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Bardo DME, Gill AE, Iyer RS, Chan SS, Cooper ML, Dasgupta RA, Guimaraes CV, Hammer MR, Krowchuk DP, Levin TL, Liang MG, Meyers ML, Samet JD, Sammer MBK, Schooler GR, Squires JH, Sura AS, Trout AT, Pruthi S. ACR Appropriateness Criteria® Soft Tissue Vascular Anomalies: Vascular Malformations and Infantile Vascular Tumors (Non-CNS)-Child. J Am Coll Radiol 2024; 21:S310-S325. [PMID: 38823953 DOI: 10.1016/j.jacr.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Soft tissue vascular anomalies may be composed of arterial, venous, and/or lymphatic elements, and diagnosed prenatally or later in childhood or adulthood. They are divided into categories of vascular malformations and vascular tumors. Vascular malformations are further divided into low-flow and fast-flow lesions. A low-flow lesion is most common, with a prevalence of 70%. Vascular tumors may behave in a benign, locally aggressive, borderline, or malignant manner. Infantile hemangioma is a vascular tumor that presents in the neonatal period and then regresses. The presence or multiple skin lesions in an infant can signal underlying visceral vascular anomalies, and complex anomalies may be associated with overgrowth syndromes. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Dianna M E Bardo
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Anne E Gill
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington
| | - Sherwin S Chan
- Panel Vice Chair, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Roshni A Dasgupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | | | | | - Daniel P Krowchuk
- Wake Forest University School of Medicine, Winston Salem, North Carolina; American Academy of Pediatrics
| | - Terry L Levin
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Marilyn G Liang
- Boston Children's Hospital, Boston, Massachusetts; Society for Pediatric Dermatology
| | - Mariana L Meyers
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan D Samet
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Gary R Schooler
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Judy H Squires
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amit S Sura
- Children's Hospital Los Angeles, Los Angeles, California
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Commission on Nuclear Medicine and Molecular Imaging
| | - Sumit Pruthi
- Specialty Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
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2
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Yanagida K, Kaneko T, Saito K, Yamamoto M, Yamamoto A, Yamada Y, Nakagawa T. Retroperitoneal capillary arteriovenous malformation mimicking a malignant neoplasm. IJU Case Rep 2023; 6:398-401. [PMID: 37928304 PMCID: PMC10622200 DOI: 10.1002/iju5.12632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/19/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Retroperitoneal tumors account for 0.2% of all neoplasms. Among these tumors, retroperitoneal vascular malformations are particularly rare, with most previously reported cases being venous malformations. Case presentation A 72-year-old woman was diagnosed with a retroperitoneal tumor on abdominal computed tomography. The 27-mm diameter tumor was located away from the right kidney and major vessels in the right perirenal adipose tissue. Contrast-enhanced computed tomography revealed a heterogeneously enhanced tumor with well-defined borders. Dynamic contrast-enhanced magnetic resonance imaging revealed rapid enhancement in the arterial phase and a progressive filling-in pattern in the delayed phase. Although vascular malformation was suspected, a definitive diagnosis could not be established. The retroperitoneal tumor was excised laparoscopically for therapeutic and diagnostic purposes, and the histopathological diagnosis confirmed it as a capillary arteriovenous malformation. Conclusion Herein, we presented a rare case of retroperitoneal capillary arteriovenous malformation that was difficult to definitively diagnose preoperatively.
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Affiliation(s)
- Kazuki Yanagida
- Department of UrologyTeikyo University School of MedicineTokyoJapan
| | - Tomoyuki Kaneko
- Department of UrologyTeikyo University School of MedicineTokyoJapan
| | - Koji Saito
- Department of PathologyTeikyo University HospitalTokyoJapan
| | | | - Asako Yamamoto
- Department of RadiologyTeikyo University School of MedicineTokyoJapan
| | - Yukio Yamada
- Department of UrologyTeikyo University School of MedicineTokyoJapan
| | - Tohru Nakagawa
- Department of UrologyTeikyo University School of MedicineTokyoJapan
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3
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Al-Hammad WE, Fujikura M, Hisatomi M, Okada S, Munhoz L, Kawazu T, Takeshita Y, Fujita M, Yanagi Y, Asaumi JI. An imaging‑based diagnostic approach to vascular anomalies of the oral and maxillofacial region. Oncol Lett 2023; 26:394. [PMID: 37600333 PMCID: PMC10433708 DOI: 10.3892/ol.2023.13980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/28/2023] [Indexed: 08/22/2023] Open
Abstract
The accurate diagnosis of vascular anomalies (VAs) is considered a challenging endeavor. Misdiagnosis of VAs can lead clinicians in the wrong direction, such as the performance of an unnecessary biopsy or inappropriate surgical procedures, which can potentially lead to unforeseen consequences and increase the risk of patient injury. The purpose of the present study was to develop an approach for the diagnosis of VAs of the oral and maxillofacial region based on computed tomography (CT), magnetic resonance imaging (MRI) and dynamic contrast-enhanced MRI (DCE-MRI). In the present study, the CT and MR images of 87 VAs were examined, and the following imaging features were evaluated: Detectability of the lesion, the periphery of the lesion, the inner nature of the lesion, the density of the lesion on CT, the signal intensity of the lesion on MRI, the detectability of phleboliths and the shape of the lesion. A total of 29 lesions were further evaluated using the contrast index (CI) curves created from the DCE-MRI images. A diagnostic diagram, which is based on the imaging features of VAs and CI curve patterns, was subsequently extrapolated. The results obtained demonstrated that the VAs were detected more readily by MRI compared with CT, whereas the detectability of phleboliths was superior when using CT compared with MRI. VAs showed a propensity for homogeneous isodensity on CT, whereas, by contrast, they exhibited a propensity for heterogeneous hyperdensity on CE-CT. VAs also showed a propensity for homogeneous intermediate signal intensity when performing T1-weighted imaging (T1WI), heterogeneous high signal intensity when performing short tau inversion recovery MRI, and heterogeneous high signal intensity when performing fat-saturated CE-T1WI. The CI curves of VAs were found to exhibit a specific pattern: Of the 29 CI curves, 23 (79.3%) showed early weak enhancement, followed by a plateau leading up to 400-600 sec. An imaging-based diagnostic diagram was ultimately formulated. This diagram can act as an aid for radiologists when they are expecting to find a VA, and hopefully serve the purpose of simplifying the diagnostic process. Taken together, the findings of the present study indicated that DCE-MRI may be considered a useful tool for the diagnosis of VAs.
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Affiliation(s)
- Wlla E. Al-Hammad
- Department of Oral and Maxillofacial Radiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
- Department of Oral Medicine and Oral Surgery, Faculty of Dentistry, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Mamiko Fujikura
- Department of Oral Diagnosis and Dentomaxillofacial Radiology, Okayama University Hospital, Okayama 700-8558, Japan
| | - Miki Hisatomi
- Department of Oral Diagnosis and Dentomaxillofacial Radiology, Okayama University Hospital, Okayama 700-8558, Japan
| | - Shunsuke Okada
- Department of Oral Diagnosis and Dentomaxillofacial Radiology, Okayama University Hospital, Okayama 700-8558, Japan
| | - Luciana Munhoz
- Department of Stomatology, School of Dentistry, University of São Paulo, São Paulo 05508-000, Brazil
| | - Toshiyuki Kawazu
- Department of Oral and Maxillofacial Radiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Yohei Takeshita
- Department of Oral and Maxillofacial Radiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Mariko Fujita
- Department of Oral and Maxillofacial Radiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Yoshinobu Yanagi
- Department of Dental Informatics, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8525, Japan
| | - Jun-Ichi Asaumi
- Department of Oral Diagnosis and Dentomaxillofacial Radiology, Okayama University Hospital, Okayama 700-8558, Japan
- Department of Oral and Maxillofacial Radiology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
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Hu YWE, O'Reilly M. Venous Malformation Compressing the Superior Lateral Genicular Nerve: A Case Report. Curr Sports Med Rep 2022; 21:322-324. [PMID: 36083706 DOI: 10.1249/jsr.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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5
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Markovic JN, Shortell CK. Venous malformations. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:456-466. [PMID: 34105926 DOI: 10.23736/s0021-9509.21.11911-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The often inexorable growth and expansion of congenital vascular malformations can result in substantial morbidity and, in some cases, premature death of these patients. Despite this, patients suffering from such lesions are often erroneously diagnosed and/or inadequately treated, due to a lack of expertise among primary care practitioners as well as specialists. Venous malformations are the most common type of congenital vascular malformations. Over the last two decades management of these lesions has significantly improved, predominantly due to the introduction and implementation of multidisciplinary team concept as well as improvement in diagnostic and treatment modalities. Relatively recently genetic studies are providing more insights into underlying pathophysiological mechanisms responsible for the development and progression of venous malformations and pharmacotherapy is becoming extensively evaluated for safety and efficacy in the treatment of these often challenging vascular lesions.
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Affiliation(s)
- Jovan N Markovic
- Department of Surgery, Division of Vascular Surgery, Duke University School of Medicine, Durham, NC, USA -
| | - Cynthia K Shortell
- Department of Surgery, Division of Vascular Surgery, Duke University School of Medicine, Durham, NC, USA
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6
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Bellamkonda KS, Fereydooni A, Trott K, Lee Y, Mehra S, Nassiri N. Superselective intranidal delivery of platinum-based high-density packing coils for treatment of arteriovenous malformations. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:230-234. [PMID: 33997560 PMCID: PMC8095044 DOI: 10.1016/j.jvscit.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/21/2021] [Indexed: 12/03/2022]
Abstract
Arteriovenous malformations (AVMs) classically feature an intervening nidus of poorly differentiated endothelium. The pillar of modern AVM treatment is intranidal delivery and deposition of various liquid embolic agents such as n-butyl cyanoacrylate, ethylene vinyl alcohol copolymer, and ethanol. These agents are cumbersome to prepare, deliver, and deploy and have been associated with complications related to limited delivery control, nonretrievability, frequent microcatheter exchanges, and nontarget embolization. Coils and other proximal occlusive agents have not been traditionally recommended as sole embolic agents for AVM treatment given the inherent lack of adequate AVM nidus penetration with previous coil technologies. In the present report, we have described a series of three patients with AVMs in whom newer generation, platinum-based, packing coils were used safely and effectively as the primary agent for superselective nidal penetration and embolization.
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Affiliation(s)
- Kirthi S. Bellamkonda
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, Conn
| | - Arash Fereydooni
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, Conn
| | - Kiley Trott
- Division of Otolaryngology, Yale School of Medicine, New Haven, Conn
- Vascular Malformations Program, Yale New Haven Hospital, New Haven, Conn
| | - Yan Lee
- Division of Otolaryngology, Yale School of Medicine, New Haven, Conn
- Vascular Malformations Program, Yale New Haven Hospital, New Haven, Conn
| | - Saral Mehra
- Division of Otolaryngology, Yale School of Medicine, New Haven, Conn
- Vascular Malformations Program, Yale New Haven Hospital, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, Conn
- Vascular Malformations Program, Yale New Haven Hospital, New Haven, Conn
- Correspondence: Naiem Nassiri, MD, Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, 333 Cedar St, Boardman 204, New Haven, CT 06510
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7
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Sun C, Zhang AD, Chen HH, Bian J, Liu ZJ. Magnet-targeted delivery of bone marrow-derived mesenchymal stem cells improves therapeutic efficacy following hypoxic-ischemic brain injury. Neural Regen Res 2021; 16:2324-2329. [PMID: 33818519 PMCID: PMC8354132 DOI: 10.4103/1673-5374.310942] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Stem cell transplantation may represent a feasible therapeutic option for the recovery of neurological function in children with hypoxic-ischemic brain injury; however, the therapeutic efficacy of bone marrow-derived mesenchymal stem cells largely depends on the number of cells that are successfully transferred to the target. Magnet-targeted drug delivery systems can use a specific magnetic field to attract the drug to the target site, increasing the drug concentration. In this study, we found that the double-labeling using superparamagnetic iron oxide nanoparticle and poly-L-lysine (SPIO-PLL) of bone marrow-derived mesenchymal stem cells had no effect on cell survival but decreased cell proliferation 48 hours after labeling. Rat models of hypoxic-ischemic brain injury were established by ligating the left common carotid artery. One day after modeling, intraventricular and caudal vein injections of 1 × 105 SPIO-PLL-labeled bone marrow-derived mesenchymal stem cells were performed. Twenty-four hours after the intraventricular injection, magnets were fixed to the left side of the rats’ heads for 2 hours. Intravoxel incoherent motion magnetic resonance imaging revealed that the perfusion fraction and the diffusion coefficient of rat brain tissue were significantly increased in rats treated with SPIO-PLL-labeled cells through intraventricular injection combined with magnetic guidance, compared with those treated with SPIO-PLL-labeled cells through intraventricular or tail vein injections without magnetic guidance. Hematoxylin-eosin and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining revealed that in rats treated with SPIO-PLL-labeled cells through intraventricular injection under magnetic guidance, cerebral edema was alleviated, and apoptosis was decreased. These findings suggest that targeted magnetic guidance can be used to improve the therapeutic efficacy of bone marrow-derived mesenchymal stem cell transplantation for hypoxic-ischemic brain injury. This study was approved by the Animal Care and Use Committee of The Second Hospital of Dalian Medical University, China (approval No. 2016-060) on March 2, 2016.
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Affiliation(s)
- Chuang Sun
- Department of Radiology, The Second Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Ao-Dan Zhang
- Department of Radiology, The Second Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Hong-Hai Chen
- Department of Radiology, The Second Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Jie Bian
- Department of Radiology, The Second Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Zheng-Juan Liu
- Department of Pediatrics, The Second Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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8
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Markovic JN, Nag U, Shortell CK. Safety and efficacy of foam sclerotherapy for treatment of low-flow vascular malformations in children. J Vasc Surg Venous Lymphat Disord 2020; 8:1074-1082. [PMID: 32284312 DOI: 10.1016/j.jvsv.2019.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/23/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Congenital vascular malformations are a heterogeneous group of lesions with the potential to cause significant lifelong morbidity in children. Diagnosis and treatment of these lesions may be complex and require a multidisciplinary approach. Sclerotherapy is widely used for the treatment of low-flow vascular malformations (LFVMs) as an alternative to surgical resection in adults; however, limited data of its use in a pediatric setting are available. The purpose of this study was to evaluate the efficacy and safety of sclerotherapy for pediatric LFVMs. METHODS In this retrospective study, we reviewed our multidisciplinary vascular malformations team database for all patients younger than 18 years treated for congenital vascular malformations from 2008 to 2017. Of these, patients with LFVM treated with foam sclerotherapy were included. Dynamic contrast-enhanced magnetic resonance imaging was used to select patients for sclerotherapy by the multidisciplinary team. Foam sclerotherapy was performed with either polidocanol or sodium tetradecyl sulfate. Patients' characteristics, including demographics, presenting symptoms, and anatomic location of malformation, were assessed. Outcomes included treatment response, number of procedures, and postprocedural complications. RESULTS The 61 patients with 61 LFVMs included 27 boys (44.3%) and 34 girls (55.7%), with mean age of 10.3 years (standard deviation, ± 5.3 years). The cohort included 32 venous (52.5%), 16 lymphatic (26.2%), and 8 mixed venous and lymphatic (13.1%) malformations along with 5 (8.2%) associated with Klippel-Trénaunay syndrome. Primary indications for intervention included pain and swelling (n = 12 [19.6%]), pain alone (n = 23 [37.7%]), swelling alone (n = 15 [24.6%]), functional impairment (n = 8 [13.1%]), and bleeding (n = 3 [4.9%]). Anatomic distributions varied, with 13 head and neck (21.3%), 5 truncal (8.2%), 10 upper extremity (16.4%), 27 lower extremity (44.3%), and 6 diffuse (9.8%). Among the head and neck lesions, 8 (13.1%) extended to the face; and of the extremity lesions, 5 (8.2%) extended to the hand and 17 (27.9%) to the foot. Overall, sclerotherapy resulted in significant improvement or complete resolution of symptoms in 53 patients (86.9%). Complications were observed in seven patients (11.4%); six cases (9.8%) of superficial skin ulceration resolved without intervention, and one infection (1.6%) required antibiotics. No patients experienced adverse hemodynamic consequences or venous thromboembolism. CONCLUSIONS This series of pediatric LFVMs, the largest of its kind to date, demonstrates that sclerotherapy with foam-based agents effectively reduces symptoms with an acceptable rate of complications. Further study is needed to determine the optimal sclerosing agents for individual subsets of LFVMs in the pediatric population.
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Affiliation(s)
- Jovan N Markovic
- Division of Vascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC.
| | - Uttara Nag
- Division of Vascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Cynthia K Shortell
- Division of Vascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
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9
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Woodford C, Tai E, Mafeld S, Al-Mubarak HA, Jaberi A, Oreopoulos GD. Vascular Reconstruction of a Brachial Artery Aneurysm Proximally to an Arteriovenous Malformation. Vasc Endovascular Surg 2019; 54:75-79. [PMID: 31506016 DOI: 10.1177/1538574419873745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Brachial artery aneurysms and arteriovenous malformations (AVM) are limb-threatening vascular anomalies. This patient presented with a bilobed brachial artery aneurysm in the antecubital fossa proximally to an AVM arising from the dorsal interosseous and ulnar arteries that had been treated with endovascular embolization, leaving the hand solely supplied by the radial artery. The aneurysm continued to increase in size and imaging revealed concomitant thrombus. A femoral vein interposition graft was used to repair the aneurysm, and postoperatively, the patient retained full left arm function.
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Affiliation(s)
| | - Elizabeth Tai
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Husain A Al-Mubarak
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada.,Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Arash Jaberi
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - George D Oreopoulos
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.,Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada
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10
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Samadi K, Salazar GM. Role of imaging in the diagnosis of vascular malformations vascular malformations. Cardiovasc Diagn Ther 2019; 9:S143-S151. [PMID: 31559160 DOI: 10.21037/cdt.2018.08.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Imaging evaluation of vascular malformations (VM) is paramount for proper diagnosis and treatment planning. These lesions often present as complex vascular masses with arterial, venous and lymphatic components, requiring the use of advanced imaging modalities for full anatomical characterization. Symptoms also depend of the location and flow characteristic of such lesions and range from: asymptomatic to severe forms of cardiac arteriovenous shunting. We present an overview of the diagnostic work-up of VM per most recent classification systems and describe imaging characteristics of such lesions at ultrasonography (US) and magnetic resonance imaging (MRI) as a diagnostic tool for work-up of such patients.
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Affiliation(s)
- Katayoun Samadi
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Gloria Maria Salazar
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Abstract
PURPOSE This study aimed to define morbidities and costs related to modern-day medical care for children with vascular anomalies. METHODS We reviewed the 2003-2009 Kids' Inpatient Database for pediatric patients (age < 21 years) hospitalized with hemangioma, arteriovenous malformation (AVM), or lymphatic malformation (LM). Patient characteristics, hospital complications, and hospital charges were compared by vascular anomaly type. Multivariable linear regression modeling was used to determine predictors of increasing hospital costs for patients with AVMs. RESULTS In total, 7485 pediatric inpatients with vascular anomalies were identified. Frequently associated complications included chronic anemia (4.0%), sepsis (4.6%), and hypertension (2.4%). Children with AVM had the highest rate of in-hospital mortality, compared to those with hemangiomas or LM (1.0% vs. 0.1% vs. 0.3%, p < 0.001). AVMs were also associated with the highest median hospital charge, more than twice the cost for hemangiomas or LM ($45,875 vs. $18,909 vs. $18,919; p < 0.001). CONCLUSIONS There is a significant rate of morbidity in children with vascular anomalies, most often from blood loss and infection. The greater cost of AVM care may be related to the higher mortality rate, associated complications, and complexity of procedures required treating them. Cost-effective management of vascular anomalies should target prevention and the early recognition of both chronic comorbidities and acute complications.
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12
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Boulouis G, Dangouloff-Ros V, Boccara O, Garabedian N, Soupre V, Picard A, Couloigner V, Boddaert N, Naggara O, Brunelle F. Arterial Spin-Labeling to Discriminate Pediatric Cervicofacial Soft-Tissue Vascular Anomalies. AJNR Am J Neuroradiol 2017; 38:633-638. [PMID: 28104640 DOI: 10.3174/ajnr.a5065] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/18/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Differentiating major subtypes of cervicofacial vascular lesions is crucial for appropriate management. The aim of our study was to evaluate the performance of an MR imaging arterial spin-labeling perfusion sequence in discriminating pediatric cervicofacial soft-tissue vascular anomalies. MATERIALS AND METHODS We conducted a retrospective analysis of data from a prospectively maintained registry including pediatric patients at a tertiary pediatric center between January 2012 and January 2014. We included pediatric patients with a final diagnosis of soft-tissue vascular anomalies and an MR imaging, including an arterial spin-labeling sequence at presentation. We performed an analysis of lesion perfusion, blinded to clinical data, by using concurrent spiral 3D pseudocontinuous arterial spin-labeling (1.5T magnet; spiral matrix, 512 × 8 mm; postlabeling delay, 1025 ms). Lesional flow was recorded with calibrated intralesional ROIs. Perfusion characteristics were compared among lesion subtypes with the Mood Median test. RESULTS Among 840 patients screened, 46 matched the inclusion criteria and were included (median age, 1.45 years; interquartile range, 0.4-5.1 years; 27 females). Hemangiomas, including infantile hemangiomas (n = 18 patients) and noninvoluting (n = 2) and rapidly involuting (n = 1) congenital types, demonstrated marked hyperperfusion (median flow, 436 mL/min/100 g; interquartile range, 212.5-603 mL/min/100 g), significantly higher than that of lymphatic malformations (median, 22.5 mL/min/100 g; interquartile range, 16-60 mL/min/100 g; P < .001) or venous malformations (median, 25 mL/min/100 g; interquartile range, 15-66.5 mL/min/100 g; P = .003). CONCLUSIONS MR imaging arterial spin-labeling is a valuable tool for the assessment of soft-tissue vascular anomaly hemodynamics and for the classification of major lesion subtypes.
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Affiliation(s)
- G Boulouis
- From the Department of Pediatric Radiology (G.B., V.D.-R., N.B., O.N., F.B.) .,Institut National de la Santé et de la Recherche Médicale U894 (G.B., O.N.), Descartes University, Paris, France.,Department of Neuroradiology (G.B., O.N.), Centre Hospitalier Sainte Anne, Paris, France
| | - V Dangouloff-Ros
- From the Department of Pediatric Radiology (G.B., V.D.-R., N.B., O.N., F.B.).,Institut National de la Santé et de la Recherche Médicale U1000 (V.D.-R., N.B., F.B.)
| | - O Boccara
- Departments of Pediatric Dermatology (O.B.).,Pediatric Oto-Rhino-Laryngology (O.B., N.G., V.C.).,Pediatric Maxillo-Facial and Plastic Surgery (O.B., V.S., A.P., O.N.), Necker Children's Hospital, Descartes University, Paris, France.,Centre de Référence des Malformations Rares de la Face de la Cavite Buccale (O.B., V.S., A.P.), Maxillofacial Malformation Reference Center, Paris, France.,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France
| | - N Garabedian
- Pediatric Oto-Rhino-Laryngology (O.B., N.G., V.C.).,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France
| | - V Soupre
- Pediatric Maxillo-Facial and Plastic Surgery (O.B., V.S., A.P., O.N.), Necker Children's Hospital, Descartes University, Paris, France.,Centre de Référence des Malformations Rares de la Face de la Cavite Buccale (O.B., V.S., A.P.), Maxillofacial Malformation Reference Center, Paris, France.,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France
| | - A Picard
- Pediatric Maxillo-Facial and Plastic Surgery (O.B., V.S., A.P., O.N.), Necker Children's Hospital, Descartes University, Paris, France.,Centre de Référence des Malformations Rares de la Face de la Cavite Buccale (O.B., V.S., A.P.), Maxillofacial Malformation Reference Center, Paris, France.,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France
| | - V Couloigner
- Pediatric Oto-Rhino-Laryngology (O.B., N.G., V.C.).,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France
| | - N Boddaert
- From the Department of Pediatric Radiology (G.B., V.D.-R., N.B., O.N., F.B.).,Institut National de la Santé et de la Recherche Médicale U1000 (V.D.-R., N.B., F.B.).,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France.,Unite Mixte de Recherche 1163 (N.B., F.B.), Institut Imagine, Paris, France
| | - O Naggara
- From the Department of Pediatric Radiology (G.B., V.D.-R., N.B., O.N., F.B.).,Institut National de la Santé et de la Recherche Médicale U894 (G.B., O.N.), Descartes University, Paris, France.,Pediatric Maxillo-Facial and Plastic Surgery (O.B., V.S., A.P., O.N.), Necker Children's Hospital, Descartes University, Paris, France.,Department of Neuroradiology (G.B., O.N.), Centre Hospitalier Sainte Anne, Paris, France
| | - F Brunelle
- From the Department of Pediatric Radiology (G.B., V.D.-R., N.B., O.N., F.B.).,Institut National de la Santé et de la Recherche Médicale U1000 (V.D.-R., N.B., F.B.).,Faculté de Médecine Paris-Descartes (O.B., N.G., V.S., A.P., V.C., N.B., F.B.), Université Paris 5, Paris, France.,Unite Mixte de Recherche 1163 (N.B., F.B.), Institut Imagine, Paris, France
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13
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Kociemba A, Karmelita-Katulska K, Stajgis M, Oszkinis G, Pyda M. Distinguishing high-flow from low-flow vascular malformations using maximum intensity projection images in dynamic magnetic resonance angiography - comparison to other MR-based techniques. Acta Radiol 2016; 57:565-71. [PMID: 26560553 DOI: 10.1177/0284185115615005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In addition to ultrasound, magnetic resonance imaging (MRI) is considered a suitable, non-invasive technique to assess the type and extent of vascular malformations. The distinction between low- and high-flow lesions is crucial because it determines appropriate patient treatment. PURPOSE To distinguish high-flow from low-flow lesions on the basis of the enhancement pattern on MIP images acquired from dynamic time-resolved MR angiography (MRA) and compare it with previously described MR-based methods. MATERIAL AND METHODS We examined 25 consecutive patients with previously diagnosed vascular malformations. Next, each malformation was classified as "high-flow" or "low-flow" using the following criteria: (i) findings on T1-weighted (T1W) and T2-weighted (T2W) imaging (signal voids, signal intensity); (ii) the time interval between the start of arterial enhancement and the onset of lesion enhancement (artery-lesion time); (iii) the time of maximum lesion enhancement; and (iv) analysis of the slope of the enhancement curve. RESULTS Of the 25 patients, seven had high-flow and 18 had low-flow malformations. Signal voids on spin-echo T1W images were observed only in four of seven high-flow malformations and in two of 18 low-flow malformations. Analysis of signal intensity on T2W images showed increased signal intensity in 17 of 18 low-flow malformations, and in two of seven high-flow lesions. Calculation of the artery-lesion time, maximum enhancement time, and slope revealed significant differences between the high- and low-flow groups. CONCLUSION In conclusion, the slope of the enhancement curve appears to be useful in distinguishing between high- and low-flow vascular malformations. Standardization of MR image evaluation criteria is essential.
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Affiliation(s)
- Anna Kociemba
- First Clinic of Cardiology, Department of Cardiology, University of Medical Sciences, Poznan, Poland
| | | | - Marek Stajgis
- Department of General Radiology, University of Medical Sciences, Poznan, Poland
| | - Grzegorz Oszkinis
- Department of Vascular Surgery, University of Medical Sciences, Poznan, Poland
| | - Małgorzata Pyda
- First Clinic of Cardiology, Department of Cardiology, University of Medical Sciences, Poznan, Poland
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14
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Li HO, Huo R, Wang XM, Xu GQ, Duan YH, Nie P, Ji XP, Cheng ZP, Xu ZD. High-pitch spiral CT with 3D reformation: an alternative choice for imaging vascular anomalies with affluent blood flow in the head and neck of infants and children. Br J Radiol 2015; 88:20150005. [PMID: 26055504 DOI: 10.1259/bjr.20150005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility of high-pitch spiral CT in imaging vascular anomalies (VAs) with affluent blood flow in the head and neck of infants and children. METHODS For patients with suspected VAs and affluent blood flow pre-detected by ultrasound, CT was performed with high-pitch mode, individualized low-dose scan protocol and three-dimensional (3D) reformation. A five-point scale was used for image quality evaluation. Diagnostic accuracy was calculated with clinical diagnosis with/without pathological results as the reference standard. Radiation exposure and single-phase scan time were recorded. Treatment strategies were formulated based on CT images and results and were monitored through follow-up results. RESULTS 20 lesions were identified in 15 patients (median age of 11 months). The mean score of image quality was 4.13 ± 0.74. 7 patients (7/15, 46.67%) were diagnosed with haemangiomas, 6 patients (6/15, 40%) were diagnosed with venous malformations and 2 patients (2/15, 13.33%) were diagnosed with arteriovenous malformations. The average effective radiation doses of a single phase and of the total procedure were 0.27 ± 0.08 and 0.86 ± 0.21 mSv. The average scanning time of a single phase was 0.46 ± 0.09 s. After treatment, 13 patients (13/15, 86.67%) achieved excellent results, and 2 patients (2/15, 13.33%) showed good results in follow-up visits. CONCLUSION High-pitch spiral CT with an individualized low-dose scan protocol and 3D reformation is an effective modality for imaging VAs with affluent blood flow in the head and neck of infants and children when vascular details are needed and ultrasound and MRI could not provide the complete information. ADVANCES IN KNOWLEDGE This study proposes an alternative modality for imaging VAs with affluent blood flow.
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Affiliation(s)
- H-O Li
- 1 Department of Radiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - R Huo
- 2 Department of Aesthetic, Plastic and Burn Surgery, Shandong Provincial Hospital, Jinan, Shandong, China
| | - X-M Wang
- 3 Department of CT, Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, China
| | - G-Q Xu
- 2 Department of Aesthetic, Plastic and Burn Surgery, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Y-H Duan
- 3 Department of CT, Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, China
| | - P Nie
- 4 Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - X-P Ji
- 3 Department of CT, Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, China
| | - Z-P Cheng
- 3 Department of CT, Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, China
| | - Z-D Xu
- 3 Department of CT, Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, China
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15
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Turley RS, Lidsky ME, Markovic JN, Shortell CK. Emerging role of contrast-enhanced MRI in diagnosing vascular malformations. Future Cardiol 2014; 10:479-86. [PMID: 25301311 DOI: 10.2217/fca.14.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Vascular malformations comprise a diverse and rare group of lesions which generally pose a formidable treatment challenge. Requisite for optimal surgical planning are imaging modalities capable of delineating involved anatomy and malformation flow characteristics. In this regard, we and others have purported the advantages of contrast-enhanced MRI. Here, we review the current body of literature regarding the emerging of role of contrast enhanced MRI for the management of vascular malformations.
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Affiliation(s)
- Ryan S Turley
- Division of Vascular Surgery, Duke University, DUMC Box 3443, Durham, NC 27710, USA
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16
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Abstract
Pediatric whole-body (WB) magnetic resonance imaging (MRI) is an established technique that, with improved accessibility and advances in technology, is being used with increasing frequency for a wide variety of applications. The advantages of WB MRI (over other imaging modalities), particularly its lack of ionizing radiation (of particular concern in pediatric imaging due to children's increased sensitivity to ionizing radiation) and the ability of MRI to image the bone marrow, solid organs, and soft tissues with superior soft-tissue contrast resolution to other techniques, promise that WB MRI has great potential in conditions that are diffuse or multifocal. There is particular interest in its role in the field of pediatric oncology (eg, lymphoma, neuroblastoma, sarcoma, and Langerhans cell histiocytosis). The main disadvantages of WB MRI are its relatively long scanning times, artifacts from motion (requiring patient cooperation or general anesthesia), and limited specificity. However, advances in hardware and imaging techniques, including additional sequences (out-of-phase imaging, diffusion-weighted imaging, and contrast enhancement) are reducing the impact of some of these challenges.
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17
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Ferkel EI, Speer AL, Anselmo D, Panossian A, Stanley P, Arkader A. Vascular Malformations and Associated Syndromes: The Role of the Orthopaedic Surgeon. JBJS Rev 2014; 2:01874474-201405000-00002. [PMID: 27500606 DOI: 10.2106/jbjs.rvw.m.00075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Eric I Ferkel
- Department of Orthopaedic Surgery, The Keck School of Medicine of the University of Southern California, 1200 North State Street, GNH-3900, Los Angeles, CA 90033
| | - Allison L Speer
- Department of General Surgery, The Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033
| | - Dean Anselmo
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #100, Los Angeles, CA 90027
| | - Andre Panossian
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #96, Los Angeles, CA 90027
| | - Philip Stanley
- Department of Radiology, Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #81, Los Angeles, CA 90027
| | - Alexandre Arkader
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, MS #69, Los Angeles, California, 90027
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18
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Markovic JN, Shortell CEK. Multidisciplinary treatment of extremity arteriovenous malformations. J Vasc Surg Venous Lymphat Disord 2014; 3:209-18. [PMID: 26993843 DOI: 10.1016/j.jvsv.2014.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
Congenital vascular malformations (CVMs) are a complex group of lesions that arise by embryologic dysmorphogenesis without increased endothelial proliferation that leads to structural and functional anomalies of the vascular system characterized by a wide range of presenting symptoms and often unpredictable clinical course. A recent advancement in the diagnostic and treatment modalities has resulted in a better understanding of the pathophysiology and natural history of CVMs and improved management of these lesions. The multidisciplinary approach and diagnostic algorithm used to distinguish high-flow (HFVM) from low-flow vascular malformations (LFVM) have been validated as clinically applicable for making an accurate anatomic and hemodynamic diagnosis of CVMs; they serve as a basis for proper treatment selection and significantly facilitate communication among different medical specialists. Dynamic contrast-enhanced magnetic resonance imaging is able to definitively distinguish HFVM from LFVM with accuracy of approximately 84%. In inconclusive cases, confirmatory angiography is required. Symptomatic, diffuse, extensive, macrocystic LFVMs and LFVMs that involve multiple tissue planes and vital structures are best treated with foam sclerotherapy. Primary surgical resection is the treatment of choice for localized, septated, and microcystic LFVMs. The management of HFVMs is characterized by multimodal treatment including preoperative embolization followed by complete surgical resection or sclerotherapy of the remaining venous component. Treatment of extensive CVMs is palliative and goal oriented. Implementation of the proposed diagnostic protocols and therapeutic algorithms in a multidisciplinary setting results in favorable outcomes with acceptable complication rates in this challenging patient population.
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Affiliation(s)
- Jovan N Markovic
- Department of Vascular Surgery, Duke University Medical Center, Durham, NC.
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19
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Ten frequently asked questions about MRI evaluation of soft-tissue vascular anomalies. AJR Am J Roentgenol 2013; 201:W554-62. [PMID: 24059392 DOI: 10.2214/ajr.13.11351] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The objective of this article was to address 10 frequently asked questions that radiologists face when planning, performing, and interpreting an MRI study in a patient with a soft-tissue vascular anomaly. CONCLUSION MRI permits a comprehensive assessment of vascular anomalies. It is important for radiologists to be familiar with the classification and correct nomenclature of vascular anomalies as well as the MRI protocol and distinct imaging findings of the different vascular malformations and tumors.
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20
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Jalali-Farahani S, Blakeley JO, Belzberg AJ, Carrino JA, Chhabra A. Plexiform nerve sheath tumor or vascular malformation--role of advanced MR neurography and diffusion tensor imaging. Skeletal Radiol 2013; 42:1007-10. [PMID: 23519761 PMCID: PMC3991119 DOI: 10.1007/s00256-013-1594-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/20/2013] [Accepted: 02/21/2013] [Indexed: 02/02/2023]
Abstract
The authors report a vascular malformation mimicking a plexiform peripheral nerve sheath tumor. Three Tesla magnetic resonance neurography with high-resolution anatomic and advanced functional diffusion tensor imaging was helpful in evaluating full extent of the lesion and characterizing its internal architecture.
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Affiliation(s)
- Sahar Jalali-Farahani
- Russell H Morgan Department of Radiology & Radiological Science, 601 N. Caroline St, JHOC 3262, Baltimore, MD 21287, USA
| | - Jaishri O. Blakeley
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Allan J. Belzberg
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John A. Carrino
- Russell H Morgan Department of Radiology & Radiological Science, 601 N. Caroline St, JHOC 3262, Baltimore, MD 21287, USA
| | - Avneesh Chhabra
- Russell H Morgan Department of Radiology & Radiological Science, 601 N. Caroline St, JHOC 3262, Baltimore, MD 21287, USA, Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31829684d2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Lidsky ME, Markovic JN, Miller MJ, Shortell CK. Analysis of the treatment of congenital vascular malformations using a multidisciplinary approach. J Vasc Surg 2012; 56:1355-62; discussion 1362. [DOI: 10.1016/j.jvs.2012.04.066] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 04/19/2012] [Accepted: 04/21/2012] [Indexed: 11/16/2022]
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