developmental venous anomaly: insights from simultaneous EEG/fMRI

Developmental venous anomalies (DVAs) are associated with epileptic seizures; however, the role of DVA in the epileptogenesis is still not established. Simultaneous interictal electroencephalogram/functional magnetic resonance imaging (EEG/fMRI) recordings provide supplementary information to electroclinical data about the epileptic generators, and thus aid in the differentiation of clinically equivocal epilepsy syndromes. The main objective of our study was to characterize the epileptic network in a patient with DVA and epilepsy by simultaneous EEG/fMRI recordings. A 17-year-old woman with recently emerging generalized tonic-clonic seizures, and atypical generalized discharges, was investigated using simultaneous EEG/fMRI at the university hospital. Previous high-resolution MRI showed no structural abnormalities, except a DVA in the right frontal operculum. Interictal EEG recordings showed atypical generalized discharges, corresponding to positive focal blood oxygen level dependent (BOLD) correlates in the right frontal operculum, a region drained by the DVA. Additionally, widespread cortical bilateral negative BOLD correlates in the frontal and parietal lobes were delineated, resembling a generalized epileptic network. The EEG/fMRI recordings support a right frontal lobe epilepsy, originating in the vicinity of the DVA, propagating rapidly to both frontal and parietal lobes, as expressed on the scalp EEG by secondary bilateral synchrony. The DVA may be causative of focal epilepsies in cases where no concomitant epileptogenic lesions can be detected. Advanced imaging techniques, such as simultaneous EEG/fMRI, may thus aid in the differentiation of clinically equivocal epilepsy syndromes.

Developmental venous anomaly with contralateral impaired venous drainage in a 17-year-old male. A case report

Developmental venous anomalies (DVA) drain normal neural tissue and are mostly discovered incidentally. We describe a young patient with a left hemisphere superficial to deep DVA and right hemisphere venous outflow restriction presenting with a seizure. The right hemisphere drainage variation is not typical of a DVA but represents another drainage pattern on the border of normality.

Thrombosis of a developmental venous anomaly in inflammatory bowel disease: case report and radiologic follow-up

Developmental venous anomalies (DVAs) are benign embryologic vascular variants, and before the advent of computed tomography and magnetic resonance imaging were supposed to be rare conditions. Usually, DVAs are asymptomatic and accidentally discovered during routine brain imaging studies, but sometimes they can be the cause of disabling neurologic symptoms. We describe the clinical and neuroradiologic follow-up of a 62-year-old man with a history of inflammatory bowel disease (IBD) presenting with new onset epilepsy and intracranial hemorrhage caused by thrombosis of a DVA who fully recovered after treatment with oral anticoagulant therapy. Patients with IBD have an increased risk of thrombosis because of inflammatory activity and the hypercoagulable state. Here we describe the first case of DVA thrombosis in a patient with IBD, and we show clinical and neuroradiologic follow-up after anticoagulant therapy.

Developmental venous anomalies: appearance on whole-brain CT digital subtraction angiography and CT perfusion

Introduction

Developmental venous anomalies (DVA) consist of dilated intramedullary veins that converge into a large collecting vein. The appearance of these anomalies was evaluated on whole-brain computed tomography (CT) digital subtraction angiography (DSA) and CT perfusion (CTP) studies.

Methods

CT data sets of ten anonymized patients were retrospectively analyzed. Five patients had evidence of DVA and five age- and sex-matched controls were without known neurovascular abnormalities. CT angiograms, CT arterial-venous views, 4-D CT DSA and CTP maps were acquired on a dynamic volume imaging protocol on a 320-detector row CT scanner. Whole-brain CTP parameters were evaluated for cerebral blood flow (CBF), cerebral blood volume (CBV), time to peak (TTP), mean transit time (MTT), and delay. DSA was utilized to visualize DVA anatomy. Radiation dose was recorded from the scanner console.

Results

Increased CTP values were present in the DVA relative to the unaffected contralateral hemisphere of 48%, 32%, and 26%; and for the control group with matched hemispheric comparisons of 2%, −10%, and 9% for CBF, CBV, and MTT, respectively. Average effective radiation dose was 4.4 mSv.

Conclusion

Whole-brain DSA and CTP imaging can demonstrate a characteristic appearance of altered DVA hemodynamic parameters and capture the anomalies in superior cortices of the cerebrum and the cerebellum. Future research may identify the rare subsets of patients at increased risk of adverse outcomes secondary to the altered hemodynamics to facilitate tailored imaging surveillance and application of appropriate preventive therapeutic measures.