Cerebral venous angioma of the pons complicated by nonhemorrhagic infarction

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

BACKGROUND

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

SUMMARY

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

CONCLUSION

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

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

BACKGROUND

Developmental venous anomalies (DVAs) are variations of normal transmedullary veins draining white and gray matter. In the vast majority of cases, DVAs are diagnosed incidentally and should be considered as benign entities. In extremely rare circumstances, DVAs may become symptomatic due to mechanical or flow-related etiologies. Thrombosis of the collector vein of a DVA is a rare type of a flow-related complication with only 29 cases reported in the literature, the majority of which are supratentorial. Infratentorial thrombosed DVAs are thus extremely rare and the few cases reported have typically caused symptoms due to venous ischemic infarctions.

SUMMARY

We report a case of an infratentorial DVA with a thrombosed drainage vein in a patient with nonhemorrhagic, noninfarcted venous congestive edema, which was successfully treated with high-dose glucocorticoids and short-term anticoagulation. We review the pertinent venous anatomy of the posterior fossa as well as the literature of symptomatic infratentorial thrombosed DVAs.

KEY MESSAGE

The presented case of an infratentorial thrombosed DVA with cerebellar and pontine venous congestive edema is extremely rare. A working knowledge of posterior fossa venous anatomy and possible pathomechanisms responsible for the rarely symptomatic lesion will aid in the timely and efficacious treatment of such lesions.

Multimodal Imaging Follow-up of a Thrombosed Developmental Venous Anomaly: CT, CT Angiography and Digital Subtraction Angiography

We report a rare case of thrombosed developmental venous anomaly (DVA) in a 31-year old male with hemorrhagic cerebral venous infarction at the initial clinical presentation. In this case, sequential CT, CT angiography and digital subtraction angiography demonstrated thrombotic obstruction of the venous drainage from DVA, its progressive recanalization and temporal evolution of the affected brain parenchyma. The relevant previous literatures were reviewed and summarized.

[Venous angioma with associated cerebellar haemorrhage]

Venous angiomas are a developmental anomaly in which embryonic venous drainage is still present into adulthood. They are usually asymptomatic and benign course but they can cause seizures and less commonly bleeding, usually associated to cavernous malformation. Normally, treatment is not necessary although bleeding, severe clinical and lesions in which it is possible a favourable approach, we can consider treatment. We show a case of a 11 years old boy with acute decrease level of consciousness. We observed hematoma in the right cerebellar hemisphere with radial tubular structures consistent with developmental venous anomaly. The hematoma was evacuated without a demonstrable other reason justifying the bleeding.

Cerebral developmental venous anomalies

INTRODUCTION

Cerebral developmental venous anomalies (DVAs) are the most frequently encountered cerebral vascular malformation. As such, they are often observed incidentally during routine CT and MRI studies. Yet, what DVAs represent from a clinical perspective is frequently not common knowledge and DVAs, therefore, still generate uncertainty and concern amongst physicians. This article reviews our current understanding of developmental venous anomalies.

RESULTS

In the majority of cases, DVAs follow a benign clinical course. On rare occasions, DVAs become symptomatic generally due to an underlying associated vascular malformation such as cavernous malformations or thrombosis of the collecting vein. Rare forms of DVAs include arterialized DVAs and DVAs involved in the drainage of sinus pericranii, which warrant additional investigation by digital subtraction angiography. Cerebral abnormalities such as atrophy, white matter lesions and calcifications within the drainage territory of asymptomatic DVAs, are often identified on CT or MR imaging studies and likely represent secondary changes due to venous hypertension. There is increasing evidence that DVAs have a propensity for developing venous hypertension, which is thought to be the cause of associated cavernous malformations and parenchymal abnormalities.

CONCLUSIONS

DVAs represent variations of the normal cerebral venous angioarchitecture and by enlargement follow an uneventful clinical course. Complications can, however, occur and their management requires a thorough understanding of the nature of DVAs, including their frequent coexistence with other types of vascular malformation, and the existence of more complex but rare forms of presentation, such as the arterialized DVAs.

DEVELOPMENTAL VENOUS ANOMALIES

DEVELOPMENTAL VENOUS ANOMALIES (DVAs), formerly known as venous angiomas, have become the most frequently diagnosed intracranial vascular malformation. DVAs are currently considered congenital cerebrovascular anomalies with mature venous walls that lack arterial or capillary elements. They are composed of radially arranged medullary veins, which converge in an enlarged transcortical or subependymal collector vein, and have characteristic appearances (caput medusae) on magnetic resonance imaging and angiography. DVAs were once thought to be rare lesions with substantial potential for intracerebral hemorrhage and considerable morbidity. The prevalence of incidental and asymptomatic DVAs has been more apparent since the advent of magnetic resonance imaging; recent cohort studies have challenged the once-held view of isolated DVAs as the cause of major neurological complications. The previously reported high incidence of intracerebral hemorrhage associated with DVAs is currently attributed to coexistent, angiographically occult cavernous malformations. Some patients may still have noteworthy neurological morbidity or die as a result of acute infarction or hemorrhage directly attributed to DVA thrombosis. DVAs can coexist with cavernous malformations and arteriovenous malformations. Such combination or transitional forms of malformations might suggest common pathways in pathogenesis. Recent data support a key role for DVAs in the pathogenesis of mixed vascular malformations.

Pathomechanisms of Symptomatic Developmental Venous Anomalies

Background and Purpose— Although it is generally accepted that developmental venous anomalies (DVAs) are benign vascular malformations, over the past years, we have seen patients with symptomatic DVAs. Therefore, we performed a retrospective study and a literature study to review how, when, and why DVAs can become clinically significant.

Methods— Charts and angiographic films of 17 patients with DVAs whose 18 vascular symptoms could be attributed to a DVA were selected from a neurovascular databank of our hospital. MRI had to be available to rule out any other associated disease. In the literature, 51 cases of well-documented symptomatic DVAs were found. Pathomechanisms were divided into mechanical and flow-related causes.

Results— Mechanical (obstructive or compressive) pathomechanisms accounted for 14 of 69 symptomatic patients resulting in hydrocephalus or nerve compression syndromes. Flow-related pathomechanisms (49 of 69 patients) could be subdivided into complications resulting from an increase of flow into the DVA (owing to an arteriovenous shunt using the DVA as the drainage route; n=19) or a decrease of outflow (n=26) or a remote shunt with increased venous pressure (n=4) leading to symptoms of venous congestion. In 6 cases, no specific pathomechanisms were detected.

Conclusions— Although DVAs should be considered benign, under rare circumstances, they can be symptomatic. DVAs, as extreme variations of normal venous drainage, may represent a more fragile venous drainage system that can be more easily affected by in- and outflow alterations. The integrity of the DVA needs to be preserved irrespective of the treatment that should be tailored to the specific pathomechanism.

Susceptibility weighted imaging: a new tool in magnetic resonance imaging of stroke

Susceptibility weighted imaging (SWI) is a magnetic resonance (MR) technique that is exquisitely sensitive to paramagnetic substances, such as deoxygenated blood, blood products, iron, and calcium. This sequence allows detection of haemorrhage as early as 6h and can reliably detect acute intracerebral parenchymal, as well as subarachnoid haemorrhage. It detects early haemorrhagic transformation within an infarct and provides insight into the cerebral haemodynamics following stroke. It helps in the diagnosis of cerebral venous thrombosis. It also has applications in the work-up of stroke patients. The sequence helps in detecting microbleeds in various conditions, such as vasculitis, cerebral autosomal dominant arteriopathy, subacute infarcts and leucoencephalopathy (CADASIL), amyloid angiopathy, and Binswanger's disease. The sequence also aids in the diagnosis of vascular malformations and perinatal cerebrovascular injuries. This review briefly illustrates the utility of this MR technique in various aspects of stroke diagnosis and management.

Brain parenchymal signal abnormalities associated with developmental venous anomalies: detailed MR imaging assessment

BACKGROUND AND PURPOSE

The occurrence of brain parenchymal signal-intensity changes within the drainage territory of developmental venous anomalies (DVAs) in the absence of cavernous malformations (CMs) has been incompletely assessed. This study was performed to evaluate the prevalence of brain parenchymal signal-intensity abnormalities subjacent to DVA, correlating with DVA morphology and location.

MATERIALS AND METHODS

One hundred sixty-four patients with brain MR imaging with contrast studies performed from July 2005 through June 2006 formed the study group. The examinations were reviewed and data were collected regarding the following: location, depth, size of draining vein, associated increased signal intensity on fluid-attenuated inversion recovery and T2-weighted images, associated CMs, and associated signal intensity on gradient recalled-echo sequences.

RESULTS

Of the 175 DVAs identified, 28 had associated signal-intensity abnormalities in the drainage territory. Seven of 28 DVAs with signal-intensity abnormalities were excluded because of significant adjacent white matter signal-intensity changes related to other pathology overlapping the drainage territory. Of the remaining DVAs imaged in this study, 21/168 (12.5%) had subjacent signal-intensity abnormalities. An adjusted prevalence rate of 9/115 (7.8%) was obtained by excluding patients with white matter disease more than minimal in degree. Periventricular location and older age were associated with DVA signal-intensity abnormality.

CONCLUSION

Signal-intensity abnormalities detectable by standard clinical MR images were identified in association with 12.5% of consecutively identified DVAs. Excluding patients with significant underlying white matter disease, we adjusted the prevalence to 7.8%. The etiology of the signal-intensity changes is unclear but may be related to edema, gliosis, or leukoaraiosis secondary to altered hemodynamics in the drainage area.

Infantile dural arteriovenous shunt draining into a developmental venous anomaly

SUMMARY

A three-year-old girl with an incidentally discovered infantile type of dural arteriovenous shunts (DAVs) along the superior sagittal sinus during investigation of a minor head trauma is presented. The DAVs drained into a developmental venous anomaly of the right cerebral hemisphere. In addition, there was a small cavernoma within the territory drained by the DVA. The patient underwent multiple transarterial embolizations to decrease the shunt flow and thus the constrained venous drainage of the DVA and right cerebral hemisphere. Pediatric dural arteriovenous shunts are a different entity from the adult type DAVs and should be managed according to the growth and development of the child. DVAs are extreme variations of the venous system with reduced flexibility to increased venous drainage. Regardless of the type of treatment employed, the DVA and its drainage pathway must be preserved.

Spontaneous Thrombosis of a Venous Malformation Leading to Intracerebral Hemorrhage -Case Report-

A 33-year-old man presented with consciousness disturbance (Glasgow Coma Scale score 7) and right hemiplegia after suffering headache persisting for 10 days. Head computed tomography revealed an irregular intracerebral hematoma in the left temporoparietal region, associated with a tubular high density area compatible with a thrombosed transcerebral vein in the left temporal lobe. The patient was free of coagulopathy. Craniectomy was performed to remove the intracerebral hematoma and venous thrombosis was confirmed. Postoperative cerebral angiography demonstrated extensive venous malformation in the left parietal and occipital lobes. Multiple transcerebral draining veins converged in the vein of Galen associated with a varix. Segmental narrowing of the straight sinus was suggestive of congestion in the venous anomaly. The patient showed progressive recovery following surgery, and was discharged with moderate aphasia, mild right hemiparesis, and right homonymous hemianopsia 1 month later. Venous malformations are usually silent, but occasionally become symptomatic due to thrombosis of the draining vein. The presence of stenosis in the draining route may lead to venous congestion, thrombus formation, and catastrophic hemorrhagic venous infarct.

Spontaneous isolated non-haemorrhagic thrombosis in a child with development venous anomaly: case report and review of the literature

INTRODUCTION

The natural history of developmental venous anomalies (DVAs) is said to be relatively benign.

CASE REPORT

We herein report the clinical case of a 9-year-old female child with sudden right hemiparesis. An ischaemic infarct secondary to an isolated spontaneous thrombosis of a DVA was diagnosed by brain magnetic resonance imaging, further confirmed by digital subtraction angiography.

CONCLUSION

Considering the therapeutic options, early diagnosis is mandatory.