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

Prevalence of Developmental Venous Anomalies in Association with Sporadic Cavernous Malformations on 7T MRI

BACKGROUND AND PURPOSE

The etiology of sporadic cavernous malformations is not well-understood. However, recent evidence suggests that they may arise from a developmental venous anomaly. The goal of this study was to evaluate the prevalence of developmental venous anomalies associated with sporadic cavernous malformations using 7T MR imaging.

MATERIALS AND METHODS

We retrospectively identified patients with a sporadic cavernous malformation imaged with 7T MR imaging between August 2019 and July 2022. Two raters determined whether a developmental venous anomaly was associated with each malformation.

RESULTS

The study included 59 patients with a total of 61 cavernous malformations. Of the sixty-one, 44 (72%) had an associated developmental venous anomaly. An associated anomaly was most common for cavernous malformations in the brainstem (88%) compared with the cerebral hemispheres or cerebellum (60%-67%).

CONCLUSIONS

By means of high-quality 7T imaging, most patients with a sporadic cavernous malformation were found to have an associated developmental venous anomaly. These findings support the hypothesis that cavernous malformations may arise secondary to hemodynamic abnormalities.

De novo cavernous angiomas associated with developmental venous anomaly: a mini-series and literature review

BACKGROUND

Despite being previously considered as congenital lesions, recent studies agree to classify cerebral cavernous malformations (CCM) as acquired forms with clear correlations with other pathological affections of the central nervous system (CNS). In addition, a special subgroup, notably known as de novo CCMs (dnCCM), are associated in a significant number of cases with developmental venous anomalies (DVAs) and, in other cases, with Radiotherapy treatments.

METHODS

A mini-series of 4 patients with clinical history characterized by developing dnCCM is reported. In three patients, the dnCCM was associated with the presence of an isolated DVA. In one case, no DVA was detected, but the patient underwent brain radiotherapy. In three cases, the dnCCM was clinically symptomatic, and the patients were submitted to a surgical procedure for lesion removal. In one case, the dnCCM was detected during MRI follow-up.

RESULTS

Adding a review of the literature, we describe 47 patients who presented dnCCMs. The most common presentation is a sporadic CCM with a DVA, and the onset presentation was bleeding in 4 out of 47 cases (8.5%). Bleeding of dnCCM was observed in 9 out of 47 cases (19%), and the choice treatment was surgical in 24 out of 47 cases (51%).

CONCLUSIONS

We present our series with a review of the recent literature and discuss the "de novo" cavernous malformation pathogenesis. A throughout review of recent literature is reported to clarify the predisposing factors that may lead to dnCCM development in patients carrying specific genetic and molecular features. Considering the high risk of bleeding, strict follow-up and aggressive treatment should be evaluated in dnCCM management.

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.

Developmental venous anomaly associated with dural arteriovenous fistula: Etiopathogenesis and hemorrhagic risk

Introduction

Developmental venous anomalies (DVAs) have traditionally been defined as non-pathological congenital lesions. Compared to isolated DVAs, the association of DVAs with arteriovenous shunts seems to have a more adverse clinical connotation. In this review, we describe the association between DVA and dAVF and discuss the hemorrhagic risk. We also advance a hypothesis about the potential de novo formation of a DVA and challenge the dogma about their "developmental" or "congenital" nature.

Methods

A systematic review of the literature on the association of DVA and dAVF was performed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines.

Results

A number of 678 papers was initially identified, but only 9 studies were included in the final qualitative analysis. Most of the patients presented with bleeding (56%), with a median GCS of 14 (range 10-15). In 56% of the cases the DVA had a supratentorial location. Supratentorial DVAs mostly drained in the superior sagittal sinus (80%), while all of infratentorial/combined DVAs drained in deep ependymal veins of the 4th ventricle. All the supratentorial dAVFs drained into the superior sagittal sinus, while the infratentorial/combined dAVFs mostly drained in the jugular bulb, Vein of Rosenthal, or transverse-sigmoid sinuses (75%). Most of the dAVFs were classified as Cognard type IIa + b (67%), while in a smaller number of cases type I (22%) and type V (11%). The dAVF was the target of treatment in each case and most patients underwent endovascular treatment (78%). The dAVF was completely occluded in 78% of cases and no periprocedural complications were reported.

Conclusion

The clinical presentation, radiological findings, and treatment outcomes of DVAs and associated dAVFs have been discussed. Despite the general opinion that DVAs are benign congenital lesions, increasing epidemiological and radiological evidence supports a potential acquired origin, and the venous system seem to play a pivotal role in their post-natal genesis and development.

Distant Recurrence of a Cerebral Cavernous Malformation in the Vicinity of a Developmental Venous Anomaly: Case Report of Local Oxy-Inflammatory Events

BACKGROUND

Cerebral cavernous malformations (CCMs) are a major type of cerebrovascular lesions of proven genetic origin that occur in either sporadic (sCCM) or familial (fCCM) forms, the latter being inherited as an autosomal dominant condition linked to loss-of-function mutations in three known CCM genes. In contrast to fCCMs, sCCMs are rarely linked to mutations in CCM genes and are instead commonly and peculiarly associated with developmental venous anomalies (DVAs), suggesting distinct origins and common pathogenic mechanisms.

CASE REPORT

A hemorrhagic sCCM in the right frontal lobe of the brain was surgically excised from a symptomatic 3 year old patient, preserving intact and pervious the associated DVA. MRI follow-up examination performed periodically up to 15 years after neurosurgery intervention demonstrated complete removal of the CCM lesion and no residual or relapse signs. However, 18 years after surgery, the patient experienced acute episodes of paresthesia due to a distant recurrence of a new hemorrhagic CCM lesion located within the same area as the previous one. A new surgical intervention was, therefore, necessary, which was again limited to the CCM without affecting the pre-existing DVA. Subsequent follow-up examination by contrast-enhanced MRI evidenced a persistent pattern of signal-intensity abnormalities in the bed of the DVA, including hyperintense gliotic areas, suggesting chronic inflammatory conditions.

CONCLUSIONS

This case report highlights the possibility of long-term distant recurrence of hemorrhagic sCCMs associated with a DVA, suggesting that such recurrence is secondary to focal sterile inflammatory conditions generated by the DVA.

Vascular Lesions of the Pineal Region: A Comprehensive Review of the Therapeutic Options

OBJECTIVE

Vascular lesions of the pineal region comprise aneurysms of the pineal region, arteriovenous malformations, cavernous malformations, and vein of Galen malformations. In the present report, we have offered an extensive review of each vascular pineal region lesion.

METHODS

We performed an extensive literature review, focusing on the current therapeutic options available for the different vascular lesions of the pineal region.

RESULTS

Vascular lesions of the pineal region are rare. Microneurosurgery remains a valid treatment of cavernomas, arteriovenous malformations, and aneurysms. Endovascular treatments seem to be the first option for the vein of Galen malformations, followed by microneurosurgery. Radiosurgery seems beneficial for small-size arteriovenous malformations. Complex and large vascular lesions will require a combination of multiple treatments.

CONCLUSIONS

Vascular lesions of the pineal region are complex, uncommon diseases. Thus, definitive therapeutic modalities for these lesions require further research.

An analysis of lesions associated with developmental venous anomalies

OBJECTIVE

The aim of this study was to describe different lesions and features associated with developmental venous anomalies (DVAs).

METHODS

The records and magnetic resonance imaging (MRI) images of 1,722 patients who underwent cranial MRI between 2010 and 2017 were retrospectively reviewed. It was found that 124 (7.2%) patients had DVAs, and 48 of these patients (38.7%) had additional anomalies accompanying DVAs. Of the patients with DVAs, 25 were female and 23 were male, with a mean age of 39.3 years (range, 3-77 years). MRI was performed in all the patients.

RESULTS

In addition to DVAs, cavernomas were present in 30 patients (62.5%), haematomas in 7 (14.5%), gliosis in 6 (12.5%), demyelinating plaques in 4 (8.3%) and a glioblastoma in 1 (2.2%). The mean diameter of the DVAs was 1.1mm and the mean diameter of the lesions was 17.4mm. The susceptibility weighted imaging (SWI) sequence was also applied to 12 patients with cavernomas. The relevant sequence in all of these patients contributed to the diagnosis.

CONCLUSION

Our study shows that DVAs can accompany a wide spectrum of lesions, especially cavernomas. Although their pathophysiology has not yet been clearly established, these lesions may have a common aetiology.

Systemic and CNS manifestations of inherited cerebrovascular malformations

Cerebrovascular malformations occur in both sporadic and inherited patterns. This paper reviews imaging and clinical features of cerebrovascular malformations with a genetic basis. Genetic diseases such as familial cerebral cavernous malformations and hereditary hemorrhagic telangiectasia often have manifestations in bone, skin, eyes, and visceral organs, which should be recognized. Genetic and molecular mechanisms underlying the inherited disorders are becoming better understood, and treatments are likely to follow. An interaction between the intestinal microbiome and formation of cerebral cavernous malformations has emerged, with possible treatment implications. Two-hit mechanisms are involved in these disorders, and additional triggering mechanisms are part of the development of malformations. Hereditary hemorrhagic telangiectasia encompasses a variety of vascular malformations, with widely varying risks, and a more recently recognized association with cortical malformations. Somatic mutations are implicated in the genesis of some sporadic malformations, which means that discoveries related to inherited disorders may aid treatment of sporadic cases. This paper summarizes the current state of knowledge of these conditions, salient features regarding mechanisms of development, and treatment prospects.

Variations of Intracranial Dural Venous Sinus Diameters from Birth to 20 Years of Age: An MRV-Based Study

BACKGROUND AND PURPOSE

The role of the dural venous sinus system in cerebrovascular pathology and the understanding of normal developmental patterns and sizes of the dural venous sinus system continue to expand. The purpose of this study was to review MR venograms to elucidate developmental patterns and diameters of the major dural venous sinuses from 0 to 20 years of age.

MATERIALS AND METHODS

All available MR venograms of patients 0-20  years of age who presented to our institution were retrospectively reviewed. Patient age at the time of image acquisition was noted, and measurements were taken of the diameters of the major dural venous sinuses. The presence of embryonic sinuses including the persistent falcine sinus and the occipital sinus was noted. Dominance patterns of the transverse sinus system were determined. Mean diameters of each sinus were plotted as a function of age. The prevalence of persistent prenatal sinuses and transverse sinus-dominance patterns was compared across ages.

RESULTS

A total of 429 MR venograms from 429 patients were reviewed. All dural venous sinuses demonstrated a maximal growth rate from 0 to 7 years of age and reached maximal diameters around 5-10 years of age. The prevalence of falcine sinuses and occipital sinuses trended downward across increasing age categories (P = .09 and, <.0001, respectively).

CONCLUSIONS

Dural venous sinuses demonstrate maximal growth between 0 and 7 years of age and reach adult size around 5-10 years of age. Involution of the prenatal sinuses continues to take place after birth into childhood but is largely absent in early adulthood.

Prevalence and anatomical characteristics of developmental venous anomalies: an MRI study

PURPOSE

Developmental venous anomalies (DVAs) are extreme anatomical venous variations formed by multiple radiating medullary veins, which converge centripetally into a single collecting vein. Their coexistence with symptomatic cavernous malformations (CMs) has been reported in the literature. The aim of this study was to assess the characteristics of DVAs using MRI.

METHODS

A total of 6948 head MRIs of adult Caucasian patients were retrospectively analyzed to determine the number and locations of DVAs. We collected the data on the termination of the collecting vein, the prevalence of DVA-related CMs, and MRI FLAIR signal-hyperintensity corresponding to the location of the DVA.

RESULTS

At least one DVA was identified in 7.46% of the patients. The prevalence decreased with age, with a Pearson correlation coefficient of - 0.7328. A total of 599 DVAs were identified. Multiple DVAs were found in 10.92% of the patients with DVAs. The DVAs were identified more often in the supratentorial region (73.12%, p < 0.0001), and the most common location was the frontal lobe (35.23%). The collecting vein usually drained into the superficial cerebral veins (68.78%). CMs were observed in 4.14% of the patients with DVAs, and the prevalence showed a positive correlation with age. Signal-intensity abnormalities were identified in the vicinity of 5.18% DVAs.

CONCLUSION

Knowledge about characteristics of DVAs and associated anomalies is essential for neuroradiologists and neurosurgeons. The large number of currently available diagnostic studies enables us to assess anatomical variants on a great number of subjects.

Hypothalamic Cavernomas: Pediatric Case Report with 8.5-Year Follow-up and Review of the Literature

BACKGROUND

Cavernous malformations (cavernomas) are angiographically occult vascular lesions that can present symptomatically or be discovered incidentally. Rarely, they present in the hypothalamus or in children.

CASE DESCRIPTION

We describe the case of a 14-year-old male patient who presented with headaches and fever and was found to have a hypothalamic cavernoma that hemorrhaged. It was managed expectantly, with 1 rehemorrhage 21 months later, and the patient remains asymptomatic to this day aside from headaches.

CONCLUSIONS

This is to our knowledge the youngest case of a hypothalamic cavernoma to be reported and includes 8.5 years of follow-up and imaging. In addition, a literature review is performed that summarizes the 11 previously reported cases of hypothalamic cavernomas, including associated symptoms, management options, and outcomes.

Arteriovenous malformation drained into a developmental venous anomaly: A case report and up-dated literature review

INTRODUCTION

Although the association of developmental venous anomalies (DVAs) with cavernous malformations is well documented, the association with arteriovenous malformations (AVM) is unusual. The aim is herein to report an additional case and to review the concepts associated to these mixed malformations in order to guide patient management.

METHODS

A case of AVM associated with a DVA was identified and a literature review was performed according to PRISMA guidelines.

CASE REPORT

In an 18-year-old man presenting with sub-acute headache but with a normal neurological examination, the MRI-scan showed a right occipital DVA associated with hemosiderin spots evocative of earlier asymptomatic bleedings. The Digital Subtraction Angiography revealed a right parieto-occipital Spetzler-Martin Grade III AVM, fed by branches from the right middle and posterior cerebral arteries, with a superficial drainage flowing into a DVA that then joined the superior sagittal sinus. Multistep embolization was performed, leading to a partial reduction of the nidus, but preserving the DVA permeability. After a six-year follow-up. bleeding did not recur and the MRI aspect of the malformation was perfectly stable.

CONCLUSION

The co-occurrence of a DVA and an AVM is rare but has a higher bleeding risk than AVM alone (69% vs 38%) and must consequently be suspected when a DVA is revealed by a haemorrhage, in the absence of associated cavernoma. These mixed malformations represent a therapeutic challenge which has to be tailored to the venous anatomy and to the malformation Spetzler-Martin grade. DVA permeability should be preserved to avoid deleterious venous infarction.

Suboccipital transtentorial approach to remove a cerebellar cavernous malformation adjacent to cerebellomesencephalic fissure

BACKGROUND

Microsurgical removal of cerebral cavernous malformations (CCMs) at the region of cerebellomesencephalic fissure is technical challenging.

METHODS

A 51-year-old gentleman complained severe vertigo and vomiting for 10 days before admission. The symptoms did not improve after medicine treatment. Neuroimaging studies in other hospital revealed a CCM and hematoma at the region of cerebellomesencephalic fissure invading both the left cerebellum and its peduncles. The CCM was successfully removed through a suboccipital transtentorial approach. The detailed surgical techniques were reported.

CONCLUSION

A suboccipital transtentorial approach could be used to remove CCMs at the region of cerebellomesencephalic fissure.

Hemorrhage from cerebral cavernous malformations

Objective

To determine the role of associated developmental venous anomalies (DVAs) in intracranial hemorrhage (ICH) caused by cerebral cavernous malformations (CCMs).

Methods

We analyzed patient registry data of 1,219 patients with cavernous malformations treated in our institution between 2003 and 2018. Patients with spinal and familial CCM and patients without complete MRI data were excluded. The impact of various variables on ICH as a mode of presentation was assessed with multivariate binary logistic regression analysis. Kaplan Meier/Cox regression analysis was performed to analyze cumulative 5-year-risk for (re)hemorrhage and to identify baseline predictors of this outcome.

Results

Seven hundred thirty-one patients with CCM were included. Multivariate logistic regression confirmed a statistically significant negative correlation with DVA (odds ratio [OR] 0.635 [95% confidence interval (CI) 0.459–0.878]) and positive correlation with brainstem localization (OR 6.277 [95% CI 4.287–9.191]) with ICH as the mode of presentation. Among 731 patients, 76 experienced (re)hemorrhage during 2,338 person-years of follow-up. Overall cumulative 5-year risk was 24.1% (95% CI 21.1%–27.5%). Cox regression analysis revealed initial presentation with ICH (hazard ratio [HR] 8.0 [95% CI 3.549–18.122]) and brainstem localization (HR 2.9 [95% CI 1.756–4.765]) as independent baseline predictors of (re)hemorrhage. Presence of DVA added no independent prognostic information (HR 1.1 [95% CI 0.717–1.885]).

Conclusion

Patients with CCM with associated DVA are at lower risk to present with ICH. During untreated 5-year follow-up, they showed equal (re)hemorrhage risk compared to patients with CCM without DVA.

Low-grade astrocytoma in the setting of a developmental venous anomaly

Developmental venous anomalies (DVAs) are the most common type of cerebrovascular malformation and are considered benign. There are a few literature studies associating DVA with brain tumors, suggesting a possible underlying predisposition in these patients for tumor neogenesis. We report a 7-year-old female with a complex DVA who developed a low-grade astrocytoma in the opposite hemisphere. With analysis of a comprehensive solid tumor panel and imaging, we describe the possible association of an underlying susceptibility to neoplastic growth in the presence of a vascular malformation.

Surgical managements and patient outcomes after severe hemorrhagic events from brainstem cavernous malformations

To evaluate the surgical outcomes and predictors and the impact of surgical timing of patients who suffered a severe hemorrhagic event from brainstem cavernous malformations (CMs). The clinical data of all patients who underwent surgical treatment after a severe bleeding ictus from brainstem CMs between 2011 and 2017 were retrospectively reviewed. The study population consisted of 61 surgical patients (40, 65.6% female). Surgical times of < 3 weeks, ≥ 3-8 weeks, and > 8 weeks since the last bleeding ictus were observed in 23 (37.7%), 24 (39.3%), and 14 (23.0%) patients, respectively. The mean modified Rankin scale (mRS) score evaluated on admission was 4.2. With a mean follow-up of 39.8 months, 39 patients (63.9%) had a favorable outcome (mRS ≤ 2), and the mean mRS score was 2.3. The logistic regression analysis identified age, having disrupted consciousness and/or respiration, and time to surgery from last hemorrhage as significant predictors of long-term outcome. In particular, patients with surgery performed during the acute period (< 3 weeks, P = 0.06) or chronic period (> 8 weeks, P = 0.01) tended to have poor outcomes when compared with those with surgery during the subacute period (≥ 3-8 weeks). Favorable neurological outcomes can be achieved in patients who were surgically treated after a severe hemorrhagic ictus from brainstem CMs, and operation during subacute hemorrhage (≥ 3-8 weeks) could benefit these patients.

A rupture risk analysis of cerebral cavernous malformation associated with developmental venous anomaly using susceptibility-weighted imaging

PURPOSE

To search for the risk factors closely related to cerebral cavernous malformation associated with developmental venous anomaly (CCM-DVA) lesions rupture, laying foundations for the development of reasonable individual treatment plans for patients.

METHODS

In this retrospective study, we collected CCM-DVA patients who met the inclusion criteria in our outpatient department from 2014 to 2017, MRI scans were performed including susceptibility-weighted imaging (SWI) and contrast-enhanced imaging, characteristics and basic clinical information were collected then statistically analyzed, CCM-DVA lesions were divided into 3 types according to the location and quantitative relationship between CCM and DVA.

RESULTS

A total number of 319 adult patients were identified with 41.2±11.9 years on average, though univariate and multivariate regression analysis, ruptured presentations were more common in patients with prior hemorrhage (p=0.003), type III CCM-DVA lesions (p=0.001), lesions volume>1 cm³ (p<0.001), infratentorial lesions especially located in midbrain (p=0.019), pontine (p=0.007), medulla (p=0.015). Caplan-Meier curve shows a lower Hemorrhage-free survival rate on patients with type III CCM-DVA lesions (log-rank, p=0.0222), functional area lesions (log-rank, p<0.001), lesions volume>1 cm³ (log-rank, p<0.001), infratentorial lesions (log-rank, p=0.0002).

CONCLUSION

The classification based on the relationship between CCM and DVA may be meaningful to predict the risk of lesion rupture and CCM lesions next to DVA distal branches showed a higher risk of rupture.

Metabolic Changes of Brain Developmental Venous Anomalies on 18F-FDG-PET

RATIONALE AND OBJECTIVES

To determine the metabolic effects of developmental venous anomalies (DVAs) and to correlate those effects with conventional magnetic resonance imaging (MRI) findings.

MATERIALS AND METHODS

We conducted a retrospective review of MRI and brain 18F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) examinations in subjects with DVAs. Conventional MRI was used to determine DVA number, location, size, and associated parenchymal findings such as atrophy, hemorrhage, cavernoma, capillary telangiectasia, cortical dysplasia/polymicrogyria, and white matter signal abnormality. Qualitative and quantitative measures of relative metabolism in the drainage territory of the DVA were measured on ¹⁸F-FDG-PET.

RESULTS

Fifty-four subjects with 57 DVAs were included in the analysis. 38% were associated with qualitative and quantitative metabolic abnormalities on ¹⁸F-FDG-PET, with decreased metabolism in the parenchyma surrounding all but one of these DVAs. DVAs draining gray matter were significantly more likely to be hypometabolic than those draining only white matter, suggesting that the metabolic effects of DVAs may be underestimated on ¹⁸F-FDG-PET.

CONCLUSION

Altered metabolism is seen in the drainage territory of a significant proportion of DVAs, suggesting that these anomalies are vascular lesions with abnormal physiologic features.

Infratentorial Developmental Venous Abnormalities and Inflammation Increase Odds of Sporadic Cavernous Malformation

GOAL

Sporadic brain cavernous malformations commonly correlate with developmental venous anomalies; however, developmental venous anomalies may exist without cavernous malformations. Infratentorial location and specific angioarchitectural features of the developmental venous anomaly increase the odds of a concomitant malformation. Animal data also suggest chronic inflammatory disease, oxidative stress, and angiogenesis promote cavernous malformation development. We sought to determine potential clinical and radiologic factors promoting development of sporadic cavernous malformations.

METHODS

One hundred and forty-five patients with sporadic, nonradiation-induced brain cavernous malformations (63 with radiologic-apparent and 82 with radiologic-occult developmental venous anomalies) were compared to developmental venous anomaly controls without associated malformation. Data collection included demographic information, comorbidities, medications at diagnosis, and location of the developmental venous anomaly and/or malformation. Logistic regression with likelihood ratios, odds ratios and 95% confidence intervals were calculated comparing malformation cases with controls. A similar analysis compared malformations with radiologic-apparent anomalies to controls.

RESULTS

Compared to controls, cases were more likely to have had a major infectious illness (10.3% versus 2.3%; P = .0003 and/or chronic inflammatory disease (31.7% versus 21.3%; P = .0184) prior to diagnostic magnetic resonance imaging. Infratentorial location was more common in cavernous malformation cases (31.7% versus 15.7% controls; P ≤ .0001) with similar findings in cavernous malformation with radiologic-apparent developmental venous anomalies versus controls.

CONCLUSIONS

Infratentorial developmental venous anomalies location, major infectious illness, and chronic inflammatory disorders increase the odds of sporadic cavernous malformation formation. Inflammation may promote local thrombosis of developmental venous anomalies, trigger angiogenic response through increased vascular permeability, or promote cavernous malformation through Toll-like receptor 4.

Coexistent Cerebral Cavernous Malformation and Developmental Venous Anomaly: Does an Aggressive Natural History Always Call for Surgical Intervention?

Coexistence of cerebral cavernous malformations (CMs) and developmental venous anomaly (DVA) represents the most common form of mixed intracranial vascular malformations. Existing literature supports not only a possible causative role of DVA for de novo CMs but also a potentially detrimental effect on an associated CM, increasing the chances of hemorrhagic complications and growth in the latter. A 52-year-old gentleman presented to us with a 17-year long history of simple motor seizures on the left faciobrachial region. On magnetic resonance imaging (MRI) of the head, a 1.5 cm × 1.5 cm CM without any evidence of recent hemorrhage was identified in the left high frontal premotor area. There was a linear enhancement in the adjoining superior frontal sulcus on contrast MRI. On intra-arterial angiogram, this hyperintensity was confirmed to be a venous channel draining into the superior sagittal sinus. Thus, a diagnosis of cavernoma associated with a DVA was made. The patient was advised conservative treatment and he was doing well at follow-up. Unless diligently looked for, DVA associated with CM may be easily missed. The coexistence has pathophysiological and management implications. Despite the reported aggressive natural history, there is a scope for conservative treatment for these complex vascular malformations.

Timing of Surgery and Surgical Strategies in Symptomatic Brainstem Cavernomas: Review of the Literature

Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.

Long-Term Outcome of Gamma Knife Radiosurgery for Brain Cavernoma: Factors Associated with Subsequent De Novo Cavernoma Formation

BACKGROUND

We aimed to evaluate the factors associated with de novo brain cavernoma formations after patients underwent gamma knife radiosurgery (GKRS) and confirmed whether developmental venous anomaly (DVA) presented with a cavernoma and whether the cavernoma was included in the GKRS target location.

METHODS

From January 2003 to December 2008, 95 patients underwent radiosurgery for brain cavernoma at our institution. Of these, 15 with multiple cavernomas related to familial cavernoma or with a history of surgical treatment for cavernoma were excluded. A total of 80 patients (44 men and 36 women; average age, 39.4 years) with sporadic cavernoma were retrospectively analyzed by considering the patient characteristics, including sex, age, target volume, radiation dose, clinical symptoms, cavernoma location, radiosurgery complications, and morphology of DVA.

RESULTS

The average target volume, mean radiation dose, and mean target percentage were 1019.2 mm³, 13.7 Gy, and 51.1%, respectively. Nineteen patients showed cavernomas associated with DVA; of these, de novo cavernoma formations were noticed in 4 patients at a median of 49.5 months after undergoing GKRS. All de novo cavernomas were related to the presence of DVA and were located near the brainstem or cerebral peduncle. De novo cavernomas occurred when DVAs were not included in the GKRS-target location.

CONCLUSIONS

All de novo cavernomas were located near the brainstem or cerebral peduncle, and they occurred in the presence of DVAs. The presence of DVA in the radiosurgery target location might be potentially an important factor associated with de novo cavernoma formation.

Clinical Management of Cavernous Malformations

PURPOSE OF REVIEW

This study aims to review the current epidemiology and clinical management of patients with cavernous malformations (CM).

RECENT FINDINGS

Hemorrhage is the most feared complication and leads to morbidity in patients with CM. Multiple studies including three meta-analyses have provided useful estimates of hemorrhage risk, but have failed to identify a modifiable risk factor for prevention of cavernous malformation related hemorrhage. In treating the CM itself, surgical risk is weighed against the natural history. However, accumulating knowledge regarding the roles of CCM 1, 2, and 3 genes has led to the discovery of potential therapeutic targets. The risk of future hemorrhage in patients with CM is highest in those who have had previously clinical hemorrhages. Estimated risks are helpful in counseling patients and comparing to the risk of surgery. Future clinical trials of candidate medications are likely to target those patients with prior clinical hemorrhage in whom the surgical risk is deemed high.

Prevalence of cerebral cavernous malformations associated with developmental venous anomalies increases with age

BACKGROUND AND PURPOSE

To test the hypothesis that the prevalence of cerebral cavernous malformation (CCM) associated with developmental venous anomalies (DVAs) increases with age, we studied the age-related prevalence of DVA-associated CCM among patients with DVAs.

MATERIALS AND METHODS

Patients with DVAs on contrast-enhanced MRI exams performed over a 2-year period were included in this study. A single neuroradiologist reviewed all imaging exams for the presence of CCMs. Baseline demographic data collected included age, gender, presence of CNS neoplasm, history of cranial radiation, and history of seizure. Patients were divided into age groups based on decade of life. Cochran-Armitage trend tests were performed to determine if increasing age was associated with CCM prevalence.

RESULTS

A total of 1689 patients with DVAs identified on contrast-enhanced MRI were included. Of these patients, 116 (6.9%) had a cavernous malformation associated with the DVA. There was a significant positive association between age and the prevalence of DVA-associated CCM (P = 0.002). The prevalence of DVA-associated CCM was 0.8% for the 0-10 age group, 1.6% for the 11-20 age group, 7.5% for the 21-30 age group, 9.5% for the 31-40 age group, 6.1% for the 41-50 age group, 6.3% for the 51-60 age group, 7.4% for the 61-70 age group, and 11.6% for the >70 age group (P < .0001).

CONCLUSIONS

Our study demonstrated an age-related increase in prevalence of DVA-associated cavernous malformations among patients with DVAs. These findings suggest that DVA-associated cavernous malformations are acquired lesions.

[Cavernomas of the central nervous system : Observational study of 111 patients]

PURPOSE

The prevalence of cavernomas (cavernous hemangioma) is 0.1-0.7%. Cavernomas are often found as an incidental finding within the framework of magnetic resonance imaging (MRI) examinations in mainly young and healthy patients. In the literature, the reported risk of hemorrhage varies greatly and is sometimes higher than that of aneurysms, which is surprising given that cavernomas are part of the low blood pressure system. After the diagnosis the medical practitioner and the patient have to decide on the further therapy, either surgical removal or the strategy of watchful waiting (conservative treatment). The aim of our study was to determine the frequency of bleeding of cavernomas and the consequences and to determine the satisfaction of patients with treatment. All these aspects should make the therapeutic decision easier for medical practitioners.

MATERIAL AND METHODS

The study included all patients who were treated in the military hospital in Ulm during the period 2002-2012 and with the diagnosis of one or more cavernomas of the central nervous system (CNS) detected by MRI. This resulted in a total number of 111 patients. We recorded the epidemiological data and analyzed all cavernomas with respect to the location, size, treatment, side effects, etc. Furthermore, all included patients were sent a comprehensive questionnaire about symptoms, course of the disease and the quality of life. The response rate was 38%. All the collected data were analyzed with respect to the various aspects.

RESULTS

Depending on the definition of a bleeding event of a cavernoma and selection of the observational period, the probability of a hemorrhage risk ranged from 1.3% to 5.9% per patient year. This relatively high proportion is, however, put into perspective by the mostly mild consequences of a bleeding event. Many cavernomas, which were detected as an incidental finding showed signs of previous bleeding but the patients remained free of symptoms. Additionally, there was no patient in this collective who suffered serious consequences due to a bleeding event. Of the patients with temporal cavernomas 45% had symptomatic epilepsy. The results of the patient survey were heterogeneous. Some patients stated that in retrospect they would not choose surgical treatment again.

CONCLUSION

As a result of our findings we think it is important to critically look at the indications for surgical removal of cavernomas and special attention must be paid to informed consent of the patient. The frequent appearance of temporal cavernomas and their propensity to epileptic seizures is an essential aspect, which certainly influences the therapeutic decision. Although cavernomas are a venous malformation in the low blood pressure system, the determined frequency of hemorrhage was 5.9%, which was higher than expected but which is confirmed by other studies. Reports on severe sequelae of cavernoma bleeding are also rare in the literature, which relativizes the resulting danger of the relatively high probability of hemorrhage.

Management of Unruptured Intracranial Aneurysms and Cerebrovascular Malformations

PURPOSE OF REVIEW

Unruptured intracranial aneurysms and vascular malformations are detected more frequently because of the increased use and availability of brain imaging. Management of these entities requires knowledge of which patients are at high risk for hemorrhage and what treatment options are available. This article summarizes the epidemiology, natural history, and management strategies for unruptured intracranial aneurysms, arteriovenous malformations, cavernous malformations, developmental venous anomalies, and capillary telangiectasias.

RECENT FINDINGS

Pooled cohort studies and meta-analyses have improved the ability to predict hemorrhage for each vascular abnormality. Scores and tools have been developed to aid the practitioner in predicting hemorrhage risk for unruptured intracranial aneurysms. Advances in endovascular techniques for unruptured intracranial aneurysms have improved the ability to treat difficult wide-necked aneurysms.

SUMMARY

Unruptured intracranial aneurysms are a common incidental finding. The PHASES (population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, site of aneurysm) score and Unruptured Intracranial Aneurysm Treatment Score may be useful tools for predicting natural history and treatment recommendations. The overall risk of hemorrhage for both arteriovenous malformations and cavernous malformations is about 2% to 4% per year. With both of these entities, prior hemorrhage predicts future hemorrhage. In addition, other select patient and radiologic factors influence risk of hemorrhage. The risk of future hemorrhage should be compared to the risk of treatment. Developmental venous anomalies and capillary telangiectasias are largely benign entities and rarely symptomatic.

Cavernous Malformation Associated With Arterialized Developmental Venous Anomaly: A Case Report

BACKGROUND AND IMPORTANCE: Formation of cavernous malformations (CMs) has been recognized to be associated with developmental venous anomaly (DVA) by many authors. Hemodynamic stress due to venous outflow restriction could be hypothesized as a cause. On the other hand, a rare subgroup of DVA with an arterial component has been reported as likely to hemorrhage or be symptomatic. Cases of arterialized DVAs reported previously have not been associated with the presence of CM.

CLINICAL PRESENTATION: We present herein a case report of arterialized DVA in the brainstem with repeated cerebellar hemorrhage. The 49-year-old patient was treated with surgical evacuation of hematoma. A surgical specimen from the hematoma cavity demonstrated CMs on histological examination.

CONCLUSION: To the best of our knowledge, this represents the first report of CM associated with an arterialized DVA. In addition to venous congestion due to outflow obstruction, bleeding from the arterial component of the DVA might be considered as a cause of CM formation.

Natural history of spinal cavernous malformations

Spinal cavernous malformations are intramedullary vascular lesions. They have low pressure and flow, so they may take many years to present with clinical symptoms. Because of their relatively benign nature, surgical intervention is not always indicated. An understanding of the natural history of cavernous malformations helps make decisions about when and if to intervene. In patients who do not have surgery, 88.7% have stable or improved neurologic function, whereas 89.3% have these outcomes in the surgical group. Of note, 51.5% of patients were found to improve in the surgical group, compared to 30.2% in the nonsurgical group. Characteristics that correlated with better neurologic outcome were: resection within 3 months of the onset of symptoms, gross total resection, presentation with motor symptoms, and an acute course. Sensory symptoms correlated with worse outcome. Given the natural history of spinal cavernous malformations, surgery may be considered for symptomatic patients, when general medical health and lesion location permit safe resection. The severity of symptoms must also be considered, as the natural history of the disease can be benign.

Pathology of cavernous malformations

Cavernous malformations (CMs) are low-pressure angiographically occult lesions, composed of blood-filled sinusoidal locules known as "caverns." Although these lesions were once believed to be congenital in nature, there is compelling evidence to support de novo formation of CMs as well. They can occur as sporadic lesions or be inherited in an autosomal-dominant phenotype in familial forms of the disease. The pathophysiology of CMs is commonly believed to be due to abnormal vascular pathology. Three genes, CCM1, CCM2, and CCM3, have been extensively studied for their role in vascular pathology, resulting in abnormal angiogenesis and compromising the structural integrity of vessel endothelial cell. The expression of growth factors has been researched to gain insight into the dynamic behavior of CM lesions. Gross and microscopic images are utilized in this chapter to illustrate the pathologic findings of these lesions. Ultrastructural analysis demonstrates the aberrations in CM endothelial cells and structural integrity that may provide better understanding into how and why these lesions have a propensity to hemorrhage.

The Management of Symptomatic Cerebral Developmental Venous Anomalies: A Clinical Experience of 43 Cases

Background

Developmental venous anomalies (DVAs) are rare vascular diseases becoming more frequently diagnosed. Most patients with DVAs have no clinical symptoms with the exception of a few patients with epilepsy, intracranial hemorrhage, or neuro-function deficit. There is still controversy with respect to treatment strategies for symptomatic DVAs.

Material/Methods

Forty-three cases of symptomatic DVAs from January 2006 to October 2015 were retrospectively reviewed and the imaging characteristics of DVAs by CT, MRI, and DSA and the treatment modalities for DVAs were studied.

Results

Typical imaging characteristics of symptomatic DVAs were wedge or umbrella-shaped collections of dilated medullary veins converging in an enlarged subependymal or transcortical collecting vein, draining to the superficial or deep vein system. Based on location and draining vein features, symptomatic DVAs were tentatively classified into six different subtypes. Of the 43 cases, 19 were treated by surgical methods and 24 were treated conservatively.

Conclusions

We concluded that the rate of accompanying abnormalities in cases of symptomatic DVAs was high. Intracerebral hemorrhage was usually attributed to associated CMs or AVMs. The associated lesions and the branches responsible for bleeding could be resected while preserving the collecting vein as far as possible.

The relation between angioarchitectural factors of developmental venous anomaly and concomitant sporadic cavernous malformation

Background

Past studies found that cerebral developmental venous anomaly (DVA) is often concurrent with cavernous malformation (CM). But the reason of the concurrency remains unknown. The purpose of this study was to confirm whether angioarchitectural factors relate to the concurrence and which angioarchitectural factors can induce the concurrency.

Methods

DVA cases were selected from the records of the same 3.0 T MR. The DVA cases was divided into two group which are DVA group and DVA concurrent with CM group. 8 angioarchitectural factors of the DVAs were selected and measured. Statistical analysis was performed by the Pearson chi-square statistic,analysis of variance (ANOVA) and multi-factor logistic regression analysis.

Results

Five hundred three DVA lesions were found and 76 CM lesions coexisting with DVA. In the single factor analysis, all the 8 angioarchitectural factors of DVA were related to the concurrency. In the multivariate analysis, 6 angioarchitectural factors. Result of multi-factor logistic regression analysis is Logit(P) = -4.858-0.932(Location) + 1.616(Direction) + 1.757(Torsion) + 0.237(Number) + 2.119(Stenosis rate of medullary vein)-0.015(Angle), goodness of fit is 90.1 %.

Conclusions

The angioarchitectural factors of DVA are related to the concurrency of DVA and CM. 6 angioarchitectural factors may induce the concurrency.

Quantitative Analysis of Metabolic Abnormality Associated with Brain Developmental Venous Anomalies

Background and Purpose: Abnormal hypometabolism is common in the brain parenchyma surrounding developmental venous anomalies (DVAs), although the degree of DVA-associated hypometabolism (DVAAh) has not been quantitatively analyzed. In this study, we demonstrate a simple method for the measurement of DVAAh and test the hypothesis that DVAs are associated with a quantifiable decrement in metabolic activity.

Materials and Methods: Measurements of DVAAh using ratios of standardized uptake values (SUVs) and comparison to a normal database were performed on a cohort of 25 patients (12 male, 13 female), 14 to 76 years old, with a total of 28 DVAs (20 with DVAAh, seven with isometabolic activity, and one with hypermetabolic activity).

Results: Qualitative classification of none, mild, moderate, and severe DVAAh corresponded to quantitative measurements of DVAAh of 1 ± 3%, 12 ± 7%, 18 ± 6%, and 37 ± 6%, respectively. A statistically significant linear correlation between DVAAh and age was observed (P = 0.003), with a 3% reduction in metabolic activity per decade. A statistically significant linear correlation between DVAAh and DVA size was observed (P = 0.01), with a 4% reduction in metabolic activity per each 1 cm in the longest dimension. The SUV_DVA-based measures of DVAAh correlated (P = 0.001) with measures derived from comparison with a standardized database.

Conclusion: We present a simple method for the quantitative measurement of DVAAh using ratios of SUVs, and find that this quantitative analysis is consistent with a qualitative classification. We find that 54% (15 of 28) of DVAs are associated with a greater than 10% decrease in metabolic activity.

Use of Actuator-Driven Pulsed Water Jet in Brain and Spinal Cord Cavernous Malformations Resection

BACKGROUND

A piezo actuator-driven pulsed water jet (ADPJ) system is a novel surgical instrument that enables dissection of tissue without thermal damage. It can potentially resect intra-axial lesions while preserving neurological function.

OBJECTIVE

To report our first experience of applying an ADPJ system to brain and spinal cord cavernous malformations.

METHODS

Four patients (2 women and 2 men, mean age 44.5 years) with brain (n = 3) and spinal cord (n = 1) cavernous malformations were enrolled in the study. All surgeries were performed with the aid of the ADPJ system. Postoperative neurological function and radiological findings were evaluated.

RESULTS

The ADPJ system was useful in dissecting boundaries between the lesion and surrounding brain/spinal cord tissues. The pulsed water jet provided a clear surgical view and helped surgeons follow the margins. Water jet dissection peeled off the brain and spinal cord tissues from the lesion wall. Surrounding gliotic tissue was preserved. As a consequence, the cavernous malformations were successfully removed. Postoperative magnetic resonance imaging confirmed total removal of lesions in all cases. Preoperative neurological symptoms completely resolved in 2 patients. The others experienced partial recovery. No patients developed new postoperative neurological deficits; facial palsy temporarily worsened in 1 patient who underwent a suprafacial colliculus approach for the brainstem lesion.

CONCLUSION

The ADPJ provided a clear surgical field and enabled surgeons to dissect boundaries between lesions and surrounding brain and spinal cord gliotic tissue. The ADPJ system is a feasible option for cavernous malformation surgery, enabling successful tumor removal and preservation of neurological function.

The Associated Venous Anomalies Variant and Adjacent Brain Function on Iron Sensitive Image Indicate Surgical Risk of Cavernous Malformation

The cavernous malformations (CMs) associated with venous anomalies (VAs) are now being described with increasing frequency. Assessment of the associated VAs is overlooked in surgical management of the CM. The clinical profiles of CMs with VAs were reviewed to investigate the value of T₂*gradient echo (GRE)/susceptibility weighted imaging (SWI) in surgical risk evaluation. Twenty-six patients with symptomatic CMs associated with VAs between 2008 and 2013 were identified. Demographic, clinical, and radiological data were reviewed and functional outcomes were assessed using the modified Rankin Scale (mRS). The T₂*GRE/SWI could allow more accurate evaluation of the boundary and drainage vicinity of VAs than contrast-enhanced images (6 vs. 2 patients with VAs on the eloquent region). Patients with VAs adjacent to eloquent brain showed poorer outcomes than those who had VAs in non-eloquent areas (P = 0.005), while the CMs adjacent to eloquent brain did not correlated with poor outcomes (P = 0.15). Type I and III variants of VAs were also significantly associated with poor outcomes, compared with type II variant (P = 0.002). Careful evaluation of VAs variant type and the association between VAs and eloquent brain is helpful for the management of CMs associated with VAs. We recommend T₂*GRE/SWI in patients with CMs to assess the associated VAs. The evaluation of VA drainage vicinity on T₂*GRE/SWI would be more useful for designing treatment strategies and risk stratification.

Cerebellar cavernous malformation in pediatric patients: defining clinical, neuroimaging, and therapeutic characteristics

OBJECT

Cerebellar cavernous malformations (CCMs) have not been specifically described in the pediatric age group. Authors of this study, after considering the published literature, describe the characteristic clinical, radiological, and surgical features of CCM in children. METHOSDS: Patients younger than 18 years of age who were known to have CCM and had undergone surgery between 1992 and 2014 at the authors' institution were reviewed. Pediatric CCM cases reported in the literature (case reports and cases included in series on CMs in the pediatric age group) were also analyzed for specific features of this entity.

RESULTS

Four male patients and 1 female patient (2.5-14 years of age) with CCM presented acutely with severe headache followed by cerebellar dysfunction. In all patients, neuroimaging (cranial CT and MRI) demonstrated hemorrhagic cerebellar lesions with heterogeneous T1 and T2 signal intensities and hyperintense blooming on susceptibility-weighted imaging. The lesions reached large sizes exhibiting spherical, cystic, and often "pseudotumoral" morphology. In 3 patients, developmental venous anomalies (DVAs) were found. In 4 of the 5 patients, the CCMs and hematomas were totally removed. All patients had a clinically excellent functional outcome without surgical complication and with complete resolution of their presenting symptoms.

CONCLUSIONS

Cerebellar CMs occur in all pediatric age groups and display characteristic clinical and imaging features. In children, CCMs reach large sizes and can result in massive hemorrhage, often leading to a possible diagnosis of hemorrhage into a tumor. An associated DVA is quite common. Surgery is a safe and efficient treatment option with excellent outcomes in patients.

Surgical Treatment of Cerebellar Cavernous Malformations: A Single-Center Experience with 58 Cases

OBJECTIVE

The goal of this study was to discuss the surgical indications, surgical approaches, and prognostic factors of cerebellar cavernous malformation (CM).

METHODS

We retrospectively reviewed the presentation, surgery, and outcome of 58 consecutive patients who underwent resection of cerebellar CMs between 2009 and 2013 in our center.

RESULTS

The study population consisted of 31 males and 27 females, mean age 39.9 years. Fifty-eight patients experienced 67 symptomatic hemorrhages. The median diameter of all lesions was 2.2 ± 0.9 cm (range, 0.8-4.8 cm). The locations were classified into 3 groups: group 1, cerebellar hemisphere (17 cases, 29.3%); group 2, vermis (18 cases, 31.0%); and group 3, cerebellar peduncle (23 cases, 39.7%). Complete resection was achieved in all patients without surgical mortality. Postoperatively, 11 patients developed new surgical complications, including facial paralysis in 6 patients, ataxia in 2 patients, dizziness in 2 patients, and decrease in facial sensation in 1 patient. The mean modified Rankin Scale (mRS) at final follow-up was significantly improved compared with the preoperative score (0.5 ± 0.5 vs. 1.4 ± 0.7, P = 0.035). The symptoms and neurologic deficits improved in most patients. The lesion location was the only factor that predicted a worse outcome, and the mRS was significantly lower in group 3 than groups 1 and group 2 (P = 0.019).

CONCLUSIONS

Patients with cerebellar CMs usually achieve favorable outcomes via surgery. Cerebellar peduncle CMs cause significantly more neurologic deficits than other locations. A reasonable surgical approach and meticulous manipulation are necessary to prevent impairment of neurologic function.

Cavernous malformations of the central nervous system (CNS) in children: clinico-radiological features and management outcomes of 36 cases

BACKGROUND

Cavernous malformations (CMs) of the central nervous system (CNS) are angiographically occult vascular lesions that affect approximately 0.5 % of the general population, and one quarter of all CMs occurs in children.

METHODS

We retrospectively analyzed demographic, clinical, radiological, management, and follow-up data of 36 pediatric patients with CMs from a single institution.

RESULTS

The mean age of the children at first presentation and at operation was 8.7 and 9.6 years, respectively. However, a bimodal age distribution was found with peak under 4 years and above 12 years. Seizure was the most common single presenting symptom (38.9 %), and 61.1 % of patients had at least one seizure before the admission. Focal neurological deficits (410.7 %), intracranial hypertension (27.8 %), and headache (2.8 %) were the other manifestations. Acute/subacute hemorrhage was evident at presentation in 63.9 %. The patients under 6 years of age were found to have significantly more giant cavernomas (69 vs 20 %; p = 0.011), and more overt hemorrhages (81 vs 47 %; p = 0.065) at diagnosis than those patients above 12 years. Surgery was performed in 31 patients (32 CMs), with 26 total and 6 incomplete resections. Mean follow-up duration was 6.9 ± 4.1 years. Of all patients, 63.8 % had excellent and 30.5 % had good clinical outcomes, and also 90.9 % of the epileptic patients were seizure-free (Engel Class I) at the last follow-up.

CONCLUSIONS

Younger children tend to harbor larger CMs and present with hemorrhage more frequently than older ones. Microsurgical resection should be the treatment of choice in symptomatic and accessible CMs.

Co-occurrence of a cerebral cavernous malformation and an orbital cavernous hemangioma in a patient with seizures and visual symptoms: Rare crossroads for vascular malformations

Background:

Cerebral cavernous malformations (CCMs) are angiographically occult vascular malformations of the central nervous system. As a result of hemorrhage and mass effect, patients may present with focal neurologic deficits, seizures, and other symptoms necessitating treatment. Once symptomatic, most often from hemorrhage, CCMs are treated with microsurgical resection. Orbital cavernous hemangiomas (OCHs) are similar but distinct vascular malformations that present within the orbital cavity. Even though CCMs and OCHs are both marked by dilated endothelial-lined vascular channels, they are infrequently seen in the same patient.

Case Description:

We provide a brief overview of the two related pathologies in the context of a patient presenting to our care with concomitant lesions, which were both resected in full without complication.

Conclusion:

This is the first known report that describes a case of concomitant CCM and OCH and explores the origins of two pathologies that are rarely encountered together in neurosurgical practice. Recognition of disparate symptomatologies is important for properly managing these patients.

Brain parenchymal signal abnormalities associated with developmental venous anomalies in children and young adults

BACKGROUND AND PURPOSE

Abnormal signal in the drainage territory of developmental venous anomalies has been well described in adults but has been incompletely investigated in children. This study was performed to evaluate the prevalence of brain parenchymal abnormalities subjacent to developmental venous anomalies in children and young adults, correlating with subject age and developmental venous anomaly morphology and location.

MATERIALS AND METHODS

Two hundred eighty-five patients with developmental venous anomalies identified on brain MR imaging with contrast, performed from November 2008 through November 2012, composed the study group. Data were collected for the following explanatory variables: subject demographics, developmental venous anomaly location, morphology, and associated parenchymal abnormalities. Associations between these variables and the presence of parenchymal signal abnormalities (response variable) were then determined.

RESULTS

Of the 285 subjects identified, 172 met inclusion criteria, and among these subjects, 193 developmental venous anomalies were identified. Twenty-six (13.5%) of the 193 developmental venous anomalies had associated signal-intensity abnormalities in their drainage territory. After excluding developmental venous anomalies with coexisting cavernous malformations, we obtained an adjusted prevalence of 21/181 (11.6%) for associated signal-intensity abnormalities in developmental venous anomalies. Signal-intensity abnormalities were independently associated with younger subject age, cavernous malformations, parenchymal atrophy, and deep venous drainage of developmental venous anomalies.

CONCLUSIONS

Signal-intensity abnormalities detectable by standard clinical MR images were identified in 11.6% of consecutively identified developmental venous anomalies. Signal abnormalities are more common in developmental venous anomalies with deep venous drainage, associated cavernous malformation and parenchymal atrophy, and younger subject age. The pathophysiology of these signal-intensity abnormalities remains unclear but may represent effects of delayed myelination and/or alterations in venous flow within the developmental venous anomaly drainage territory.

Diffusion and perfusion MRI findings of the signal-intensity abnormalities of brain associated with developmental venous anomaly

BACKGROUND AND PURPOSE

Developmental venous anomalies are the most common intracranial vascular malformation. Increased signal-intensity on T2-FLAIR images in the areas drained by developmental venous anomalies are encountered occasionally on brain imaging studies. We evaluated diffusion and perfusion MR imaging findings of the abnormally high signal intensity associated with developmental venous anomalies to describe their pathophysiologic nature.

MATERIALS AND METHODS

We retrospectively reviewed imaging findings of 34 subjects with signal-intensity abnormalities associated with developmental venous anomalies. All subjects underwent brain MR imaging with contrast and diffusion and perfusion MR imaging. Regions of interest were placed covering abnormally high signal intensity around developmental venous anomalies on fluid-attenuated inversion recovery imaging, and the same ROIs were drawn on the corresponding sections of the diffusion and perfusion MR imaging. We measured the apparent diffusion coefficient, relative cerebral blood volume, relative mean transit time, and time-to-peak of the signal-intensity abnormalities around developmental venous anomalies and compared them with the contralateral normal white matter. The Mann-Whitney U test was used for statistical analysis.

RESULTS

The means of ADC, relative cerebral blood volume, relative mean transit time, and TTP of signal-intensity abnormalities around developmental venous anomalies were calculated as follows: 0.98 ± 0.13 10(-3)mm(2)/s, 195.67 ± 102.18 mL/100 g, 16.74 ± 7.38 seconds, and 11.65 ± 7.49 seconds, respectively. The values of normal WM were as follows: 0.74 ± 0.08 10(-3)mm(2)/s for ADC, 48.53 ± 22.85 mL/100 g for relative cerebral blood volume, 12.12 ± 4.27 seconds for relative mean transit time, and 8.35 ± 3.89 seconds for TTP. All values of ADC, relative cerebral blood volume, relative mean transit time, and TTP in the signal-intensity abnormalities around developmental venous anomalies were statistically higher than those of normal WM (All P < .001, respectively).

CONCLUSIONS

The diffusion and perfusion MR imaging findings of the signal-intensity abnormalities associated with developmental venous anomaly suggest that the nature of the lesion is vasogenic edema with congestion and delayed perfusion.

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.

Cerebellar cavernous malformations with and without associated developmental venous anomalies

BACKGROUND

The clinical profiles of cerebellar cavernous malformations (CCMs) with and without associated developmental venous anomalies (DVAs) are not well known. The aims of this study were to analyze the clinical and radiological characteristics of CCMs and to assess the various therapeutic strategies.

METHODS

A consecutive series of 41 patients with identified CCMs were retrospectively reviewed. Of these, 11 patients (26.8%) were found to have associated DVAs. We compared the clinical profile of the two groups of patients (CCMs with and without DVAs). The CCMs with DVAs cases underwent radical resection of the CCMs, and the distal radicles of the DVAs that directly drain from the CCMs were coagulated and dissected at the length of the CCMs.

RESULTS

There were no statistically significant differences between the two groups with regard to age, sex, location and size of lesions, multiplicity, and surgical prognosis. The patients with CCMs with DVAs did not experience any brain swelling or hemorrhagic tendency intraoperatively. The postoperative course was uneventful for all of the 36 surgical patients with the exception of two of the patients with CCMs with associated DVAs, who suffered from serious cerebellar edema, and one of these two patients underwent an emergency suboccipital decompression craniotomy. With the exception of three patients who were lost to follow-up (mean, 22.3 months), all of the CCMs patients exhibited good long-term prognosis (modified Rankin scale values of 0-2) and no reoccurrence.

CONCLUSIONS

It is not rare that associated DVAs occur in CCMs. The total removal of the CCM combined with the coagulation and dissection of the distal radicles of DVA at the length of the associated CCM may result in good long-term prognosis in patients.

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.