Aqueductal developmental venous anomaly causing obstructive hydrocephalus: A case report and review of the literature

A developmental venous anomaly (DVA) is a venous drainage of the associated parenchyma that is normally asymptomatic. However, a DVA located adjacent to the aqueduct can cause obstructive hydrocephalus by blocking the flow of cerebrospinal fluid. We describe a rare case of obstructive hydrocephalus due to aqueductal stenosis secondary to a DVA. A 43-year-old man presented with sudden bilateral temporal pain during weight training. Using a 3-Tesla scanner, cranial magnetic resonance imaging (MRI) was performed, and hydrocephalus was found with mild enlargement of the lateral and third ventricles. Susceptibility-weighted imaging and postcontrast MRI revealed that the DVA from the bilateral thalami narrowed the orifice of the aqueduct on its drainage route towards the vein of Galen. We assumed that force exerted during weight training may have caused dilation of the anomalous veins, leading to his symptom. A review of the relevant English-language literature yielded only 19 cases of aqueductal stenosis due to DVA. In comparison to these cases, the duration of symptom in our case was extremely short because the patient had a history of ventriculomegaly detected on plain computed tomography and was diagnosed quickly based on the characteristic finding of DVA: the caput medusae appearance.

Eagle jugular syndrome accompanied by de novo brainstem cavernous malformation: a case-based systematic review

BACKGROUND

Eagle jugular syndrome (EJS), recently identified as a cause of cerebrovascular disease (CVD) due to venous obstruction by an elongated styloid process (SP), is reported here alongside a case of concurrent de novo cerebral cavernous malformation (CCM). This study aims to explore the potential causal relationship between EJS and de novo CCM through a comprehensive literature review.

METHOD

Systematic literature reviews, spanning from 1995 to 2023, focused on EJS cases with definitive signs and symptoms and de novo CCM cases with detailed clinical characteristics. Data on the pathophysiology and clinical manifestations of EJS, as well as potential risk factors preceding de novo CCM, were collected to assess the relationship between the two conditions.

RESULT

Among 14 patients from 11 articles on EJS, the most common presentation was increased intracranial hypertension (IIH), observed in 10 patients (71.4%), followed by dural sinus thrombosis in four patients (28.6%). In contrast, 30 patients from 28 articles were identified with de novo CCM, involving 37 lesions. In these cases, 13 patients developed CCM subsequent to developmental venous anomalies (43%), seven following dural arteriovenous fistula (dAVF) (23%), and two after sinus thrombosis (6%). In a specific case of de novo brainstem CCM, the development of an enlarged condylar emissary vein, indicative of venous congestion due to IJV compression by the elongated SP, was noted before the emergence of CCM.

CONCLUSION

This study underscores that venous congestion, a primary result of symptomatic EJS, might lead to the development of de novo CCM. Thus, EJS could potentially be an indicator of CCM development. Further epidemiological and pathophysiological investigations focusing on venous circulation are necessary to clarify the causal relationship between EJS and CCM.

Angioarchitecture of the hemorrhagic developmental venous anomaly with stenosis of the collecting vein and cavernous malformation: a case report

We herein report a case of developmental venous anomaly (DVA) with venous congestion caused by stenosis of the collecting vein that presented with intracerebral hemorrhage (ICH). A 74-year-old woman was referred to our hospital a few days after the onset of motor aphasia. Computed tomography (CT) and magnetic resonance imaging (MRI) showed ICH in the left frontal lobe. Angiography revealed DVA in the left frontal lobe in the late venous phase. Stenosis of the collecting vein of DVA at the entrance to the superior sagittal sinus was detected and accompanied by cavernous malformation (CM) beside DVA. Cone-beam CT revealed the absence of the left septal vein and hypoplastic transverse caudate veins. The patient was treated by blood pressure management and no additional neurological symptoms were detected. DVA develops to compensate for the absence of pial or deep venous systems, and generally benign and clinically asymptomatic. However, the outflow restriction of DVA causes chronic venous hypertension and the formation of CM. These abnormalities are considered to occur during post-natal life and may result in ICH. The risk of hemorrhage needs to be considered in cases of DVA with restricted venous outflow or CM.

Cavernous malformations of the central nervous system: An international consensus statement

Introduction

Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial.

Research question

A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs.

Material and methods

A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%.

Results

A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases.

Discussion and conclusion

Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.

Quiz case: a clinical reasoning challenge in the emergency stroke setting

A right-handed woman in her 80s was admitted to the emergency department 1 h after sudden-onset global aphasia and right-sided hemiparesis. Medical history included arterial hypertension, dyslipidemia, hyperuricemia, aortic stenosis, osteoporosis, and recent pulmonary embolism. Medication consisted of apixaban, bisoprolol, hydrochlorothiazide, allopurinol, fenofibrate, and vitamin D. Vital parameters (blood pressure, heart rate, body temperature, oxygen saturation) and glycemia were all within normal range. Electrocardiogram showed a first-degree atrioventricular block. The patient was promptly transported to the emergency computed tomography (CT) scanner. Non-contrast brain CT revealed a unilateral hyperdensity in the left caudate and lentiform nuclei. No other intracranial lesion was visualized. Laboratory studies were not yet available at the time of imaging. What is your diagnosis?

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.

Awake craniotomy removal of a corticospinal tract developmental venous anomaly hemorrhage: A case report

Developmental venous anomalies (DVAs) are composed of mature venous vessels that lack malformed or neoplastic elements. Although the hemorrhage risk is considered negligible, some patients may have neurological symptoms attributable to acute infarction or intracranial hemorrhage secondary to thrombosis, in the absence of a coexisting cavernous malformation. We report the case of a 42-year-old patient who presented with acute left-hand paresis secondary to a subcortical hemorrhage. This bleeding originated from a DVA in the corticospinal tract area and was surgically drained through an awake craniotomy. To accomplish this, we used a trans-precentral sulcus approach. After the complete removal of the coagulum, small venous channels appeared, which were coagulated. No associated cavernoma was found. Although the main DVA trunk was left patent, no signs of ischemia or venous infarction were observed after coagulating the small venous channels found inside the hematoma cavity. Two weeks after the procedure, the patient's hand function improved, and he was able to resume desktop work. DVA-associated hemorrhage within the cortico-spinal tract could be safely removed with modern awake mapping techniques. This technique allowed the patient to rapidly improve his hand function.

Cerebrofacial venous metameric syndrome type 2+3: face is the index of brain

We describe a rare case of a 20-year-old man who presented with an extensive facial and orbital venous malformation associated with multiple intracranial venous malformations. The co-existence of cerebrofacial venous malformations points towards a common final pathway in development of these malformations. Our findings are consistent with few previous similar case descriptions. In addition, we describe some novel observations which, to the best of our knowledge, have not been described in the literature. This case reinforces the concept of metameric and segmental distribution of cerebrofacial vasculature, and the aberrations thereof leading to the metameric venous malformations, as proposed by Lasjaunias et al.

Infratentorial developmental venous anomaly concurrent with a cavernoma and dural arteriovenous fistula

OBJECTIVES

While developmental venous anomaly (DVA) may be associated with cavernous malformation, mixed vascular malformation associated with dural arteriovenous fistula (dAVF) has not been previously reported. We observed a case with rare association of infratentorial DVA, cavernous malformation, and dAVF that presented with cerebellar ataxia. We report our endovascular treatment for this complex cerebrovascular condition.

CASE PRESENTATION

A 32-year-old woman with ataxia had an infratentorial DVA associated with a cavernoma and dAVF. The dAVF had two shunting points. The dAVF was fed by the posterior meningeal arteries and drained through the sigmoid sinus into the transverse sinus. The dAVF was also fed by the occipital artery and retrogradely drained through the left jugular bulb into the dilated collecting vein of the DVA. Endovascular embolization was performed for the dAVF and dilated collecting vein of the DVA. Postoperative complications did not occur after embolization with no recurrence for three years.

CONCLUSIONS

This is the first reported case of infratentorial DVA associated with a cavernoma and dAVF. Endovascular treatment was effective in treating this symptomatic complex cerebrovascular disorder.

Giant, symptomatic mixed vascular malformation containing a cavernoma, developmental venous anomaly, and capillary telangiectasia in a 19-month-old infant

Intracranial mixed vascular malformations (MVMs) are defined as any combination of a developmental venous anomaly (DVA), cerebral cavernous malformation (CCM), capillary telangiectasia (CTG), or arteriovenous malformation (AVM) within a single, contiguous lesion. However, most MVMs described in the literature contain only 2 pathologically discrete malformations; juxtaposition of 3 or more abnormalities in a single lesion remains exceedingly rare. We present the case of a 19-month-old female with new onset focal seizures and a 4-cm right basal ganglia lesion initially believed to be an embryonal neoplasm. She subsequently underwent gross total resection (GTR) of the lesion via a transsylvian-transinsular approach. Intraoperatively, the lesion appeared to be heterogenous and highly vascular, with areas of purplish-gray friable tissue. Pathology confirmed the lesion to be a MVM containing a CCM, CTG, and a DVA. This appears to be the first reported case of such a lesion confirmed on pathology in the literature.

An analysis of lesions associated with developmental venous anomalies

OBJECTIVE

The aim of this study was to describe different lesions and features associated with developmental venous anomalies (DVAs).

METHODS

The records and magnetic resonance imaging (MRI) images of 1,722 patients who underwent cranial MRI between 2010 and 2017 were retrospectively reviewed. It was found that 124 (7.2%) patients had DVAs, and 48 of these patients (38.7%) had additional anomalies accompanying DVAs. Of the patients with DVAs, 25 were female and 23 were male, with a mean age of 39.3 years (range, 3-77 years). MRI was performed in all the patients.

RESULTS

In addition to DVAs, cavernomas were present in 30 patients (62.5%), haematomas in 7 (14.5%), gliosis in 6 (12.5%), demyelinating plaques in 4 (8.3%) and a glioblastoma in 1 (2.2%). The mean diameter of the DVAs was 1.1mm and the mean diameter of the lesions was 17.4mm. The susceptibility weighted imaging (SWI) sequence was also applied to 12 patients with cavernomas. The relevant sequence in all of these patients contributed to the diagnosis.

CONCLUSION

Our study shows that DVAs can accompany a wide spectrum of lesions, especially cavernomas. Although their pathophysiology has not yet been clearly established, these lesions may have a common aetiology.

Recurrent Transient Neurological Deficit Due to Intracerebral Steal Phenomenon in Association with a Developmental Venous Anomaly

We report a symptomatic developmental venous anomaly (DVA) not causing parenchymal abnormality to provide a pathophysiologic clue in patients with recurrent transient neurologic deficit. A 32-year-old male presented with recurrent transient motor aphasia and headache in the left fronto-temporal region for three years. The symptoms usually lasted for one hour. Brain computed tomography (CT) angiography and magnetic resonance imaging using gradient recalled echo showed a prominent penetrating vein at the left frontal periventricular region. Brain CT perfusion imaging performed during the symptoms revealed increased perfusion in the corresponding area with relatively decreased perfusion in the left fronto-temporal cortices. Digital subtraction angiography revealed collecting venous blood from the left septal and thalamostriate veins draining into the left cavernous sinus without early arteriovenous shunting. In this patient, an inciting incident might have led to imbalance of the venous flow surrounding the DVA, causing venous hypertension and the intracerebral steal phenomenon in the surrounding area. The relatively hypoperfused cortical area adjacent to the DVA could be considered the cause of the transient motor aphasia, while venous hypertension could be the cause of the headache.

Follow the Venous Path to the Hidden Lesion: A Technical Trick in Brainstem Cavernous Malformation Surgery

OBJECTIVE

Deep-seated brainstem cavernous malformations (BSCMs) pose a particular challenge for brainstem entry intraoperatively and their treatment can require comprehensive application of neuronavigation, electrophysiological brainstem mapping and monitoring, and full knowledge of safe brainstem entry zones. In the present report, we have introduced a supplementary technical trick for localizing a hidden tiny lesion inside the brainstem when a developmental venous anomaly (DVA) is present on the brainstem surface.

METHODS

A retrospective analysis of a 74-case cohort treated surgically from January 2011 to December 2019 was conducted. We identified 11 patients (14.9%) whose deep-seated BSCMs were exposed and removed following a brainstem surface DVA path as a supplementary technical trick. We have presented 2 typical cases to illustrate the operative nuances.

RESULTS

Of the 11 patients, 5 were male and 6 were female. Their average age was 38.0 ± 14.0 years (range, 15-62 years). Most BSCMs were located in the pons (n = 5; 45.5%), followed by the pontomesencephalic area (n = 3; 27.3%), midbrain (n = 2; 18.2%), and medulla oblongata (n = 1; 9.1%). All BSCMs were successfully located and completely removed. In 5 cases, the DVA was impaired after lesion removal (45.5%). However, no aggravated postoperative brainstem edema occurred in any of the 11 patients. After 3.6 ± 2.0 years of follow-up (2 patients were lost to follow-up; follow-up rate, 81.8%), no rebleeding was found, and the modified Rankin scale score of the patients had improved from 2.7 ± 1.1 preoperatively to 1.7 ± 0.9 at follow-up (P = 0.031).

CONCLUSIONS

The presented method could help surgeons trace deep-seated BSCMs with minimal brainstem parenchyma impairment, avoiding unnecessary aggressive exploration.

Constitutional mismatch repair deficiency (CMMRD) presenting with high-grade glioma, multiple developmental venous anomalies and malformations of cortical development-a multidisciplinary/multicentre approach and neuroimaging clues to clinching the diagnosis

Constitutional mismatch repair deficiency syndrome (CMMRD) is a rare cancer-predisposition syndrome associated with a high risk of developing a spectrum of malignancies in childhood and adolescence, including brain tumours. In this report, we present the case of an 8-year-old boy with acute headache, vomiting and an episode of unconsciousness in whom brain imaging revealed a high-grade glioma (HGG). The possibility of an underlying diagnosis of CMMRD was suspected radiologically on the basis of additional neuroimaging findings, specifically the presence of multiple supratentorial and infratentorial developmental venous anomalies (DVAs) and malformations of cortical development (MCD), namely, heterotopic grey matter. The tumour was debulked and confirmed to be a HGG on histopathology. The suspected diagnosis of CMMRD was confirmed on immunohistochemistry and genetic testing which revealed mutations in PMS2 and MSH6. The combination of a HGG, multiple DVAs and MCD in a paediatric or young adult patient should prompt the neuroradiologist to suggest an underlying diagnosis of CMMRD. A diagnosis of CMMRD has an important treatment and surveillance implications not only for the child but also the family in terms of genetic counselling.

Crossed brainstem syndrome revealing bleeding brainstem cavernous malformation: an illustrative case

BACKGROUND

Since the nineteenth century, a great variety of crossed brainstem syndromes (CBS) have been described in the medical literature. A CBS typically combines ipsilateral cranial nerves deficits to contralateral long tracts involvement such as hemiparesis or hemianesthesia. Classical CBS seem in fact not to be so clear-cut entities with up to 20% of patients showing different or unnamed combinations of crossed symptoms. In terms of etiologies, acute brainstem infarction predominates but CBS secondary to hemorrhage, neoplasm, abscess, and demyelination have been described. The aim of this study was to assess the proportion of CBS caused by a bleeding episode arising from a brainstem cavernous malformation (BCM) reported in the literature.

CASE PRESENTATION

We present the case of a typical Foville syndrome in a 65-year-old man that was caused by a pontine BCM with extralesional bleeding. Following the first bleeding episode, a conservative management was decided but the patient had eventually to be operated on soon after the second bleeding event.

DISCUSSION

A literature review was conducted focusing on the five most common CBS (Benedikt, Weber, Foville, Millard-Gubler, Wallenberg) on Medline database from inception to 2020. According to the literature, hemorrhagic BCM account for approximately 7 % of CBS. Microsurgical excision may be indicated after the second bleeding episode but needs to be carefully weighted up against the risks of the surgical procedure and openly discussed with the patient.

CONCLUSIONS

In the setting of a CBS, neuroimaging work-up may not infrequently reveal a BCM requiring complex multidisciplinary team management including neurosurgical advice.

Spinal Neurovascular Malformations in Klippel-Trenaunay Syndrome: A Single Center Study

BACKGROUND

A number of studies have demonstrated spinal anomalies associated with Klippel-Trenaunay syndrome (KTS). To date, there are no large consecutive series examining the prevalence and subtype distribution of spinal neurovascular malformations in patients with KTS.

OBJECTIVE

To report the spectrum and incidence of spinal neurovascular manifestations in the KTS population.

METHODS

This was a cross-sectional study. Consecutive patients with definite KTS as defined by International Society for the Study of Vascular Anomalies criteria who underwent spinal neuroimaging at our institution were included. All studies were evaluated by a staff neuroradiologist and a senior radiology resident for the presence of developmental venous anomalies, cavernous malformations (CMs), and arteriovenous shunts (AVS).

RESULTS

A total of 116 patients with definite KTS who underwent spinal neuroimaging were included. A total of 23 neurovascular anomalies were found in 19 patients (16.4%), including 4 patients with multiple anomalies. These included 5 patients with spinal cord CMs (4.3%), 14 patients with a paraspinal or epidural venous malformation (12.1%), and 4 patients with an AVS (3.4%). Of the AVS, 3 were epidural arteriovenous fistulas, 1 of which likely formed de novo in an epidural venous malformation. One was a conus medullaris arteriovenous malformation.

CONCLUSION

Our study cohort of 116 KTS patients demonstrated a wide spectrum of spinal neurovascular anomalies with a relatively high prevalence. Potential phenotypic descriptions of KTS should include the possibility for spinal neurovascular anomalies.

High prevalence of developmental venous anomaly in adult patients with midline thalamic diffuse gliomas

OBJECTIVE

This study aimed to assess the prevalence of developmental venous anomaly (DVA) in patients with thalamic glioma. Furthermore, we explored the association between DVA and some important biomarkers, such as IDH1 mutation, and H3K27M mutation.

PATIENTS AND METHODS

Patients who received tumor resection in West China Hospital between August 2009 and October 2017 were enrolled. Propensity score matching was conducted based on a logistic regression model and 1:1 matching for case and control was used to generate a new cohort from patients with meningioma. Chi-square test, t-test, univariate and multivariate analyses were employed to assess the prevalence of DVA in thalamic glioma and meningioma and to identify risk factors associated with DVA.

RESULTS

Ninety-nine patients with thalamic glioma were enrolled in the current study (male, n = 54; female, n = 45). The mean age was 42.9 ± 15.3 years old. We identified a higher prevalence of DVA in 99 patients with thalamic glioma when compared with 99 patients with meningioma (18.18% vs. 7.07%), which was slightly lower than the prevalence of DVA in glioma reported in previous studies. Furthermore, the distribution of gender, age, and tumor grade in DVA did not reach statistical significance. Chi-square test, univariate and multivariate analyses showed that IDH1 mutation, ATRX mutation, MGMT promoter methylation, p53 mutation, MMP9, EGFR, and Top II positive expression, TERT mutation, and H3K27M mutation were not associated with the development of DVA in thalamic glioma.

CONCLUSION

A higher prevalence of DVA was found in thalamic glioma compared with meningioma.

Prevalence and anatomical characteristics of developmental venous anomalies: an MRI study

PURPOSE

Developmental venous anomalies (DVAs) are extreme anatomical venous variations formed by multiple radiating medullary veins, which converge centripetally into a single collecting vein. Their coexistence with symptomatic cavernous malformations (CMs) has been reported in the literature. The aim of this study was to assess the characteristics of DVAs using MRI.

METHODS

A total of 6948 head MRIs of adult Caucasian patients were retrospectively analyzed to determine the number and locations of DVAs. We collected the data on the termination of the collecting vein, the prevalence of DVA-related CMs, and MRI FLAIR signal-hyperintensity corresponding to the location of the DVA.

RESULTS

At least one DVA was identified in 7.46% of the patients. The prevalence decreased with age, with a Pearson correlation coefficient of - 0.7328. A total of 599 DVAs were identified. Multiple DVAs were found in 10.92% of the patients with DVAs. The DVAs were identified more often in the supratentorial region (73.12%, p < 0.0001), and the most common location was the frontal lobe (35.23%). The collecting vein usually drained into the superficial cerebral veins (68.78%). CMs were observed in 4.14% of the patients with DVAs, and the prevalence showed a positive correlation with age. Signal-intensity abnormalities were identified in the vicinity of 5.18% DVAs.

CONCLUSION

Knowledge about characteristics of DVAs and associated anomalies is essential for neuroradiologists and neurosurgeons. The large number of currently available diagnostic studies enables us to assess anatomical variants on a great number of subjects.

Evolution of Developmental Venous Anomalies in the Setting of a Torcular Dural Arteriovenous Fistula and Cerebrofacial Venous Metameric Syndrome

BACKGROUND

We describe evolution of a developmental venous anomaly (DVA) over time in a patient with a complex intracranial vascular malformation.

CASE DESCRIPTION

A 26-year-old male patient initially presented with a scalp vascular malformation and was later diagnosed to have a torcular dural arteriovenous fistula resembling a dural sinus malformation. The dural fistula increased in size over 4 years. The dural fistula also was associated with multiple complex developmental venous anomalies draining the bilateral cerebral hemispheres and cerebellum. The DVA was only faintly demonstrated on the baseline magnetic resonance imaging but appeared to increase in size and extent over time as the dural arteriovenous fistula developed more aggressive angioarchitecture features. In addition to the evolution manifestation of the DVAs, the patient developed multiple de novo cavernous malformations in the venous radicles of the DVA. Increased venous hypertension in the superficial venous system from the dural fistula likely resulted in growth of the DVAs, as they served as the primary means of venous drainage for the bilateral cerebral hemispheres. The patient also had reopening of the persistent falcine sinus, which was not present at baseline.

CONCLUSIONS

This would be the first reported case of growth or evolution of a DVA in association with a dural arteriovenous fistula in an adult patient and highlights the dynamic nature of both the medullary venous and dural venous sinuses of the cerebral venous system, even into adulthood.

Persistent Falcine Sinus-The Variant Venous Structure With Anterior Interhemispheric Type And The Classic Posterior Location: Report of Two Cases

A 14-year-old girl presented with suspected dermoid cyst of scalp underwent Neuroimaging to look for intracranial communication. Her neurological examination was essentially normal. On Magnetic Resonance Imaging(MRI), an anterior persistent falcine sinus(PFS) was noted draining into the middle portion of the superior sagittal sinus. There was developmental venous anomaly (DVA) involving the right frontal lobe. To our knowledge, it is a rare instance of the combination of an anterior persistent falcine sinus and associated DVA.

Arteriovenous malformation drained into a developmental venous anomaly: A case report and up-dated literature review

INTRODUCTION

Although the association of developmental venous anomalies (DVAs) with cavernous malformations is well documented, the association with arteriovenous malformations (AVM) is unusual. The aim is herein to report an additional case and to review the concepts associated to these mixed malformations in order to guide patient management.

METHODS

A case of AVM associated with a DVA was identified and a literature review was performed according to PRISMA guidelines.

CASE REPORT

In an 18-year-old man presenting with sub-acute headache but with a normal neurological examination, the MRI-scan showed a right occipital DVA associated with hemosiderin spots evocative of earlier asymptomatic bleedings. The Digital Subtraction Angiography revealed a right parieto-occipital Spetzler-Martin Grade III AVM, fed by branches from the right middle and posterior cerebral arteries, with a superficial drainage flowing into a DVA that then joined the superior sagittal sinus. Multistep embolization was performed, leading to a partial reduction of the nidus, but preserving the DVA permeability. After a six-year follow-up. bleeding did not recur and the MRI aspect of the malformation was perfectly stable.

CONCLUSION

The co-occurrence of a DVA and an AVM is rare but has a higher bleeding risk than AVM alone (69% vs 38%) and must consequently be suspected when a DVA is revealed by a haemorrhage, in the absence of associated cavernoma. These mixed malformations represent a therapeutic challenge which has to be tailored to the venous anatomy and to the malformation Spetzler-Martin grade. DVA permeability should be preserved to avoid deleterious venous infarction.

High Prevalence of Developmental Venous Anomaly in Diffuse Intrinsic Pontine Gliomas: A Pediatric Control Study

BACKGROUND

No link has been demonstrated between diffuse intrinsic pontine glioma and developmental venous anomaly in pediatric patients.

OBJECTIVE

To determine the prevalence of developmental venous anomaly in a pediatric cohort of diffuse intrinsic pontine glioma.

METHODS

We performed a retrospective cohort study (1998-2017) of consecutive pediatric patients harboring a diffuse intrinsic pontine glioma (experimental set, n = 162) or a craniopharyngioma (control set, n = 142) in a tertiary pediatric neurosurgical center. The inclusion criteria were the following: age <18 yr at diagnosis; histopathological diagnosis of diffuse intrinsic pontine glioma or craniopharyngioma according to the 2016 World Health Organization classification of tumors of the central nervous system; no previous oncological treatment; and available preoperative magnetic resonance imaging performed with similar acquisition protocol.

RESULTS

We found a significantly higher prevalence of developmental venous anomaly in the experimental set of 162 diffuse intrinsic pontine gliomas (24.1%) than in the control set of 142 craniopharyngiomas (10.6%; P = .001). The prevalence of developmental venous anomalies was not significantly impacted by demographic data (sex, age at diagnosis, and underlying pathological condition), biomolecular analysis (H3-K27M-mutant subgroup, H3.1-K27M-mutant subgroup, and H3.3-K27M-mutant subgroup), or imaging findings (anatomic location, anatomic extension, side, and obstructive hydrocephalus) of the studied diffuse intrinsic pontine gliomas.

CONCLUSION

We report a higher prevalence of developmental venous anomaly in pediatric diffuse intrinsic pontine glioma patients than in control patients, which suggests a potential underlying common predisposition or a causal relationship that will require deeper investigations.

Cerebrovascular Malformations in a Pediatric Hereditary Hemorrhagic Telangiectasia Cohort

BACKGROUND

We determined the frequency of cerebrovascular malformations in a pediatric cohort with hereditary hemorrhagic telangiectasia.

METHODS

Retrospective cohort study of 54 children diagnosed with hereditary hemorrhagic telangiectasia at a tertiary care center. All neuroimaging was reviewed to assess for number and types of cerebrovascular malformations and for intracerebral hemorrhage and arterial ischemic stroke. Clinical charts were reviewed for clinical manifestations, genetic mutation, and clinically evident intracerebral hemorrhages and arterial ischemic strokes.

RESULTS

Among 54 children with hereditary hemorrhagic telangiectasia with a median age of 3.5 years (interquartile range 0.4 to 7.9 years) at diagnosis, neuroimaging was performed in 52 (96.3%) at a median age of 5.2 years (interquartile range 1.8 to 9 years). Fourteen of 52 imaged children (26.9%) had cerebrovascular malformations. Cerebrovascular malformations included arteriovenous malformations, arteriovenous fistulas, vein of Galen malformations, and developmental venous anomalies. Six of the 14 children with cerebrovascular malformations (42.9%) had multiple malformations. Three children developed new cerebral arteriovenous malformations over time. Six children (11.1%) had clinically evident intracerebral hemorrhage, arterial ischemic stroke, or transient ischemic attack. The three children with intracerebral hemorrhage presented at young ages (4.3 to 7.7 years).

CONCLUSIONS

More than a quarter of children with hereditary hemorrhagic telangiectasia who were imaged had cerebrovascular malformations, and overt stroke occurred in more than 10%. Intracerebral hemorrhages can occur in pediatric hereditary hemorrhagic telangiectasia patients at young ages, and new cerebral arteriovenous malformations may develop over time. Early screening with neuroimaging including neurovascular imaging as well as repeat neuroimaging may be warranted in children with hereditary hemorrhagic telangiectasia.

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.

Hemifacial spasm caused by the brainstem developmental venous anomaly: A case report and review of the literature

Background:

Hemifacial spasm (HFS) is usually caused by vascular compression of the root exit zone (REZ) of the facial nerve. Dual compression of the REZ by veins and arteries is also associated with HFS, but venous origin alone is rarely reported. We present a rare case of HFS caused by the brainstem developmental venous anomaly (DVA) treated with microvascular decompression (MVD).

Case Description:

A 30-year-old women presented with the left-sided HFS since the age of 18 years. The brainstem DVA was diagnosed by magnetic resonance imaging (MRI) and followed by two attempts of MVD at some other clinics without any improvement. At our hospital, MVD was performed through a left retromastoid craniotomy. Intraoperatively, after detaching the strong adhesions between the cerebellar hemisphere, petrosal dura and lower cranial nerves, and removing the Teflon sponge inserted during the previous operations, the compressing large vein was found, separated from facial nerve REZ and MVD was completed. The postoperative computed tomography angiography and MRI showed the thrombosis of the main trunk of DVA and decompression of the facial nerve REZ. Complete cessation of HFS with hearing preservation was observed with only slight weakness of mimic muscles which disappeared within 3 months after surgery.

Conclusion:

HFS associated with brainstem DVA is a very rare condition. MVD of the facial nerve REZ with transposition of the large draining vein should be considered as an effective treatment option.

Surgically Treated Epilepsy due to Developmental Venous Anomaly of the Brain: Case Report and Review of the Literature

BACKGROUND

A congenital malformation of the brain vessels, developmental venous anomaly (DVA) is considered a benign lesion, requiring no intervention unless symptomatic. Epilepsy is a well-known clinical manifestation of DVA. Successful surgery for DVA-associated epilepsy with has been sporadically reported in the literature; however, in all published cases, the anomaly was left intact along with the accompanying lesion. Here we present a surgical case of DVA located in the vicinity of the motor cortex causing drug-resistant simple partial epilepsy.

CASE DESCRIPTION

A 34-year-old man was referred due to medically intractable simple partial seizures. He was found to have DVA anterior to the motor cortex that was surgically removed. Following the surgical resection, the patient's seizures stopped, and there were no long-term complications of the procedure.

CONCLUSIONS

DVA removal can be performed in selected cases, but more studies are needed to assess the complication rate.

Outflow-Restricted Developmental Venous Anomaly Masquerading as a Tumefactive Lesion on Imaging

BACKGROUND

Developmental venous anomalies (DVA) are rarely symptomatic. We report an unusual case of outflow-restricted DVA presenting with seizures.

CASE DESCRIPTION

Expansile signal changes due to a hemorrhagic venous infarction in the draining territory of collector vein of DVA simulated a neoplasm. Follow-up imaging showed regression of mass effect and asymptomatic thrombosis of another distant vein. Investigation for prothrombotic conditions returned negative.

CONCLUSIONS

Atypical imaging findings in the draining territory of DVA ought to raise the possibility of outflow restriction.

Multiparametric MRI Evaluation of Developmental Venous Anomalies in the Brain: Association with Signal Changes on FLAIR in Patients with Multiple Sclerosis

BACKGROUND

Developmental venous anomalies (DVAs) can be determined on magnetic resonance imaging (MRI), and they may be associated with multiple sclerosis (MS) lesions.

PURPOSE

The objective was to evaluate the MRI findings of DVAs in the brain, to compare the prevalence of them between MS patients and control subjects, and to investigate the correlation of DVA-associated fluid-attenuated inversion recovery (FLAIR) hyperintensities and MRI-derived parameters between MS patients and control subjects having DVA.

METHODS

Total 160 patients with a mean age of 45 ± 16 years who underwent multiparametric MRI including susceptibility-weighted imaging (SWI), diffusion-weighted imaging, 3D FLAIR, and contrast-enhanced imaging were included in this retrospective study. First, the presence of DVA was compared between the MS and control groups using the Chi-square test. Then, among the subjects having DVA, age, gender, and MRI-derived parameters such as the signal increase of DVA on FLAIR, location, and drainage of DVA were compared between the MS and control groups using Chi-square test.

RESULTS

The presence of DVA did not differ between the MS and control groups (P = 0.828). Signal increase around DVA on FLAIR (P = 0.03) and the age of less than 45 years demonstrated a significant correlation with MS group (P = 0.022).

CONCLUSION

In our study, DVAs were effectively detected using SWI and 3D contrast-enhanced T1-weighted imaging on MRI. The signal increase of DVA was better revealed on 3D FLAIR on MRI, and it was the only significant MRI-derived parameter in patients with MS.

Epilepsy Lesion Localization is not Predicted by Developmental Venous Anomaly Location or its FDG-PET Metabolic Activity

BACKGROUND AND PURPOSE

This study's purpose is to correlate location and metabolic activity of developmental venous anomalies (DVAs) in epilepsy patients to the seizure focus as determined by ictal/interictal encephaloelectrogram (EEG).

METHODS

A retrospective search was performed for epilepsy patients with DVAs who underwent brain ¹⁸ F-fluorodeoxyglucose positron emission tomography (¹⁸ F-FDG-PET) and magnetic resonance imaging (MRI). MRI exams were analyzed to characterize DVA location and associated structural findings. MRI and PET images were co-registered and assessment of ¹⁸ F-FDG uptake in the DVA territory was performed. The electronic medical record was reviewed for each subject to determine seizure semiology and site of seizure focus by ictal/interictal EEG.

RESULTS

Twenty-eight DVAs in 25 patients were included. Twelve DVAs demonstrated regional metabolic abnormality on ¹⁸ F-FDG-PET. There was no significant correlation between DVA site and seizure focus on EEG. DVA location was concordant with EEG seizure focus in three subjects, and all three demonstrated hypometabolism on ¹⁸ F-FDG-PET. This significance remains indeterminate, as one of these DVAs was associated with cavernoma, which could serve as the true seizure focus, and one of the patients underwent resection of the DVA without decrease in seizure frequency. Furthermore, there was no statistically significant relationship between DVA metabolic activity and DVA-EEG lobar or laterality concordance.

CONCLUSIONS

In this sample, there is no significant correlation between location of DVA and seizure focus, and hypometabolism within the DVA territory is not predictive of EEG/DVA co-localization. As use of ¹⁸ F-FDG-PET for evaluation of epilepsy increases, knowledge of this poor correlation is important to avoid diagnostic confusion and potentially unnecessary surgery in epilepsy patients.

Symptomatic developmental venous anomalies

Cerebral developmental venous anomalies (DVAs) are variations of venous vascular anatomy related to an underdevelopment of either the superficial or deep venous emissary system, resulting in a dilated transmedullary vein fed by multiple smaller venous radicles responsible for drainage of normal brain parenchyma. While typically benign and found incidentally on imaging studies, DVAs can rarely be symptomatic. The radiographic appearance of DVAs, as well as their symptomatic manifestations, is diverse. Herein, we will discuss the pathophysiology of symptomatic DVAs while providing illustrative case examples depicting each of their pathogenic mechanisms.

Hemorrhage owing to cerebral cavernous malformation: imaging, clinical, and histopathological considerations

Cavernous malformation (CM) is the second most common cerebral vascular malformation and is often found incidentally. Their natural history is usually benign, however, patients with CM who present with symptomatic hemorrhage may later follow a serious clinical course if left untreated. The risk of hemorrhage is associated with previous hemorrhage, lesion location (infratentorial and deep), and the presence of associated developmental venous anomaly (DVA). Histopathological specimens also indicate that coexistence of DVA and other vascular malformations may be associated with hemorrhage owing to CMs. Diagnosing CMs is difficult, even in patients who initially present with symptomatic hemorrhage. Computed tomography scans typically reveal a hemorrhagic CM as a nonspecific heterogenous mass of high density, which may not be misdiagnosed as a solitary hematoma, especially when located in the infratentorial region. Magnetic resonance imaging demonstrates internal loculation with mixed-signal intensities typical for CMs, although this may be partially or completely masked by acute hemorrhage. Susceptibility-weighted imaging (SWI) reveals a significant "blooming" effect of hemosiderin deposition. Three-dimensional postcontrast T1-weighted imaging is essential to identify associated DVAs, and this is important for both diagnosis and planning of surgical treatment. Contrast-enhanced MRI should be performed to diagnose hemorrhagic CMs and differentiate them from spontaneous solitary hematoma or hemorrhagic tumors.

Atypical Intracerebral Developmental Venous Anomalies in Sturge-Weber Syndrome: A Case Series and Review of Literature

BACKGROUND

Intracranial vascular abnormalities in Sturge-Weber syndrome, including leptomeningeal angiomatosis, anomalous cortical venous structures, and transmedullary developmental venous anomalies, are well recognized. Prominent vascular flow voids on T2-weighted magnetic resonance imaging (MRI) are occasionally identified in patients with Sturge-Weber syndrome, raising concern of arteriovenous malformations, a congenital high-flow vascular malformation with a risk of bleeding.

METHODS

We report four patients with prominent flow voids on conventional MRI that suggested high-flow lesions.

RESULTS

Diagnostic evaluation was performed with cerebral angiography in one patient and with a combination of magnetic resonance angiography and magnetic resonance venography in three patients. In all four patients, the conventional MRI-identified lesions represented prominent developmental venous anomalies and not arteriovenous malformations.

CONCLUSIONS

This series highlights that developmental venous anomalies may appear in individuals with Sturge-Weber syndrome as unusually large and seemingly high-flow lesions on MRI. Noninvasive imaging with magnetic resonance angiography and magnetic resonance venography can be used in the management of such patients for further characterization of these vascular structures.

Cerebrofacial venous metameric syndrome-spectrum of imaging findings

Cerebrofacial venous metameric syndrome (CVMS) is a complex craniofacial vascular malformation disorder in which patients have a constellation of venous vascular malformations affecting soft tissues, bone, dura, and neural structures including the eye and brain. It is hypothesized that a somatic mutation responsible for the venous abnormalities occurred prior to migration of the neural crest cells, and because of this, facial, osseous, and cerebral involvement typically follows a segmental or "metameric" distribution. The most commonly recognized form of CVMS is Sturge-Weber syndrome. However, a wide spectrum of CVMS phenotypical presentations exist with various metameric distributions of slow-flow vascular lesions including facial venous vascular malformations, developmental venous anomalies, venous angiomas, cavernous malformations (cavernomas), dural sinus malformations, and maybe even vascular tumors such as cavernous hemangiomas. Awareness of the various manifestations as described herewith is important for treatment and screening purposes.

Successful Cesarean Section Deliveries in a Patient with a History of Developmental Venous Anomaly-Induced Hemorrhage

While hemorrhage can occur because of developmental venous anomalies (DVAs), there is no established opinion concerning their association with pregnancy and childbirth. In the present report, we discuss the case of a now 39-year-old woman with DVA in whom pregnancy and childbirth were successful. When she was 28, she experienced disturbance of consciousness and paralysis on the left side of the body, and brain computed tomography revealed cerebral hemorrhage coupled with subarachnoid hemorrhage. Cerebral angiography revealed a DVA with an arteriovenous shunt, with superficial drainage surrounding the hematoma. No associated cavernous hemangiomas were observed, and the patient was diagnosed with DVA-induced hemorrhage and treated via conservative therapy. Later, at the ages of 32 and 35, she gave birth via Caesarean section under general anesthesia. At the age of 37, she experienced sudden headache and nausea, following which she was again diagnosed with DVA-induced hemorrhage. Fortunately, she experienced no exacerbation of symptoms such as paralysis. However, she currently has mild, residual paralysis on the left side of the body, and she regularly walks to the hospital using a cane for follow-up examinations.

A rupture risk analysis of cerebral cavernous malformation associated with developmental venous anomaly using susceptibility-weighted imaging

PURPOSE

To search for the risk factors closely related to cerebral cavernous malformation associated with developmental venous anomaly (CCM-DVA) lesions rupture, laying foundations for the development of reasonable individual treatment plans for patients.

METHODS

In this retrospective study, we collected CCM-DVA patients who met the inclusion criteria in our outpatient department from 2014 to 2017, MRI scans were performed including susceptibility-weighted imaging (SWI) and contrast-enhanced imaging, characteristics and basic clinical information were collected then statistically analyzed, CCM-DVA lesions were divided into 3 types according to the location and quantitative relationship between CCM and DVA.

RESULTS

A total number of 319 adult patients were identified with 41.2±11.9 years on average, though univariate and multivariate regression analysis, ruptured presentations were more common in patients with prior hemorrhage (p=0.003), type III CCM-DVA lesions (p=0.001), lesions volume>1 cm³ (p<0.001), infratentorial lesions especially located in midbrain (p=0.019), pontine (p=0.007), medulla (p=0.015). Caplan-Meier curve shows a lower Hemorrhage-free survival rate on patients with type III CCM-DVA lesions (log-rank, p=0.0222), functional area lesions (log-rank, p<0.001), lesions volume>1 cm³ (log-rank, p<0.001), infratentorial lesions (log-rank, p=0.0002).

CONCLUSION

The classification based on the relationship between CCM and DVA may be meaningful to predict the risk of lesion rupture and CCM lesions next to DVA distal branches showed a higher risk of rupture.

Focal limb dystonia caused by a complication of the cerebellar developmental venous anomaly: a case report

Background

There are no established theories regarding the role of the cerebellum in dystonia. We report a case of focal limb dystonia secondary to a vasogenic edema of the dentate nucleus caused by a symptomatic developmental venous anomaly.

Case presentation

A 44-year-old woman presented with sudden onset dystonia in her left arm for 1 week. Brain imaging revealed vasogenic edema in the deep white matter of the left cerebellar hemisphere, including the left dentate nucleus, secondary to a developmental venous anomaly. ¹⁸F-fluorodeoxyglucose positron emission tomography images showed hypometabolism in the corresponding cerebellar deep nuclei without the involvement of other brain regions. She was treated with a steroid. At the one-month follow-up, computed tomography scan demonstrated remission of the cerebellar edema, which was thought to be the cause of dystonia.

Conclusions

This case demonstrates that the cerebellum has an important role in the development of dystonia. Further studies are needed to elucidate the relationship between dystonia and cerebellar dysfunction.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1446-8) contains supplementary material, which is available to authorized users.

Relationship between Abnormal Hyperintensity on T2-Weighted Images Around Developmental Venous Anomalies and Magnetic Susceptibility of Their Collecting Veins: In-Vivo Quantitative Susceptibility Mapping Study

Objective

A developmental venous anomaly (DVA) is a vascular malformation of ambiguous clinical significance. We aimed to quantify the susceptibility of draining veins (χ_vein) in DVA and determine its significance with respect to oxygen metabolism using quantitative susceptibility mapping (QSM).

Materials and Methods

Brain magnetic resonance imaging of 27 consecutive patients with incidentally detected DVAs were retrospectively reviewed. Based on the presence of abnormal hyperintensity on T2-weighted images (T2WI) in the brain parenchyma adjacent to DVA, the patients were grouped into edema (E+, n = 9) and non-edema (E−, n = 18) groups. A 3T MR scanner was used to obtain fully flow-compensated gradient echo images for susceptibility-weighted imaging with source images used for QSM processing. The χ_vein was measured semi-automatically using QSM. The normalized χ_vein was also estimated. Clinical and MR measurements were compared between the E+ and E− groups using Student's t-test or Mann-Whitney U test. Correlations between the χ_vein and area of hyperintensity on T2WI and between χ_vein and diameter of the collecting veins were assessed. The correlation coefficient was also calculated using normalized veins.

Results

The DVAs of the E+ group had significantly higher χ_vein (196.5 ± 27.9 vs. 167.7 ± 33.6, p = 0.036) and larger diameter of the draining veins (p = 0.006), and patients were older (p = 0.006) than those in the E− group. The χ_vein was also linearly correlated with the hyperintense area on T2WI (r = 0.633, 95% confidence interval 0.333–0.817, p < 0.001).

Conclusion

DVAs with abnormal hyperintensity on T2WI have higher susceptibility values for draining veins, indicating an increased oxygen extraction fraction that might be associated with venous congestion.

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

OBJECTIVE

Trigeminal neuralgia (TN) related to a brainstem cavernous malformation (CM) is a rare entity. We present the first radiosurgical management of a patient with TN secondary to a CM.

CLINICAL PRESENTATION

An 80-year-old female presented with a 33-year history of progressively severe TN refractory to medications. Imaging confirmed a solitary CM located at the pontine dorsal root entry zone of cranial nerve 5.

TREATMENT

Stereotactic radiosurgery of the trigeminal nerve was performed using the Leksell gamma knife. A single 4-mm isocenter of radiation was focused on the trigeminal nerve and a maximum dose of 80 Gy (40 Gy at the 50% isodose line) was delivered to the nerve.

RESULTS

At 1 year, the patient noted that the severe pain attacks had been reduced by 75%, although a background lingering discomfort persisted. Pain suppression medications had been significantly reduced to lamotrigine 100 mg twice daily. Her preoperative distribution of sensory dysfunction mildly increased.

CONCLUSION

For medically refractory TN related to a CM, radiosurgery of the afferent nerve may ameliorate pain without a major decrease in sensation. The more than 30-year history of pain in our patient may have reduced the chance of more significant pain relief.

Developmental venous anomalies and brainstem cavernous malformations: a proposed physiological mechanism for haemorrhage

The incidental diagnosis of both developmental venous anomalies (DVAs) and cavernous malformations (CMs) in the central nervous system is increasing with improved imaging techniques. While classically silent diseases, these cerebrovascular pathologies can follow an aggressive course, particularly when present in the brainstem. In the last decade, substantial research has focussed on KRIT1-mediated tight junction gene expression and their role in CM development. However, our understanding of the physiologic conditions precipitating symptomatic CM development or CM haemorrhage with and without concomitant DVAs, remains lacking. The only established risk factor for CM haemorrhage is a previous history of haemorrhage, and literature currently reports trauma as the only precipitant for symptomatic events. While plausible, this occurs in a minority, with many patients experiencing occult events. This manuscript presents a hypothesis for symptomatic CM events by first discussing the anatomical pathways for intracranial venous outflow via the internal jugular veins (IJV) and vertebral venous plexus (VVP), then exploring the role of venous flow diversion away from the IJVs under physiologic stress during dynamic postural shift. The resultant increase in intracranial venous pressure can exacerbate normal and pre-existing structural DVA pathologies, with repeated exposure causing symptomatic or CM-inducing events. This pathophysiological model is considered in the context of the role of the autonomic nervous system (ANS) in postural intracranial venous outflow diversion, and how this may increase the risk of DVA or CM events. It is hoped that this hypothesis invokes further investigation into precipitants for DVA or CM events and their sequela and, also, furthers the current knowledge on pathophysiological development of DVAs and CMs.

Formation During Lifetime of Arteriovenous Shunt in Developmental Venous Anomaly That Caused Intracerebral Hemorrhage

BACKGROUND

Developmental venous anomaly (DVA) or venous angioma is a common anomaly of cerebral veins that is found incidentally in the majority of cases. There are few cases of arteriovenous shunting in DVA associated with a more malignant course of the disease. Whether these DVAs with shunts are of congenital pathology or lifetime formations is unclear.

CASE DESCRIPTION

We report a case of lifetime arteriovenous shunt formation in DVA that caused intracerebral hemorrhage in a child. The patient underwent 2 sequential direct surgeries: an emergency evacuation of the intracerebral hematoma and a scheduled excision of the DVA with arteriovenous shunting.

CONCLUSIONS

Arteriovenous shunting in DVA may develop during a lifetime and cause intracerebral hemorrhages. This case showed that localization of DVA with arteriovenous shunting in a noneloquent area enables its complete microsurgical excision with favorable functional outcomes.

Long-Term Outcome of Gamma Knife Radiosurgery for Brain Cavernoma: Factors Associated with Subsequent De Novo Cavernoma Formation

BACKGROUND

We aimed to evaluate the factors associated with de novo brain cavernoma formations after patients underwent gamma knife radiosurgery (GKRS) and confirmed whether developmental venous anomaly (DVA) presented with a cavernoma and whether the cavernoma was included in the GKRS target location.

METHODS

From January 2003 to December 2008, 95 patients underwent radiosurgery for brain cavernoma at our institution. Of these, 15 with multiple cavernomas related to familial cavernoma or with a history of surgical treatment for cavernoma were excluded. A total of 80 patients (44 men and 36 women; average age, 39.4 years) with sporadic cavernoma were retrospectively analyzed by considering the patient characteristics, including sex, age, target volume, radiation dose, clinical symptoms, cavernoma location, radiosurgery complications, and morphology of DVA.

RESULTS

The average target volume, mean radiation dose, and mean target percentage were 1019.2 mm³, 13.7 Gy, and 51.1%, respectively. Nineteen patients showed cavernomas associated with DVA; of these, de novo cavernoma formations were noticed in 4 patients at a median of 49.5 months after undergoing GKRS. All de novo cavernomas were related to the presence of DVA and were located near the brainstem or cerebral peduncle. De novo cavernomas occurred when DVAs were not included in the GKRS-target location.

CONCLUSIONS

All de novo cavernomas were located near the brainstem or cerebral peduncle, and they occurred in the presence of DVAs. The presence of DVA in the radiosurgery target location might be potentially an important factor associated with de novo cavernoma formation.

Unusual location of developmental venous anomaly within fourth ventricle causing obstructive hydrocephalus - A case report

Developmental venous anomaly (DVA) is now considered common and benign disease within the field of cerebral vascular malformation. Though symptomatic DVA is uncommon, further management is necessary to alleviate the symptoms and signs induced by symptomatic DVA, such as parenchymal hemorrhage, venous infarction, brain edema, obstructive hydrocephalus, and nerve root compression. From the viewpoint of obstructive hydrocephalus, mostly resulted from obstruction of aqueduct of Sylvius. Herein, we reported a case with presentation of obstructive hydrocephalus caused by DVA induced fourth ventricle outlet obstruction.

Prevalence of cerebral cavernous malformations associated with developmental venous anomalies increases with age

BACKGROUND AND PURPOSE

To test the hypothesis that the prevalence of cerebral cavernous malformation (CCM) associated with developmental venous anomalies (DVAs) increases with age, we studied the age-related prevalence of DVA-associated CCM among patients with DVAs.

MATERIALS AND METHODS

Patients with DVAs on contrast-enhanced MRI exams performed over a 2-year period were included in this study. A single neuroradiologist reviewed all imaging exams for the presence of CCMs. Baseline demographic data collected included age, gender, presence of CNS neoplasm, history of cranial radiation, and history of seizure. Patients were divided into age groups based on decade of life. Cochran-Armitage trend tests were performed to determine if increasing age was associated with CCM prevalence.

RESULTS

A total of 1689 patients with DVAs identified on contrast-enhanced MRI were included. Of these patients, 116 (6.9%) had a cavernous malformation associated with the DVA. There was a significant positive association between age and the prevalence of DVA-associated CCM (P = 0.002). The prevalence of DVA-associated CCM was 0.8% for the 0-10 age group, 1.6% for the 11-20 age group, 7.5% for the 21-30 age group, 9.5% for the 31-40 age group, 6.1% for the 41-50 age group, 6.3% for the 51-60 age group, 7.4% for the 61-70 age group, and 11.6% for the >70 age group (P < .0001).

CONCLUSIONS

Our study demonstrated an age-related increase in prevalence of DVA-associated cavernous malformations among patients with DVAs. These findings suggest that DVA-associated cavernous malformations are acquired lesions.

Management of Arteriovenous Malformations Associated with Developmental Venous Anomalies: A Literature Review and Report of 2 Cases

BACKGROUND

Classification of cerebrovascular malformations has revealed intermediary lesions that warrant further review owing to their unusual presentation and management. We present 2 cases of arteriovenous malformation (AVM) associated with a developmental venous anomaly (DVA), and discuss the efficacy of previously published management strategies.

METHODS

Two cases of AVMs associated with DVA were identified, and a literature search for published cases between 1980 and 2016 was conducted. Patient demographic data and clinical features were documented.

RESULTS

In case 1, a 29-year-old female presenting with parenchymal hemorrhage and left homonymous hemianopia was found to have a right parieto-occipital AVM fed from the anterior cerebral, middle cerebral, and posterior cerebral arteries, with major venous drainage to the superior sagittal sinus. In case 2, imaging in a 34-year-old female evaluated for night tremors and incontinence revealed a left parietal AVM with venous drainage to the superior sagittal sinus. Including our 2 cases, 22 cases of coexisting AVMs and DVAs have been reported in the literature. At presentation, 68% had radiographic evidence of hemorrhage. Stereotactic radiosurgery was performed in 7 cases, embolization in 6 cases, surgical resection in 4 cases, and multimodal therapy in 5 cases. Radiography at follow-up demonstrated successful AVM obliteration in 67% of cases (12 of 18).

CONCLUSIONS

Patients with coexisting AVMs and DVAs tend to have a hemorrhagic presentation. Contrary to traditional AVM management, in these cases it is important to preserve the draining vein via the DVA to ensure a safe, sustained circulatory outflow of the associated brain parenchyma while achieving safe AVM obliteration.

Unique Imaging Features Enabling the Prenatal Diagnosis of Developmental Venous Anomalies: A Persistent Echogenic Brain Lesion Drained by a Collecting Vein in Contrast with Normal Brain Parenchyma on MRI

OBJECTIVE

To describe the prenatal imaging features enabling diagnosis of developmental venous anomalies (DVA).

METHODS

Four fetuses with unexplained persistent echogenic parenchymal brain lesions were studied. The evaluation included dedicated neurosonography, fetal MRI, serology for intrauterine infection, screening for coagulation abnormalities, and chromosomal microarray. Postnatal neurodevelopmental follow-up or autopsy results were assessed.

RESULTS

DVA presented as very slowly growing echogenic brain lesions without cystic components, calcifications, or structural changes on otherwise normal neurosonographic scans performed at 2- to 3-week intervals. A specific Doppler feature was a collecting vein draining the echogenic parenchyma. Fetal brain MRI depicted normal anatomy on half-Fourier acquisition single-shot turbo spin-echo and diffusion-weighted imaging. The rest of the evaluation was normal.

CONCLUSIONS

In cases with a persistent, parenchymal echogenic lesion without clastic or structural changes, DVA should be considered. Demonstration of a collecting vein draining the lesion and normal brain anatomy on MRI confirm the diagnosis.

Tumefactive demyelination associated with developmental venous anomaly: Report of two cases

We present two cases of tumefactive demyelination (TD) occurring in close association with a developmental venous anomaly (DVA). Our purpose is to describe the association between demyelinating lesions and venous anomalies, as only one case of TD associated with a DVA has been published in the literature. Appropriate recognition of this "do not touch" lesion may avoid invasive and potentially harmful procedures such as biopsy or resection.