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Ahmed A, Patel B, Wang R, Luna L, Verde A, Besheli LD, Intrapiromkul J, Nabi M, Edpuganti N, Deng F, Yedavalli V. Clinical applications of arterial spin labeling of the intracranial compartment in vascular anomalies-A case-based review. Neuroradiol J 2023; 36:638-650. [PMID: 36172883 PMCID: PMC10649537 DOI: 10.1177/19714009221130490] [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] [Indexed: 11/16/2022] Open
Abstract
Arterial spin labeling (ASL) is a magnetic resonance perfusion technique that allows for quantification of cerebral blood flow (CBF) without the use of contrast or radiation. Several applications of ASL have been described in diagnosis of strokes and stroke mimics, intracranial tumors, and other conditions. Various vascular anomalies exhibit specific CBF patterns that correlate with different signal intensities on ASL. In this case-based review, we demonstrate the utility of ASL in diagnosis and surveillance of vascular anomalies in the intracranial compartment.
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Affiliation(s)
- Amara Ahmed
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Bhumi Patel
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | | | - Laleh Daftari Besheli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Jarunee Intrapiromkul
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Namratha Edpuganti
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Francis Deng
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Vivek Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
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Ahmed S, Saini J, Gorantla P, Kulanthaivelu K, Shashidhar A, Deora H, Holla VV, Arora A. An Illustrative Review of the Pathomechanisms of Symptomatic Developmental Venous Anomalies. J Comput Assist Tomogr 2023; 47:940-950. [PMID: 37948370 DOI: 10.1097/rct.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Symptomatic developmental venous anomalies (DVAs) are rare. Here, we illustrate the varied clinicoradiologic profiles of symptomatic DVAs and contemplate the mechanisms that render these (allegedly) benign entities symptomatic supported by a review of literature. METHODS Institutional databases were searched to identify cases of symptomatic DVAs. Clinical and imaging (angiographic and cross-sectional) data of 9 cases with 11 neurovascular symptoms consequent to inflow/outflow perturbations and mechanical obstruction that manifested because of the strategic topography of underlying DVAs were analyzed. A review of the existing literature on DVAs in agreement with our case series was performed on publications retrieved from the PubMed database. RESULTS Symptoms secondary to venous hypertension arising from flow-related perturbations were broadly divided into those arising from restricted outflow and increased inflow. Restricted outflow occurred because of collector vein stenosis (n = 2) and collector vein/DVA thrombosis (n = 3), whereas the latter pathomechanism was initiated by arterialized/transitional DVAs (n = 2). A mechanical/obstructive pathomechanism culminating in moderate supratentorial ventriculomegaly was noted in 1 case. One patient was given a diagnosis of hemorrhage associated with a cavernoma. CONCLUSIONS Awareness and contextualization of potential flow-related perturbations and mechanical insults that render DVAs symptomatic aid in accurate diagnosis, management, and prognostication.
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Affiliation(s)
- Sabha Ahmed
- From the Departments of Neuroimaging and Interventional Radiology
| | - Jitender Saini
- From the Departments of Neuroimaging and Interventional Radiology
| | | | | | - Abhinith Shashidhar
- Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Harsh Deora
- Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Vikram V Holla
- Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Ankit Arora
- From the Departments of Neuroimaging and Interventional Radiology
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Yoo DH, Sohn CH, Kang HS, Cho YD, Kim KM. Arterial Spin-Labeling MR Imaging for the Differential Diagnosis of Venous-Predominant AVMs and Developmental Venous Anomalies. AJNR Am J Neuroradiol 2023; 44:916-921. [PMID: 37385682 PMCID: PMC10411836 DOI: 10.3174/ajnr.a7922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Venous-predominant AVMs are almost identical in appearance to developmental venous anomalies on conventional MR imaging. Herein, we compared and analyzed arterial spin-labeling findings in patients with developmental venous anomalies or venous-predominant AVMs, using DSA as the criterion standard. MATERIALS AND METHODS We retrospectively collected patients with either DVAs or venous-predominant AVMs, each available on both DSA and arterial spin-labeling images. Arterial spin-labeling imaging was visually assessed for the presence of hyperintense signal. CBF measured at the most representative section was normalized to the contralateral gray matter. The temporal phase of developmental venous anomalies or venous-predominant AVMs was measured on DSA as a delay between the first appearance of the intracranial artery and the lesion. Correlation between the normalized CBF and the temporal phase was evaluated. RESULTS Analysis of 15 lesions (13 patients) resulted in categorization into 3 groups: typical venous-predominant AVMs (temporal phase, <2 seconds), intermediate group (temporal phase between 2.5 and 5 seconds), and classic developmental venous anomalies (temporal phase, >10 seconds). Arterial spin-labeling signal was markedly increased in the typical venous-predominant AVM group, while there was no discernible signal in the classic developmental venous anomaly group. In the intermediate group, however, 3 of 6 lesions showed mildly increased arterial spin-labeling signal. The normalized CBF on arterial spin-labeling and the temporal phase on DSA were moderately negatively correlated: r(13) = 0.66, P = .008. CONCLUSIONS Arterial spin-labeling may predict the presence and amount of arteriovenous shunting in venous-predominant AVMs, and using arterial spin-labeling enables confirmation of typical venous-predominant AVMs without DSA. However, lesions with an intermediate amount of shunting suggest a spectrum of vascular malformations ranging from purely vein-draining developmental venous anomalies to venous-predominant AVMs with overt arteriovenous shunting.
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Affiliation(s)
- D H Yoo
- From the Departments of Radiology (D.H.Y., C.-H.S., Y.D.C.)
| | - C-H Sohn
- From the Departments of Radiology (D.H.Y., C.-H.S., Y.D.C.)
| | - H-S Kang
- Neurosurgery (H.-S.K., K.M.K.), Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Y D Cho
- From the Departments of Radiology (D.H.Y., C.-H.S., Y.D.C.)
| | - K M Kim
- Neurosurgery (H.-S.K., K.M.K.), Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Hsu CCT, Krings T. Symptomatic Developmental Venous Anomaly: State-of-the-Art Review on Genetics, Pathophysiology, and Imaging Approach to Diagnosis. AJNR Am J Neuroradiol 2023; 44:498-504. [PMID: 36997285 PMCID: PMC10171382 DOI: 10.3174/ajnr.a7829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
Developmental venous anomalies (DVAs) are the most common slow-flow venous malformation in the brain. Most DVAs are benign. Uncommonly, DVAs can become symptomatic, leading to a variety of different pathologies. DVAs can vary significantly in size, location, and angioarchitecture, and imaging evaluation of symptomatic developmental venous anomalies requires a systematic approach. In this review, we aimed to provide neuroradiologists with a succinct overview of the genetics and categorization of symptomatic DVAs based on the pathogenesis, which forms the foundation for a tailored neuroimaging approach to assist in diagnosis and management.
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Affiliation(s)
- C C-T Hsu
- From the Division of Neuroradiology (C.C.-T.H.), Department of Medical Imaging, Gold Coast University Hospital, Southport, Queensland, Australia
- Division of Neuroradiology (C.C.-T.H.), Lumus Imaging, Varsity Lakes, Queensland, Australia
| | - T Krings
- Division of Neuroradiology (T.K.), Department of Medical Imaging, Toronto Western Hospital; University Medical Imaging Toronto and University of Toronto, Ontario, Canada
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Sarma A, Martin D, Pruthi S, Jones R, Little SB. Imaging the Cerebral Veins in Pediatric Patients: Beyond Dural Venous Sinus Thrombosis. Radiographics 2023; 43:e220129. [PMID: 36656758 DOI: 10.1148/rg.220129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The range of intracranial venous anomalies in children differs from that in adults. As a commonly encountered highly morbid disease, sinovenous thrombosis has been discussed extensively in the literature, and the associated imaging considerations are similar in pediatric and adult patients. The authors shift the focus to less frequently discussed cerebral venous diseases in pediatric patients. First, the practical embryology pertinent to malformations, syndromes, and variants such as vein of Galen aneurysmal malformation, Sturge-Weber syndrome, and developmental venous anomalies are discussed. Second, anatomic considerations that are applicable to neuroimaging in pediatric patients with cerebral venous anomalies are reviewed. In the discussion of anatomy, special attention is given to the medullary venous system that serves the cerebral white matter, superficial cortical veins (tributaries of the dural venous sinuses), and bridging veins, which carry blood from the superficial cortical veins through the potential subdural space into the dural venous sinuses. Third, the selection of imaging modalities (US, CT and CT venography, and MRI) is addressed, and various MR venographic pulse sequences (time-of-flight, phase-contrast, and contrast-enhanced sequences) are compared. Finally, a broad variety of congenital and acquired superficial and deep venous diseases in children are reviewed, with emphasis on less frequently discussed entities involving the medullary (eg, deep medullary venous engorgement and thrombosis, periventricular hemorrhagic venous infarction due to germinal matrix hemorrhage), cortical (eg, cortical venous thrombosis), and bridging (eg, acute and chronic manifestations of injury in abusive head trauma) veins, as well as the deep veins and dural venous sinuses (eg, varix). © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.
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Affiliation(s)
- Asha Sarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital, 2200 Children's Way, Nashville, TN 37323 (A.S., D.M., S.P.); and Department of Radiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (R.J., S.B.L.)
| | - Dann Martin
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital, 2200 Children's Way, Nashville, TN 37323 (A.S., D.M., S.P.); and Department of Radiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (R.J., S.B.L.)
| | - Sumit Pruthi
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital, 2200 Children's Way, Nashville, TN 37323 (A.S., D.M., S.P.); and Department of Radiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (R.J., S.B.L.)
| | - Richard Jones
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital, 2200 Children's Way, Nashville, TN 37323 (A.S., D.M., S.P.); and Department of Radiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (R.J., S.B.L.)
| | - Stephen B Little
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital, 2200 Children's Way, Nashville, TN 37323 (A.S., D.M., S.P.); and Department of Radiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (R.J., S.B.L.)
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Wang DJJ, Le Bihan D, Krishnamurthy R, Smith M, Ho ML. Noncontrast Pediatric Brain Perfusion: Arterial Spin Labeling and Intravoxel Incoherent Motion. Magn Reson Imaging Clin N Am 2021; 29:493-513. [PMID: 34717841 DOI: 10.1016/j.mric.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Noncontrast magnetic resonance imaging techniques for measuring brain perfusion include arterial spin labeling (ASL) and intravoxel incoherent motion (IVIM). These techniques provide noninvasive and repeatable assessment of cerebral blood flow or cerebral blood volume without the need for intravenous contrast. This article discusses the technical aspects of ASL and IVIM with a focus on normal physiologic variations, technical parameters, and artifacts. Multiple pediatric clinical applications are presented, including tumors, stroke, vasculopathy, vascular malformations, epilepsy, migraine, trauma, and inflammation.
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Affiliation(s)
- Danny J J Wang
- USC Institute for Neuroimaging and Informatics, SHN, 2025 Zonal Avenue, Health Sciences Campus, Los Angeles, CA 90033, USA
| | - Denis Le Bihan
- NeuroSpin, Centre d'études de Saclay, Bâtiment 145, Gif-sur-Yvette 91191, France
| | - Ram Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive - ED4, Columbus, OH 43205, USA
| | - Mark Smith
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive - ED4, Columbus, OH 43205, USA
| | - Mai-Lan Ho
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive - ED4, Columbus, OH 43205, USA.
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Parikh N, Williamson R, Kulzer M, Sohn A, Chang WM, Li CQ. Unique enlarging cavernous malformation secondary to abnormal arteriovenous shunting through an associated developmental venous anomaly. Neuroradiol J 2021; 35:399-402. [PMID: 34464162 DOI: 10.1177/19714009211042883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cavernous malformations are angiographically occult vascular malformations. They are often associated with a developmental venous anomaly through poorly understood mechanisms. We present an unusual case of a gradually enlarging cavernous malformation associated with a developmental venous anomaly with arteriovenous shunting, suggesting venous hypertension or reflux as a potential cause of progressive growth.
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"Trapped labelled spins"-related signal on arterial spin labelling in the assessment of flow-diverted aneurysms: preliminary experience. Neuroradiology 2021; 64:77-93. [PMID: 34128085 DOI: 10.1007/s00234-021-02721-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To investigate ASL-MRI features of flow-diverted aneurysms, review their haemodynamic surrogates, and discuss their pertinent clinical implications. METHODS Retrospective single institutional analysis was performed on the clinical and imaging data of patients who underwent digital subtraction angiography (DSA) and ASL-MRI after endovascular flow diversion for cerebral aneurysms. Pseudo-continuous ASL-MRI was performed with post-label delays of 1525-1800 ms. Intra-aneurysmal "trapped labelled spins" (TLS)-related hypersignal, as seen on cerebral blood flow (CBF)-weighted maps of ASL-MRI, was investigated. Intermodality equivalence with DSA [O'Kelly-Marotta (OKM) grading for occlusion], 3D-TOF-MRA, and 3D spin-echo T1-weighted ("black-blood") images was assessed. RESULTS Ten cases were included. "TLS" signal was demonstrable in 7/8 (87.5%) of the DSA-visible flow-diverted aneurysms (OKM grade B3, n = 6; OKM grade A3, n = 2). No TLS was seen in both OKM-D (excluded) aneurysms. TLS was not visualised in an OKM-B3 aneurysm with < 3 mm opacifying remnant. 3D-TOF-MRA and ASL-MRI were discordant at 5 instances (45.4%; TOF-MRA false negative, n = 4; false positive, n = 1). Loss of flow void on black-blood images corresponded to the absence of TLS and vice versa in all cases but one. CONCLUSION "Trapped labelled spins"-related signal on ASL-MRI occurs in patent large aneurysms that have undergone successful endovascular flow diversion. This phenomenon likely represents an interplay of a multitude of haemodynamic factors including decelerated intra-aneurysmal inflow and outflow restriction. Serial intra-saccular TLS signal changes may hold diagnostic value, including contexts where 3D-TOF-MRA interpretation becomes dubious. "Trapped labelled spins"-related signal as a non-invasive proxy marker of aneurysm patency can possibly obviate unnecessary DSA.
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