The juxtaposition of a capillary telangiectasia, cavernous malformation, and developmental venous anomaly in the brainstem of a single patient: case report

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.

Brain capillary telangiectasias: from normal variants to disease

BACKGROUND

Brain capillary telangiectasias (BCTs) are small, dilated capillary networks in the brain that are most commonly asymptomatic. Though rare, symptomatic cases of BCTs have been reported, and it is therefore important to understand the nature of these lesions in order to facilitate proper recognition. Relative to other intracranial vascular malformations, updated information on the various epidemiologic, radiographic, and pathologic features of BCTs within the published literature may be inadequate.

METHODS

We searched the PubMed database for prior reports of symptomatically-manifested BCTs. Moreover, Google Scholar and PubMed were searched in order to review current epidemiologic, radiographic, pathologic, and pathogenetic features of BCTs.

RESULTS

Forty-eight published studies were included for a total of 99 individual cases of BCTs with symptomatic manifestations. Thirty-three symptomatic BCTs were hemorrhagic in nature, while 66 were non-hemorrhagic. The mean age at presentation of hemorrhagic lesions was 25.5 years, and the most common location was the supratentorial CNS (54.5%) with motor disturbance representing the most commonly encountered presenting symptom (26.1%). 15.2% of hemorrhagic lesions were treated with surgical removal. In non-hemorrhagic lesions, the mean age at presentation was 39.8 years with the pons being the most common lesion location (78.5%) and headache being the most common presenting symptom (22.2%). 12.1% of patients with non-hemorrhagic lesions were treated with surgical removal.

CONCLUSIONS

Despite their rarity, symptomatic BCTs, both hemorrhagic and non-hemorrhagic, can cause devastating neurological sequelae, potentially through multiple mechanisms. The large majority of these lesions do not require intervention, though surgical removal has been achieved with good outcome in select cases. Further documentation of symptomatic manifestations with or without surgical intervention is vital in order to further understand the clinical, surgical, and pathogenic implications of these less-appreciated vascular malformations.

Post-irradiation lumbosacral radiculopathy associated with multiple cavernous malformations of the cauda equina: Case report and review of the literature

BACKGROUND

Multiple radiation-induced cavernous malformations of the cauda equina are extremely rare. A review of the literature suggested that the post-irradiation lumbosacral radiculopathy in our patient was most likely associated with a diagnosis of multiple radiation-induced cavernous malformations of the cauda equina.

CASE DESCRIPTION

A 76-year-old man with a remote history of abdominal radiation therapy presented with a 6-month history of progressively worsening right foot drop and balance impairment. Magnetic resonance imaging (MRI) revealed multiple enhancing areas of the cauda equina concerning for carcinomatous meningitis, however, cerebrospinal fluid (CSF) analysis was unrevealing. Intraoperative findings were consistent with multiple radiation-induced cavernous malformations of the cauda equina.

CONCLUSIONS

Multiple radiation-induced cavernous malformations of the cauda equina may mimic carcinomatous or infectious meningitis. Clinicians should be suspicious of this diagnosis when CSF and MRI findings are inconsistent with metastatic disease or infectious meningitis in patients who present with radiculopathy and a history of radiation therapy.

Symptomatic large or giant capillary telangiectasias: management and outcome in 5 cases

Brain capillary telangiectasias (BCTs) are usually small and benign with a predilection in the pons and basal ganglion. Reports of large and symptomatic BCTs are rare. Large BCTs have a much higher risk of causing uncontrolled bleeding and severe neurological defects, and they can be fatal if left untreated. Therefore, large BCTs should be managed with special caution. Because of the lack of reports, diagnosis of large BCTs has been difficult. Strategies of management are undefined for large or giant BCTs.

The current study presents 5 cases of giant and large BCTs. To the authors’ knowledge, this is the largest series of this disease ever reported. Radiological findings, histopathological characteristics, clinical presentations, and surgical management were analyzed in 5 symptomatic, unusually large BCTs (mean diameter 5.06 cm, range 1.8–8 cm).

Four patients presented with focal or generalized seizures, and 1 patient presented with transient vision loss attributed to the lesions. Gross-total resection of the lesion was achieved in all patients. After surgery, the 4 patients with seizures were symptom free for follow-up periods varying from more than 1 to 5 years with no additional neurological deficits.

The unique location, radiological characteristics, and clinical course suggest that giant BCTs could be a different entity from small BCTs. Surgery might be a good option for treatment of patients with intractable neurological symptoms, especially in those with surgically accessible locations. Complete removal would be anticipated to provide relief of the symptoms without causing new neurological deficits.

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

Background

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

Methods

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

Results

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

Conclusions

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

Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations

OBJECT

The aim of this study was to evaluate the pre- and postoperative rehemorrhage risk, neurological function outcome, and prognostic factors of surgically treated brainstem cavernous malformations (CMs) with long-term follow-up.

METHODS

The authors conducted a retrospective review of the clinical data from 242 patients with brainstem CMs that were surgically treated between 1999 and 2010. Patient charts, imaging findings, and outcomes were examined.

RESULTS

The study included 242 patients, with a male-to-female ratio of 1.3 and mean age of 32.6 years. The mean modified Rankin Scale scores on admission, at discharge, at 3 and 6 months after surgery, and at recent evaluation were 2.2, 2.6, 2.3, 1.8, and 1.5, respectively. The preoperative calculated annual hemorrhage and rehemorrhage rates were 5.0% and 60.9%, respectively. The complete resection rate was 95%. Surgical morbidity occurred in 112 patients (46.3%). Eighty-five patients (35.1%) demonstrated worsened condition immediately after surgery; 34 (41.0%) and 51 (61.4%) of these patients recovered to their baseline level within 3 and 6 months after surgery, respectively. At a mean follow-up of 89.4 months, the patients' condition had improved in 147 cases (60.7%), was unchanged in 70 cases (28.9%), and had worsened in 25 cases (10.3%). A total of 8 hemorrhages occurred in 6 patients, and the postoperative annual hemorrhage rate was 0.4%. Permanent morbidity remained in 65 patients (26.9%). The adverse factors for preoperative rehemorrhage were age ≥ 50 years, size ≥ 2 cm, and perilesional edema. The risk factors for postoperative hemorrhage were developmental venous anomaly and incomplete resection. The independent adverse factors for long-term outcome were increased age, multiple hemorrhages, ventral-seated lesions, and poor preoperative status. Favorable, complete improvement in the postoperative deficits over time was correlated with good preoperative neurological function and continuing improvement thereafter.

CONCLUSIONS

Favorable long-term outcomes and significantly low postoperative annual hemorrhage rates were achieved via surgery. Total resection should be attempted with an aim of minimal injury to neurological function; however, postoperative deficits can improve during the postoperative course. Close follow-up with radiological examination is proposed for patients with adverse factors predictive of rehemorrhage.

A new strategic neurosurgical planning tool for brainstem cavernous malformations using interactive computer graphics with multimodal fusion images

OBJECT

In this study, the authors used preoperative simulation employing 3D computer graphics (interactive computer graphics) to fuse all imaging data for brainstem cavernous malformations. The authors evaluated whether interactive computer graphics or 2D imaging correlated better with the actual operative field, particularly in identifying a developmental venous anomaly (DVA).

METHODS

The study population consisted of 10 patients scheduled for surgical treatment of brainstem cavernous malformations. Data from preoperative imaging (MRI, CT, and 3D rotational angiography) were automatically fused using a normalized mutual information method, and then reconstructed by a hybrid method combining surface rendering and volume rendering methods. With surface rendering, multimodality and multithreshold techniques for 1 tissue were applied. The completed interactive computer graphics were used for simulation of surgical approaches and assumed surgical fields. Preoperative diagnostic rates for a DVA associated with brainstem cavernous malformation were compared between conventional 2D imaging and interactive computer graphics employing receiver operating characteristic (ROC) analysis.

RESULTS

The time required for reconstruction of 3D images was 3-6 hours for interactive computer graphics. Observation in interactive mode required approximately 15 minutes. Detailed anatomical information for operative procedures, from the craniotomy to microsurgical operations, could be visualized and simulated three-dimensionally as 1 computer graphic using interactive computer graphics. Virtual surgical views were consistent with actual operative views. This technique was very useful for examining various surgical approaches. Mean (±SEM) area under the ROC curve for rate of DVA diagnosis was significantly better for interactive computer graphics (1.000±0.000) than for 2D imaging (0.766±0.091; p<0.001, Mann-Whitney U-test).

CONCLUSIONS

The authors report a new method for automatic registration of preoperative imaging data from CT, MRI, and 3D rotational angiography for reconstruction into 1 computer graphic. The diagnostic rate of DVA associated with brainstem cavernous malformation was significantly better using interactive computer graphics than with 2D images. Interactive computer graphics was also useful in helping to plan the surgical access corridor.

Susceptibility-weighted MR imaging for diagnosis of capillary telangiectasia of the brain

BACKGROUND AND PURPOSE

BCT is a benign entity, whose appearance on conventional MR imaging makes its differentiation from neoplastic, inflammatory, or subacute ischemic disease challenging. SWI is sensitive to susceptibility effects from deoxyhemoglobin with excellent spatial resolution. Only scarce case reports have described the utility of SWI in cases of BCT. Our aim was to show the diagnostic value of SWI applied to a larger series of cases.

MATERIALS AND METHODS

This was an observational retrospective study of 33 BCTs in 27 consecutive patients examined from August 2009 to January 2011 with MR imaging, including SWI. Morphology, signal intensity characteristics, and additional vascular malformations were analyzed. Preceding or follow-up examinations were available in 18 patients with a median time interval of 14.5 months (range, 2-115 months).

RESULTS

Twenty-five pontine and 8 supratentorial BCTs demonstrated distinct signal-intensity loss on SWI in combination with postcontrast enhancement. Mean lesion diameter was 4.9 mm (range, 1.5-17 mm). Thirty-nine percent showed slight signal-intensity changes on T1 and/or T2; the remainder were isointense to normal brain. In 30%, a prominent draining vessel was observed. Additional cerebral vascular malformations were found in 5 patients.

CONCLUSIONS

SWI represents a valuable tool for confirmation of presumed BCT. Demonstration of signal-intensity loss on SWI in an enhancing focal brain lesion, otherwise unremarkable on conventional MR images, is highly specific for BCT, thus excluding serious pathology and reassuring the patient and referring physician. This is particularly helpful for BCT in less typical locations.

The putative role of the venous system in the genesis of vascular malformations

Recent clinical and experimental evidence has challenged the traditional concept of the venous system as a “passive” element in the genesis and evolution of intracranial vascular malformations. The authors review the clinical and experimental evidence linking the venous system and its anomalies to the genesis of various intracranial vascular malformations, including dural arteriovenous fistulas, cavernous malformations, parenchymal arteriovenous malformations, and capillary telangiectasia. They also describe the potential significance of different associations of these vascular anomalies.

The neurovascular triad: mixed cavernous, capillary, and venous malformations of the brainstem

Object

The four types of cerebrovascular malformations may sometimes be combined and more often occur in pairs; triads are exceptional. The authors present six patients with the clinicoradiographic profile of mixed vascular malformations of the brainstem, including cavernous malformation (CM), capillary telangiectasia, and developmental venous anomaly (DVA).

Methods

Five patients (one of whom was a child) suffered from hemorrhage, suggesting that this complex association has a high bleeding potential. Progressive growth, rebleeding, and de novo occurrence of the associated CM were documented in three cases. Magnetic resonance imaging of the brain was obtained in all patients by using one or more of the following modalities: T1-weighted sequences before and after gadolinium administration; T2-weighted sequences; T2-weighted fluid attenuated inversion recovery; T1-weighted fast spin echo; and diffusion weighted, diffusion tensor, and perfusion imaging in three cases.

Results

Three patients were surgically treated with the intention of excising the hemorrhagic lesion, but only two patients had their malformations successfully removed. In the third case, diffuse pontine telangiectasia precluded the safe excision of the CM. Histological examination demonstrated a blended pathological milieu characterized by coalescent telangiectasia and venules associated with loculated endothelial chambers resembling an immature or de novo CM. Three patients were treated conservatively; recurrent minor hemorrhage occurred in one case. The authors found these malformations to be arranged in two basic relationships: CM inside the telangiectasia and CM in the radicles of the DVA. Stenosis of the main venous collector and dilation of the medullary veins were important findings.

Conclusions

The pathogenesis of this malformation may be referred to a developmental deviance of the brainstem capillary–venous network associated with transitional vessels and loculated endothelial vascular spaces related to genetic and acquired origins, probably in a restrictive venous outflow milieu.

The association of venous developmental anomalies and cavernous malformations: pathophysiological, diagnostic, and surgical considerations

✓Developmental venous anomalies (DVAs) are often associated with intracranial cavernous malformations (CMs). The frequency of this association and the observation of de novo CMs located near a known, preexisting DVA raise speculations as to the possible etiopathogenetic relationship between the two. In this article, the authors review the recent literature dealing with the potential etiopathogenetic, prognostic, and therapeutic implications of the association between DVAs and CMs.

Hemangioma from head to toe: MR imaging with pathologic correlation

Hemangioma is a common benign vascular neoplasm that closely resembles normal vessels and can be found in all organs of the human body. Vascular lesions can be classified as infantile hemangiomas or vascular malformations on the basis of their natural history, location, cellular turnover, and histologic characteristics. The magnetic resonance (MR) imaging features of vascular malformations of the central nervous system depend on the pathologic subtype. Soft-tissue vascular malformations can be categorized with combined MR imaging and MR angiography as either high- or low-flow. Osseous vascular malformations commonly demonstrate a high-signal-intensity trabecular pattern at both T1- and T2-weighted MR imaging. A group of more aggressive vascular neoplasms, including hemangioendothelioma, hemangiopericytoma, and glomus tumor, have a nonspecific appearance at MR imaging. In the liver and spleen, hemangiomas are typically hyperintense at T2-weighted MR imaging, with a centripetal filling pattern after administration of gadopentetate dimeglumine. Vascular lesions can involve several organs or systems in angiomatous syndromes. MR imaging allows characterization of a hemangioma with typical features, which vary depending on anatomic location. Familiarity with these features facilitates diagnosis and management of these anomalies.