Repeated intracerebral hemorrhage from developmental venous anomaly alone

Different Aspects on Clinical Presentation of Developmental Venous Anomalies: Are They as Benign as Known? A Single Center Experience

BACKGROUND

Cerebral developmental venous anomalies (DVAs) are frequently diagnosed incidentally owing to the advances in neuroimaging. They are regarded as clinically insignificant due to their supposed quiescent existence which the authors aimed to contradict in this paper.

AIM

In the aim of constituting a better understanding of clinical presentation of DVAs and making an estimation regarding the probability of resulting in a hemorrhage, the authors presented their experiences with a case series of DVAs.

METHODS

A retrospective analysis was carried out among patients who underwent brain MRI in a radiology department of a university between January of 2019 and January of 2020.

RESULTS

A total of 101 patients with DVA were extracted. 38 patients had isolated DVAs, while 63 patients had various accompanying cerebral pathologies, mostly cavernomas (39 patients) and AVMs (11 patients). The main complaints leading investigation were headache, dizziness, ataxia, nausea\vomiting, seizures and focal neurological deficits. 41 patients were truly symptomatic with indicative findings of seizures, neurological deficits or intracranial hemorrhages, and 12 of them had solitary DVAs. 22 patients presented with hemorrhages, and of them, 10 had only DVA, while the rest had some associated lesions, most often cavernoma. Of 22 patients with hemorrhage, 5 were operated, 5 were applied radiosurgery; while the rest were followed without any intervention.

CONCLUSION

Although the symptoms in patients with DVA are generally charged on other associated pathologies, the fact that isolated DVAs may occasionally be problematic in the range of minor symptoms and severe hemorrhage should not be underestimated.

Paediatric developmental venous anomalies (DVAs): how often do they bleed and where?

INTRODUCTION

Developmental venous anomalies (DVAs) are anomalies of venous drainage and considered a low-flow malformation. Studies evaluating natural history and risk factors for intracranial haemorrhage in the paediatric population are rare. We evaluate clinical and radiological features, risk factors and outcomes of paediatric DVAs.

METHODS

A retrospective study was conducted over a 10-year period between 2004 and 2014. Medical records, imaging and prospective databases were reviewed. Three-hundred-and-three radiological studies in total were evaluated.

RESULTS

Fifty-two children (20 boys and 32 girls [median age: 6 years] were identified with DVAs. Their age distribution was as follows: 1.9% neonates (< 1 month), 11.5% infants (1 month to 1 year), 30.8% 1-5 years, 30.8% 5-12 years and 25% 12-16 years. The majority (92.3%) presented with asymptomatic DVAs identified incidentally. Overall, anatomical distribution revealed predilection for frontal region (42.3%) with other common sites being posterior fossa (17.3%) and basal ganglia (13.5%). Temporal (11.5%), parietal (9.6%) and occipital (5.8%) were the remainder. Associated cavernous malformations (CMs) were present in 3/52 (5.8%), and no DVAs were associated with aneurysms or arteriovenous malformations (AVMs). Three patients had more than one DVA. There were three deaths unrelated to DVAs over median follow-up of 3.8 years. Four patients (7.7%) suffered DVA-related intracranial haemorrhage presenting with neurological deficits. The ages of the children with DVA-related haemorrhages were 21 days, 2 years and 6 months, 7 years and 1 month and 11 years and 7 months. Left-sided DVA haemorrhages predominated (3/4, 75%). The relative risk of a cerebellar DVA haemorrhage compared to its supratentorial counterpart was 5.35 (OR 6.8, 95% CI 0.8-58).

DISCUSSION

DVA-related haemorrhage is sevenfold greater in our paediatric cohort compared to adults and is significantly associated with cerebellar location and cavernous malformations. There were no haemorrhages over a median period of 3.8 years of prospective follow-up.

Value of susceptibility-weighted MR imaging (SWI) in the detection of developmental venous anomaly

Background

Developmental venous anomaly (DVA) is probably the most common anomaly of the intracranial vasculature. DVAs consist of multiple, radially oriented dilated medullary veins that converge into a transcerebral vein. Susceptibility-weighted imaging (SWI) is a high spatial resolution 3D gradient-echo MRI sequence with phase post-processing that accentuates the paramagnetic properties of blood products such as deoxyhemoglobin, intracellular methemoglobin, and hemosiderin. Its high sensitivity to hemorrhagic particles by means of susceptibility dephasing effects within the veins allow for the accurate detection, grading, and monitoring of brain venous anomalies. In this review, we evaluated the prevalence of the brain DVAs identified by SWI in many patients who had undergone magnetic resonance imaging (MRI) with contrast administration. All images were independently reviewed by two radiologists who were blinded to other MR imaging finding. It is hoped that as SWI becomes more widely available, it will provide additional diagnostic and prognostic information that will improve the care and outcome of patients with DVAs.

Results

A total of 29 DVAs were observed with its prevalence 2.8%. The DVA caputs had mostly deep localization in about 44.8% of our DVA cases. SWI proved excellent demonstration of DVAs with the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were significantly higher than the other non-contrast MR sequences. On SWI, DVA is delineated as a signal void lesion with the normal cerebral veins.

Conclusion

Susceptibility-weighted imaging (SWI) is valuable in the diagnosis of DVA and should be included in routine MR assessment of the brain.

Developmental venous anomaly presenting as a spontaneous intraparenchymal hematoma without thrombosis

INTRODUCTION

Developmental venous anomalies (DVAs) are cited as the most common cerebral vascular malformations. Still, intracerebral hematomas are rarely thought to be caused by DVAs. In this report, the authors present a unique case of a DVA that hemorrhaged spontaneously, rather than hemorrhaging into a venous infarction following DVA thrombosis as has been more commonly reported.

CLINICAL PRESENTATION

A 22-year-old previously healthy male presented to the emergency department with a severe headache, confusion, and progressive hemiparesis. A computed tomography (CT) scan demonstrated a spontaneous left parietal intraparenchymal hemorrhage (IPH), with intraventricular extension and acute hydrocephalus. CT angiography did not demonstrate an underlying vascular malformation. The patient was taken emergently to the operating room for a left parietal craniotomy for evacuation of the hematoma. Intraoperative pathology was consistent with a DVA Postoperative magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) did not demonstrate a mass lesion, ischemic stroke, or underlying vascular malformation. An MRI obtained three years previously for headaches was normal. A postoperative diagnostic cerebral angiogram was normal. An MRI/MRA performed six months postoperatively demonstrated two foci of abnormal vessels on susceptibility-weighted imaging (SWI), suggesting the presence of a venous vascular malformation. A diagnostic cerebral angiogram obtained six months postoperatively was again normal, including delayed imaging.

CONCLUSION

Few reports have cited DVA as the sole cause of intracerebral hemorrhage. While very rare, these reports suggest hemorrhagic conversion of a venous infarction secondary to a thrombosed DVA as a possible etiology, and several provide imaging consistent with this diagnosis. This case study demonstrates a unique presentation of a hemorrhagic DVA in the absence of thrombosis or stroke.

Hemorrhagic cerebrovascular disease

Primary or nontraumatic spontaneous intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes, and has a poor prognosis. ICH has a mortality rate of almost 50% when associated with intraventricular hemorrhage within the first month, and 80% rate of dependency at 6 months from onset. Neuroimaging is critical in identifying the underlying etiology and thus assisting in the important therapeutic decisions. There are several imaging modalities available in the workup of patients who present with ICH, including computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA). A review of the current imaging approach, as well as a differential diagnosis of etiologies and imaging manifestations of primary versus secondary intraparenchymal hemorrhage, is presented. Active bleeding occurs in the first hours after symptom onset, with early neurologic deterioration. Identifying those patients who are more likely to have hematoma expansion is an active area of research, and there are many ongoing therapeutic trials targeting this specific patient population at risk.

Developmental Venous Anomalies (DVA): What Are They Really?

Purpose: The aim of this paper is to analyse the pathophysiology of 3 DVA cases from our institution, review the literature and propose a classification of these lesions. Materials & Methods: The pathophysiology of DVAs were analysed with CT perfusion (CTP), 4 dimensional dynamic computed tomography angiography (4D CTA) and catheter digital subtraction angiography. Results: Symptomatic DVAs may be caused by associated lesions and compression of neural structures by the DVAs. The imbalance between the inflow and outflow of these lesions, including venous ischaemia, has also been postulated as a cause. Our analysis showed that increased cerebral blood flow (CBF) and cerebral blood volume (CBV) and decreased mean transit time (MTT) and time to peak (TTP) were found in DVAs with micro arteriovenous shunting. DVAs without shunting had raised MTT and TTP instead. Conclusion: We postulate that the arteriovenous shunting resulted in arterial steal and chronic hypoxia which could be a pathophysiological mechanism for symptomatic DVAs. CTP and 4D CTA are effective non invasive tools to study DVAs. A classification is proposed.