Magnetic Resonance (MR) Imaging of Vascular Malformations

Magnetic Resonance Imaging (MRI) Evaluation and Classification of Vascular Malformations

Introduction Vascular malformations of the soft tissues are a diverse collection of lesions frequently encountered in clinical practice. Vascular malformations are rare and complex abnormalities that affect both children and young adults. Low-flow malformations are more common in children and often become symptomatic in later years. These malformations are common causes of soft tissue masses in children and can affect any part of the body at any age. Significant advancements in the management of these conditions have been made due to the implementation of a comprehensive binary categorization system, which classifies vascular abnormalities into tumors and malformations based on their clinicopathological characteristics. Imaging, particularly magnetic resonance imaging (MRI), plays a crucial role in the accurate identification, localization, and classification of these lesions, aiding in the development of appropriate treatment plans. Materials and methods This prospective study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, from August 2022 to June 2024. Fifty patients of all age groups with clinically suspected soft tissue vascular malformations were included. MRI was performed using a MAGNETOM Vida (3T) Scanner (Siemens Healthcare Private Limited, Mumbai, India), and ultrasound was used as an adjunct. Institutional Ethics Committee clearance and informed consent were obtained. The study employed various MRI sequences, including T1-weighted imaging (T1WI) fast spin echo (FSE), T2-weighted imaging (T2WI) FSE, short tau inversion recovery (STIR), T2-weighted gradient recalled echo (GRE), pre-contrast fat-saturated T1WI, 3D post-contrast T1WI, diffusion-weighted imaging (DWI), and ANGIO TWIST (time-resolved angiography with interleaved stochastic trajectories) ISO. Results The study included 50 patients, with a male predominance of 28 (56%). The mean age was 22.13 years, and the average duration of vascular malformations was 32.94 months. The swelling was present in 43 (86%) of patients, and 35 (70%) had superficial lesions. MRI findings revealed hypointensity on T1 imaging in 40 (80%) patients and hyperintensity on T2 imaging in 49 (98%) cases. STIR sequences showed hyperintensity in all patients. The most common type of vascular malformation was slow-flow 46 (92%), with venous malformations being the most prevalent 39 (78%). Conclusion MRI is a valuable imaging modality for the evaluation and classification of vascular malformations, providing detailed information on lesion extent and involvement of surrounding tissues. The findings support the use of MRI as a primary tool in the assessment of vascular malformations, with ultrasound serving as a useful adjunct in certain cases. Further studies with larger sample sizes are recommended to validate these findings and refine imaging protocols.

Soft Tissue Vascular Anomalies of the Extremities: A Proposed Diagnostic Approach

This narrative review aims to summarise the classification of vascular anomalies, their clinical presentation, and their radiological features to propose a diagnostic algorithm to approach patients with suspected soft tissue vascular anomalies of the extremities. The management of vascular anomalies necessitates a multidisciplinary approach. Clinical presentation and physical examination are sufficient in most cases to achieve a correct diagnosis. This is especially true for small congenital lesions of the skin and subcutaneous tissue. Imaging is used for accurate characterization of these lesions, especially in cases of atypical or vague clinical presentation, and to assess extension in cases of lesions that are larger and localized in deeper tissues.

Magnetic resonance - guided treatment of low-flow vascular malformations and the technologies to potentiate adoption

Vascular malformations are congenital, non-neoplastic lesions that arise secondary to defects in angiogenesis. Vascular malformations are divided into high-flow (arteriovenous malformation) and low-flow (venous malformations and lymphatic malformations). Magnetic resonance imaging (MRI) is the standard for pre-and post-intervention assessments, while ultrasound (US), X-ray fluoroscopy and computed tomography (CT) are used for intra-procedural guidance. Sclerotherapy, an image-guided therapy that involves the injection of a sclerosant directly into the malformation, is typically the first-line therapy for treating low-flow vascular malformations. Sclerotherapy induces endothelial damage and necrosis/fibrosis with eventual involution of the malformation. Image-guided thermal therapies involve freezing or heating target tissue to induce cell death and necrosis. MRI is an alternative for intra-procedural guidance and monitoring during the treatment of vascular malformations. MR can provide dynamic, multiplanar imaging that delineates surrounding critical structures such as nerves and vasculature. Multiple studies have demonstrated that MR-guided treatment of vascular malformations is safe and effective. This review will detail (1) the use of MR for the classification and diagnosis of vascular malformations, (2) the current literature surrounding MR-guided treatment of vascular malformations, (3) a series of cases of MR-guided sclerotherapy and thermal ablation for the treatment of vascular malformations, and (4) a discussion of technologies that may potentiate interventional MRI adoption including high intensity focused ultrasound and guided laser ablation.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

Review of diagnosis, differential diagnosis, and management of retroperitoneal lymphangioma

Lymphatic malformation (LM) is the currently preferred term for what was previously known as lymphangioma. Retroperitoneal LMs are extremely rare, benign, cystic masses that arise from lymphatic vessels. They can be challenging to diagnose because they resemble other retroperitoneal cystic tumors. The development of treatment strategies for rare diseases, including retroperitoneal LM, requires the acquisition of new knowledge to enhance our understanding of the disease progression. Therefore, we present an update regarding fundamental and advanced issues associated with retroperitoneal LM. This review describes the epidemiology, histopathology, biomedicine, clinical manifestations, radiological features, differential diagnosis, and management of this lesion.

Hemorrhagic stroke: Uncommon complication of diabetic ketoacidosis in pediatric patients

Diabetic ketoacidosis (DKA) is a well-known complication of type 1 diabetes mellitus. Diabetic ketoacidosis predisposes patients into devastating neurological complications. The most common neurologic complication is cerebral edema. Stroke either ischemic or hemorrhagic are uncommon complications of DKA with worse patient's outcome. Hemorrhagic stroke can manifest as subarachnoid or intraparenchymal hemorrhage. We present a 14-year-girl presented with DKA and complicated with both subarachnoid and intraparenchymal hemorrhages. Owing to early diagnosis and prompt treatment the patient had good outcome.

Clinical and Radiological Correlation of Low Flow Vascular Malformation Treated With Percutaneous Sclerotherapy

Objective: To retrospectively correlate imaging findings post-sclerotherapy of low-flow vascular malformations with clinical outcome. Materials and Methods: We retrospectively evaluated 81 pediatric patients who had sclerotherapy in our department over a 14-year period. Patients with a diagnosis of low-flow vascular malformation, pre and post-treatment ultrasound (US) and clinical follow-up evaluation were included in the study. Exclusion criteria were coexisting high-flow vascular malformations, history of additional surgical or medical treatment to their malformation and large infiltrative lesions difficult to measure on US. Pre and post-treatment sonographic volumes of the malformation were assessed. Changes in volume were categorized into 6- increased volume, stable and volume decrease of 1-25%/26-50%/51-75%/75-100%. Clinical outcomes were categorized into 4 - worse, no change, improved and symptom free. In cases where pre-treatment MRI was available, the estimated malformation volumes in both modalities were correlated using Spearman's rank correlation. The change in sonographic volume was correlated with clinical outcome using Spearman's rank correlation. P-values < .05 were considered significant. Results: Twenty-nine patients were included in the study; 13 with venous malformation (VM), and 16 with lymphatic malformation (LM). Nineteen patients had both pre-treatment US and MRI, showing correlation in volume between the 2 modalities (P < .001). Post-treatment change in volume correlated with clinical outcome for combined venous and LMs (rho = .44, P = .02). No correlation was found when venous (rho = .48, P = .09) and lymphatic (rho = .33, P = .21) malformations were considered separately. Conclusion: Ultrasound can potentially be used as an objective tool in evaluating sclerotherapy treatment response of low-flow vascular malformations in the pediatric population.

Atlas of Nervous System Vascular Malformations: A Systematic Review

Vascular malformations are frequent in the head and neck region, affecting the nervous system. The wide range of therapeutic approaches demand the correct anatomical, morphological, and functional characterization of these lesions supported by imaging. Using a systematic search protocol in PubMed, Google Scholar, Ebsco, Redalyc, and SciELO, the authors extracted clinical studies, review articles, book chapters, and case reports that provided information about vascular cerebral malformations, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 385,614 articles were grouped; using the inclusion and exclusion criteria, three of the authors independently selected 51 articles about five vascular cerebral malformations: venous malformation, brain capillary telangiectasia, brain cavernous angiomas, arteriovenous malformation, and leptomeningeal angiomatosis as part of Sturge–Weber syndrome. We described the next topics—“definition”, “etiology”, “pathophysiology”, and “treatment”—with a focus on the relationship with the imaging approach. We concluded that the correct anatomical, morphological, and functional characterization of cerebral vascular malformations by means of various imaging studies is highly relevant in determining the therapeutic approach, and that new lines of therapeutic approaches continue to depend on the imaging evaluation of these lesions.

MR Imaging of Vascular Malformations and Tumors of Head and Neck

Soft tissue vascular anomalies show a wide heterogeneity of clinical manifestations and imaging features. MR imaging has an important role in the diagnosis and management of vascular lesions of the head and neck. MR angiography is mandatory in cases of arteriovenous and combined malformations to assess the high-flow nature/component of the lesions and plan therapy. Infantile hemangiomas can be differentiated from congenital hemangiomas by clinical course. Reactive vascular tumors have nonspecific features similar to infantile hemangiomas. Locally malignant and malignant vascular tumors have irregular borders, infiltration of different tissue planes, and lower apparent diffusion coefficient values than benign vascular tumors.

Clinical and radiographic characteristics of sacral arteriovenous fistulas: a multicenter experience

OBJECTIVE

Available data on management of sacral arteriovenous fistulas (sAVFs) are limited to individual case reports and small series. Management includes observation, endovascular embolization, or surgical ligation, with no clear guidelines on the optimal treatment modality. The authors' objective was to report their multiinstitutional experience with management of sAVF patients, including clinical and radiographic characteristics and postprocedural outcomes.

METHODS

The electronic medical records of patients with a diagnosis of spinal arteriovenous fistula treated from January 2004 to December 2019 at the authors' institutions were reviewed, and data were summarized using descriptive statistics, including percentage and count for categorical data, median as a measure of central tendency for continuous variables, and interquartile range (IQR) as a measure of dispersion.

RESULTS

A total of 26 patients with sAVFs were included. The median (IQR) age was 65 (57-73) years, and 73% (n = 19) of patients were male. Lower-extremity weakness was the most common presenting symptom (n = 24 [92%]), and half the patients (n = 13 [50%]) reported bowel and bladder sphincter dysfunction. The median (IQR) time from symptom onset to treatment was 12 (5.25-26.25) months. Radiographically, all patients had T2 hyperintensity at the level of the conus medullaris (CM) (n = 26 [100%]). Intradural flow voids were identified in 85% (n = 22) of patients. The majority of the lesions had a single identifiable arterial feeder (n = 19 [73%]). The fistula was located most commonly at the S1 level (n = 13 [50%]). The site where the draining vein connects to the pial venous plexus was seen predominantly at the lumbar level (n = 16 [62%]). In total, 29 procedures were performed: 10 open surgeries and 19 endovascular embolization procedures. Complete occlusion was achieved in 90% (n = 9) of patients after open surgery and 79% (n = 15) after endovascular embolization. Motor improvement was seen in 68% of patients (n = 15), and bladder and bowel function improved in 9 patients (41%). At last follow-up, 73% (n = 16) of patients had either resolution or improvement of the pretreatment intramedullary T2 signal hyperintensity.

CONCLUSIONS

T2 hyperintensity of the CM and a dilated filum terminale vein are consistent radiographic signs of sAVF, and delayed presentation is common. Complete occlusion was achieved in almost all patients after surgery, and endovascular embolization was effective in 70% of the patients. Further studies are needed to determine the best treatment modality based on case-specific characteristics.

Arteriovenous Malformations-Current Understanding of the Pathogenesis with Implications for Treatment

Arteriovenous malformations are a vascular anomaly typically present at birth, characterized by an abnormal connection between an artery and a vein (bypassing the capillaries). These high flow lesions can vary in size and location. Therapeutic approaches are limited, and AVMs can cause significant morbidity and mortality. Here, we describe our current understanding of the pathogenesis of arteriovenous malformations based on preclinical and clinical findings. We discuss past and present accomplishments and challenges in the field and identify research gaps that need to be filled for the successful development of therapeutic strategies in the future.

MRI in verrucous venous malformation: role in diagnosis and treatment

Verrucous venous malformation (VVM), recently reclassified from verrucous hemangioma, is a rare congenital vascular anomaly that is traditionally diagnosed on histopathologic analysis of deep tissue biopsy. This case report documents the utility of magnetic resonance imaging in confirming VVM diagnosis, characterizing lesion extent and guiding therapy.

Towards precision nanomedicine for cerebrovascular diseases with emphasis on Cerebral Cavernous Malformation (CCM)

Introduction: Cerebrovascular diseases encompass various disorders of the brain vasculature, such as ischemic/hemorrhagic strokes, aneurysms, and vascular malformations, also affecting the central nervous system leading to a large variety of transient or permanent neurological disorders. They represent major causes of mortality and long-term disability worldwide, and some of them can be inherited, including Cerebral Cavernous Malformation (CCM), an autosomal dominant cerebrovascular disease linked to mutations in CCM1/KRIT1, CCM2, or CCM3/PDCD10 genes.Areas covered: Besides marked clinical and etiological heterogeneity, some commonalities are emerging among distinct cerebrovascular diseases, including key pathogenetic roles of oxidative stress and inflammation, which are increasingly recognized as major disease hallmarks and therapeutic targets. This review provides a comprehensive overview of the different clinical features and common pathogenetic determinants of cerebrovascular diseases, highlighting major challenges, including the pressing need for new diagnostic and therapeutic strategies, and focusing on emerging innovative features and promising benefits of nanomedicine strategies for early detection and targeted treatment of such diseases.Expert opinion: Specifically, we describe and discuss the multiple physico-chemical features and unique biological advantages of nanosystems, including nanodiagnostics, nanotherapeutics, and nanotheranostics, that may help improving diagnosis and treatment of cerebrovascular diseases and neurological comorbidities, with an emphasis on CCM disease.

Case Report: Multidisciplinary Approach for a Rare Case of Thymic Vascular Malformation

We report the rare case of a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation (ISSVA classification, 2008) in a 58 years old man. Diagnosis was obtained only after surgical removal that was complicated by a sudden massive bleeding (about 1,500 cc) requiring emergency conversion to median sternotomy. Difficulty in preoperative diagnosis, rarity of histologic pattern, and surgical challenges make this case very interesting for surgeons, pathologists and radiologist. Our message, dealing with mediastinal masses, is: (a) differential diagnosis between the more frequent solid antero-superior mediastinal tumors and vascular malformation should be always considered (b) preoperative angiography should always be performed in case of uncertain diagnosis (c) coil embolization should always be considered to reduce potentially fatal bleeding (d) histologic differentiation with other thymic neoplasms must be always considered.

Multiparametric Magnetic Resonance Imaging Features That Predict Treatment Response to Endovascular Sclerotherapy in Craniofacial Venous Malformations

PURPOSE

Craniofacial venous malformations (VMs) cause severe psychological and physiological burden to patients, and treatment is meaningful only when the benefits of treatment outweigh the risks. Therefore, it is very important to predict the treatment response before treatment. This study was performed to explore the value of multiparametric magnetic resonance imaging for predicting treatment response to endovascular sclerotherapy in VMs.

MATERIALS AND METHODS

We designed and implemented a case-control study and enrolled a sample from patients with VM treated by endovascular sclerotherapy at our hospital from January 2014 to January 2018. The primary predictor variables were pretreatment volume (prevolume), lesion classification, phleboliths, initial slope of increase (ISI), gender, age, and sclerosants. The primary outcome variable was treatment response (positive response or negative response). Descriptive, univariate and multivariate binary logistic regressions, and Firth's penalized maximum likelihood estimate were computed to measure the association between predictor variables and treatment response. The level of statistical significance was set at a P value less than or equal to .05.

RESULTS

The sample was composed of 42 patients with a median age of 17.50 years, and 33.3% were males. There were 27 and 15 patients in the positive and negative response groups, respectively. There were significant differences between the 2 groups for ISI (adjusted odds ratio [OR], 2.184; P = .0268; 95% confidence interval [95% CI], 1.094 to 4.360), lesion classification (adjusted OR, 9.072; P = .0226; 95% CI, 1.363 to 60.400), and prevolume (adjusted OR, 1.020; P = .0268; 95% CI, 1.002 to 1.038). The cutoff point for prevolume and ISI was 40.42 cm³ and 2.61.

CONCLUSIONS

Multiparametric magnetic resonance imaging could provide an approach for predicting treatment response in craniofacial VMs. When the prevolume was greater than 40.42 cm³, ISI was greater than 2.61, and the classification was infiltrating type, the response to sclerotherapy was negative.

Therapeutic evaluation of sclerotherapy for limb venous malformations: A case series

OBJECTIVES

To examine three different methods for evaluating the effect of percutaneous sclerotherapy on limb venous malformations in a series of patients with a relatively long follow-up.

METHOD

The study was a retrospective study.

RESULTS

Thirty-eight patients treated with percutaneous sclerotherapy underwent sclerotherapy, with a median number of sessions of 4 (range, 1-10). They were followed up for 1-60 months (average 12.5 months). The kappa between clinical manifestations and Doppler ultrasound was 0.684 (P < 0.001). The kappa between clinical manifestations and magnetic resonance imaging was 0.217 (P = 0.006). The kappa between Doppler ultrasound and magnetic resonance imaging was 0.323 (P < 0.001). The rate of grade IV patients evaluated by clinical manifestations was significantly higher than that by Doppler ultrasound and magnetic resonance imaging.

CONCLUSIONS

Magnetic resonance imaging is the gold standard for VM imaging. Its consistency with clinical examination and Doppler ultrasound is poor, and Doppler ultrasound and clinical examination could be more appropriate for follow-up imaging after sclerotherapy.

Case Report of a Mediastinal Vascular Malformation Mimicking Esophageal Varices on Endoscopy, with Emphasis on Radiological Findings

Patient: Male, 48-year-old

Final Diagnosis: Mediastinal vascular malformation

Symptoms: Cough • fever

Medication:—

Clinical Procedure: —

Specialty: Radiology

Role of imaging in the diagnosis of vascular malformations vascular malformations

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.

MR Imaging in Neurocritical Care

How to cite this article: Patra A, Janu A, Sahu A. MR Imaging in Neurocritical Care. Indian J Crit Care Med 2019;23(Suppl 2):S104–S114.

Efficacy of Percutaneous Sclerotherapy in Low Flow Venous Malformations - A Single Center Series

Purpose

We analyzed results of percutaneous sclerotherapy for venous malformations (VMs) in head, neck and extremities.

Materials and Methods

Thirty-five patients with head and neck and extremities VM treated by sclerotherapy with bleomycin and sodium tetradecyl sulphate (STS) were retrospectively reviewed. A pre-treatment magnetic resonance imaging was done for all patients to diagnose the lesion. Each lesion received 1 to 11 sessions (average, 2.7; standard deviation [SD], 2.03). We evaluated percentage reduction in swelling size and a Likert scale review of subjective feelings of the patients.

Results

Sixteen had a complete obliteration; by sclerotherapy alone (n=13) and surgery after a 75% reduction (n=3). Ten patients had a significant reduction up to 75% and three patients by 50%. Four had a minimal decrease with reduction of 25% or less. Follow-up duration of the patients varied from a minimum of 6 months up to 3 years (average, 15.7 months; SD, 7.8 months). Of all patients, three refused further treatment and were lost to follow-up, while another two were referred to a dermatologist. Thirteen patients reported feeling excellent after the sessions. Eight patients claimed to feel slightly better compared to before the sessions started. Only three patients complained of feeling the same before and after the sessions. None of the patients still in follow-up have reported a recurrence of a lesion thus far.

Conclusion

Sclerotherapy using bleomycin and STS as sclerosants is a safe and effective primary treatment for VMs in the head and neck as well as in extremities.