Symptomatic Infratentorial Thrombosed Developmental Venous Anomaly: Case Report and Review of the Literature

Oculomotor Nerve Palsy Induced by a Cerebral Developmental Venous Anomaly: A Case Report and Comprehensive Review

BACKGROUND Symptoms caused by developmental venous anomalies (DVAs) are usually mild and unspecific. Despite the benign nature of DVAs, they can occasionally be symptomatic. CASE REPORT A 67-year-old woman presented with sudden diplopia and left eyelid ptosis for 10 days. A neurologic examination revealed left complete oculomotor nerve palsy. Other neurologic deficits, including eye pain or pulsatile tinnitus, were not detected. Furthermore, the visual acuity was normal. Additionally, no retinal hemorrhage, venous dilatation, or fundus tortuosity were observed. No ischemia lesions or neoplasms were observed in MRI, and no widening or enhancement of the cavernous sinus was detected in post-contrast T1-weighted images, but magnetic resonance tomography cerebral angiography (MRTA) detected an offending vessel compressing the left oculomotor nerve in the fossa interpeduncular. We hypothesized that oculomotor nerve palsy (ONP) was caused by an abnormal arterial structure. However, digital subtraction angiography (DSA) revealed no aneurysm or abnormal arterial structure in the arterial phase, while a tortuous and dilated collecting vein was detected in the venous phase, connecting the left temporal lobe to the left cavernous sinus. This indicated a typical caput medusae appearance, suggesting the mechanism of oculomotor palsy caused by compressive impairment of the DVA. The patient refused microvascular decompression surgery, and ONP persisted after 30 days. Management was conservative, with spontaneous resolution at 60 days and no recurrence during the 2-year follow-up. CONCLUSIONS ONP is rarely caused by DVAs, which are easily ignored due to their benign nature. Cerebral vein examinations are advised for patients exhibiting clinical symptoms of unknown etiology.

Management of Symptomatic Hemorrhage From a Developmental Venous Anomaly

Developmental venous anomalies (DVAs) are clinically benign, low-flow vascular malformations that classically hemorrhage only when associated with a cerebral cavernous malformation. It is very rare for an isolated DVA to hemorrhage. Resection of the DVA is generally contraindicated because of the high risk of venous infarct. We present the case of a large symptomatic hemorrhage stemming from an isolated DVA. The hematoma was evacuated and the hemorrhagic portion of the DVA was resected. This case demonstrates that in rare circumstances, careful resection can successfully treat hemorrhagic DVAs.

Case report: Delayed outflow obstruction of a DVA: A rare complication of brainstem cavernoma surgery

Introduction

Developmental venous anomalies (DVAs) are considered variants of normal transmedullary veins. Their association with cavernous malformations is reported to increase the risk of hemorrhage. Expert consensus recommends meticulous planning with MR imaging, use of anatomical “safe zones”, intraoperative monitoring of long tracts and cranial nerve nuclei, and preservation of the DVA as key to avoiding complications in brainstem cavernoma microsurgery. Symptomatic outflow restriction of DVA is rare, with the few reported cases in the literature restricted to DVAs in the supratentorial compartment.

Case

We present a case report of the resection of a pontine cavernoma complicated by delayed outflow obstruction of the associated DVA. A female patient in her 20's presented with progressive left-sided hemisensory disturbance and mild hemiparesis. MRI revealed two pontine cavernomas associated with interconnected DVA and hematoma. The symptomatic cavernoma was resected via the infrafacial corridor. Despite the preservation of the DVA, the patient developed delayed deterioration secondary to venous hemorrhagic infarction. We discuss the imaging and surgical anatomy pertinent to brainstem cavernoma surgery, as well as the literature exploring the management of symptomatic infratentorial DVA occlusion.

Conclusion

Delayed symptomatic pontine venous congestive edema is extremely rare following cavernoma surgery. DVA outflow restriction from a post-operative cavity, intraoperative manipulation, and intrinsic hypercoagulability from COVID-10 infection are potential pathophysiological factors. Improved knowledge of DVAs, brainstem venous anatomy, and “safe entry zones” will further elucidate the etiology of and the efficacious treatment for this complication.

Case report: Successful thromboprophylaxis with enoxaparin in a pregnant woman with internal jugular vein agenesis

Internal jugular agenesis is a vascular malformation that is often associated with a history of recurrent headache. Due to the resulting abnormalities in intracranial venous drainage, it may be complicated by neurological dysfunction, such as intracranial hypertension, intracranial micro-thromboses, and neurodegenerative diseases such as multiple sclerosis. The simultaneous presence of jugular vein agenesis and thrombosis is possible in cases of acute illness, hormonal treatment, pregnancy, hypomobility, or venous drainage abnormalities (VDA) (e.g., May-Thurner syndrome). In particular, the literature still lacks data on thromboprophylaxis in pregnant women with jugular vein agenesis. Here, we report a positive experience with prophylaxis using enoxaparin during pregnancy in a patient with internal jugular agenesis.

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.

Cerebral Cavernous Malformations, Developmental Venous Anomaly, and Its Coexistence: A Review

BACKGROUND

Cerebral cavernous malformations (CCMs) are intracranial vascular malformations that can exist as a single lesion or mixed vascular lesions. The most common mixed form is the coexistence of CCM with an associated developmental venous anomaly (DVA). In this paper, we aim to give a comprehensive review of CCM, DVA, and their coexistence as mixed lesions. A PubMed search using the keywords "Cerebral cavernous malformations, Developmental venous anomaly, Mixed Cerebral cavernous malformations with Developmental venous anomaly" was done. All studies in the English language in the past 10 years were analyzed descriptively for this review.

SUMMARY

The search yielded 1,249 results for "Cerebral cavernous malformations," 271 results for "Developmental venous anomaly," and 5 results for "Mixed Cerebral cavernous malformations with Developmental venous anomaly." DVA is the most common intracranial vascular malformation, followed by CCM. CCM can have a wide array of clinical presentations like hemorrhage, seizures, or focal neurological deficits or can also be an incidental finding on brain imaging. DVAs are benign lesions by nature; however, venous infarction can occur in a few patients due to acute thrombosis. Mixed CCM with DVA has a higher risk of hemorrhage. CCMs are angiographically occult lesion, and cerebral digital subtraction angiography is the gold standard for the diagnosis of DVA. Mixed lesions, on the other hand, are best diagnosed with magnetic resonance imaging, which has also been effective in detecting specific abnormalities. Asymptomatic lesions are treated through a conservative approach, while clinically symptomatic lesions need surgical management.

CONCLUSION

Individual CCM or DVA lesions have a benign course; however, when they coexist in the same individual, the hemorrhagic risk is increased, which prompts for rapid diagnosis and treatment.

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.

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.

Isolated hemorrhagic arterialized DVAs: revisiting symptomatic DVAs

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

[Vascular pathologies and vascular anatomical variants of the posterior cranial fossa]

CLINICAL/METHODICAL ISSUE

The posterior fossa is the location of some specific vascular pathologies and vascular anatomical variants that are important for radiologists to know and recognize. Vascular malformations that are also found in the supratentorial region have some divergent characteristics in the posterior fossa.

PRACTICAL RECOMMENDATIONS

Knowledge of the vascular anatomy of the posterior fossa and its variants is important for an understanding of vascular pathologies.

Association of Developmental Venous Anomalies with Demyelinating Lesions in Patients with Multiple Sclerosis

We present 5 cases of demyelination in patients diagnosed with multiple sclerosis that are closely associated with a developmental venous anomaly. Although the presence of a central vein is a known phenomenon with multiple sclerosis plaques, demyelination occurring around developmental venous anomalies is an underreported phenomenon. Tumefactive demyelination can cause a diagnostic dilemma because of its overlapping imaging findings with central nervous system neoplasm. The relationship of a tumefactive plaque with a central vein can be diagnostically useful, and we suggest that if such a lesion is closely associated with a developmental venous anomaly, an inflammatory or demyelinating etiology should be a leading consideration.

Serial imaging and SWAN sequence of developmental venous anomaly thrombosis with hematoma: Diagnosis and follow-up

Developmental venous anomalies (DVAs) are usually asymptomatic. We report a case of DVA thrombosis with recurrent tiny frontal hematoma in a 24-year-old man. The contribution of T2-GRE and SWAN sequences are discussed. Follow-up attested complete recanalization after anticoagulation.