Microvascular decompression for developmental venous anomaly causing hemifacial spasm: illustrative case

BACKGROUND

Developmental venous anomaly (DVA) is a rare cause of hemifacial spasm (HFS). The treatment of HFS caused by a DVA varies in the literature and includes medication management, botulinum toxin injections, and microvascular decompression (MVD).

OBSERVATIONS

A 64-year-old woman presented with right-sided HFS. Preoperative magnetic resonance imaging showed a DVA in the right inferior pons, with an enlarged segment compressing the facial nerve at its root detachment point prior to drainage into the superior petrosal sinus. MVD was performed, and the facial nerve was decompressed without sacrifice of the vein. Immediately following the procedure, the patient had significantly reduced spasms. The patient became spasm-free 3 months after MVD and maintained spasm freedom for 3 months. Six months after MVD, the patient had a partial return of spasms. At 8 months, the patient continued to have reduced and intermittent spasms in the right orbicularis oculi muscle.

LESSONS

MVD for HFS caused by a DVA is a safe procedure and can be effective at reducing spasm frequency and severity.

Developmental Venous Anomaly Presenting as an Acute Stroke Mimic

Several mimics of acute ischemic stroke may complicate the decision to administer intravenous thrombolysis. Developmental venous anomalies (DVA) are fairly common variants of normal cerebral vasculature and may occasionally present with acute focal neurologic symptoms. We report a case of DVA presenting with the acute onset of focal neurologic deficits and focal hypodensities on the CT of the brain, resulting in a dilemma regarding whether to administer intravenous tissue-type plasminogen activator (IV tPA) for stroke thrombolysis. Recognition of subtle brain changes on the CT that were inconsistent with an acute ischemic stroke led to further imaging and a definitive diagnosis. Developmental venous anomalies should be considered in the differential diagnosis of acute ischemic stroke.

Conjoined Pathways: Unraveling the Coexistence of Developmental Venous Anomaly With Arteriovenous Malformation

Developmental venous anomalies (DVAs) are intracranial vascular malformations typically characterized by their benign nature, often obviating the need for radiological follow-up. These anomalies arise from variations in the standard drainage pattern. While previously deemed congenital, there has been ongoing debate about a developmental component contributing to their etiology. They frequently coexist with other cerebral venous malformations (CVM); however, their association with arteriovenous malformations (AVM) is exceedingly rare. Such mixed malformations pose a therapeutic challenge, necessitating meticulous consideration for appropriate treatment. We present a noteworthy case involving a patient with arteriovenous malformation along with dual developmental venous anomalies, one of which served as the draining vein for the AVM.

Epilepsy and cerebral developmental venous anomalies (DVAs): a systematic review

OBJECTIVE

Cerebral developmental venous anomalies (DVAs) are frequent and rarely symptomatic. When symptomatic, DVAs may present with seizures, however, little is known about the characteristics of DVA-related epilepsy. In this systematic review, we aim to describe the clinical and paraclinical features of patients with DVA-related epilepsy.

METHODS

This review was registered on PROSPERO (CRD42021218711). We searched the MEDLINE/PubMed and Scopus databases for case reports/series on patients with DVAs complicated by seizures. Studies reporting on patients with a potentially epileptogenic comorbid lesion close to their seizure focus were excluded. Descriptive statistical analyses were performed to synthetize patient characteristics. The methodological quality of each study was evaluated using a standardized appraisal tool.

RESULTS

In total, 66 patients were included from 39 articles. The frontal lobe was the most common location for DVAs. The superior sagittal sinus drained half of the DVAs. Seizures were inaugural in most cases, and the most common manifestations accompanying seizures were headaches. EEG was abnormal in 93% of cases, but only 26% had characteristic epileptic spikes. More than half the patients suffered a medical complication due to their DVA, with haemorrhage and thrombosis being the most common. Refractory seizures were encountered in 19% of individuals. At 12 months of follow-up, 75% of patients were seizure-free. Most included studies were at low risk of bias.

SIGNIFICANCE

Epilepsy can be a complication of DVAs; these DVAs are mostly frontal or parietal, draining via the superior sagittal sinus or the vein of Galen.

Developmental venous anomaly thrombosis in a patient with coronavirus disease 2019-associated hypercoagulability: illustrative case

BACKGROUND

Spontaneous thrombosis of a developmental venous abnormality (DVA) is a rare complication associated with hypercoagulability. The objective of this case report is to describe an association between DVA thrombosis and mild coronavirus disease 2019 (COVID-19) infection in a vaccinated patient.

OBSERVATIONS

A 28-year-old male with hypertension presented with severe headache and left-sided hemiparesis. Five weeks prior to presentation, the patient experienced mild respiratory symptoms and tested positive for COVID-19. Admission brain computed tomography (CT) showed a large right parieto-occipital intracerebral hemorrhage with surrounding edema. CT venography and catheter angiography showed a thrombosed DVA with associated venous infarction as the hemorrhage etiology. He was treated with decompressive hemicraniectomy, external ventricular drain placement, and systemic anticoagulation. The patient was functionally independent (modified Rankin Scale score, 2) at 4-month follow-up. Hypercoagulability work-up was unremarkable.

LESSONS

Delayed DVA thrombosis after the COVID-19 infectious period may represent an association between the infection and a protracted systemic viral-induced hypercoagulable state. The severity of COVID-19 symptomatology does not appear to correlate with risk of DVA thrombosis. Young patients with a recent history of COVID-19 infection who present with venous infarction should be evaluated for an underlying thrombosed DVA.

Cerebellar cavernous angioma associated with developmental venous anomaly presenting as a cerebellopontine angle neoplasm in CT scan

Association of developmental venous anomaly (DVA) and cavernous malformation (CM) of the posterior fossa is rare. If bleeding occurs, it must be assigned to the CM. Developmental venous anomalies, considered as normal vascular variation, are rarely symptomatic. Indeed, the CMs are true malformations and have a high bleeding potential.

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.

Dynamic Contrast-Enhanced MR Perfusion in Differentiation of Benign and Malignant Brain Lesions

Background- We aimed to differentiate Glioblastoma Multiforme (GBM) from benign lesions like Developmental Venous Anomaly (DVA) and Cavernous Malformation (CM) by Dynamic Contrast-Enhanced MR Perfusion (DCE-MRP) markers such as Ktrans, Ve, Kep, and IAUC. Method-We retrospectively evaluated 20 patients; 10 GBM as the malignant group, 5 CM and 5 DVA as the benign group. Ktrans, Kep, Ve, and IAUC parameters were measured by DCE-MRP, within the lesion, at perilesional nonenhancing white matter (PLWM) and at contralateral normal appearing white matter (CLWM). All benign and malignant lesions exhibited significantly increased Ktrans, Ve, and IAUC values compared to PLWM and CLWM (p < 0.001, p=0.006 and p<0.001). Result-Subtracted Kep values between lesion and PLWM were significantly different between the benign and malignant groups, as the malignant group exhibited higher subtracted Kep values (p 0.035). For the malignant group; Ktrans and IAUC values at the lesion were positively correlated (r 0.911), while Kep and Ve at CLWM were negatively and strongly correlated (r 0.798). For the benign group; Ktrans with Ve and Ktrans with IAUC lesion (r 0.708 and r 0.816 respectively), Ktrans and IAUC at PLWM (r 0.809), Ktrans and IAUC at CLWM(r 0.798) were strongly and positively correlated. Ktrans, Ve, and IAUC values can be used to demarcate the lesion in both groups. Conclusion- Ktrans strongly correlates with IAUC and they can be used instead of each other in both benign and malignant lesions. DCE-MRP cannot be used in the differentiation of malignant lesions from benign vascular lesions. However, subtracted Kep values can be used to differentiate GBM from benign vascular lesions.

Unique enlarging cavernous malformation secondary to abnormal arteriovenous shunting through an associated developmental venous anomaly

Cavernous malformations are angiographically occult vascular malformations. They are often associated with a developmental venous anomaly through poorly understood mechanisms. We present an unusual case of a gradually enlarging cavernous malformation associated with a developmental venous anomaly with arteriovenous shunting, suggesting venous hypertension or reflux as a potential cause of progressive growth.

Sinus pericranii with facial involvement-A great mimicker

Sinus pericranii is a rare vascular anomaly characterized by an abnormal communication between the intra- and extracranial venous systems through a calvarial defect(s). We present three cases of congenital sinus pericranii with facial involvement, emphasizing its cutaneous presentation with diagnostic pitfalls and discuss the multidisciplinary management of this vascular anomaly.

Spontaneous Intracranial Hemorrhage: A Sign of Cavernous Angioma Diagnosis in Pediatric Age Group

Cerebral cavernous malformation (CCM) is a developmental abnormality of blood vessels that supply the brain. It is composed of large, adjacent capillaries which contain little or no neural tissue. They mostly occur in the supratentorial region. However, the occurrence of these vascular lesions can be seen at different sites of the central nervous system (CNS). The prevalence of CCM is estimated to be 0.4% in the general population and among the affected patients, 18.7% have multiple lesions. However, about 30-50% of CCM cases are asymptomatic and are found incidentally. Here we report a case of an eight-year-old girl with a massive hemorrhagic presentation of a left parietooccipital CCM.

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.

Developmental venous anomaly associated ischemic stroke caused by minor head trauma: A case report

RATIONALE

A developmental venous anomaly (DVA) is the most common intracranial congenital anomaly and is mostly asymptomatic. Thrombosis rarely develops in a DVA due to hypercoagulation. We report a case of ischemic stroke in the area of a DVA after minor head trauma in a patient with DVA and without a predisposition thrombosis.

PATIENT CONCERNS

A healthy 17-year-old male was admitted to the emergency room due to left hemiparesis, which was caused by a ball hitting the right side of his head during a soccer game.

DIAGNOSIS

Brain magnetic resonance (MR) susceptibility-weighted image showed several small veins draining to the central vein in the area from the right posterior putamen to the periventricular white matter.

INTERVENTIONS

We diagnosed the patient with an ischemic stroke associated with a DVA and administered antiplatelet agents. The patient's autoantibodies (including antiphospholipid antibody) and factors of blood coagulation were normal.

OUTCOMES

The left hemiparesis of the patient worsened by the second day of admission. Moreover, high signal intensity was observed in the DVA region of the diffusion weighted image of brain MR. The patient's symptoms gradually improved afterward, and left hemiparesis recovered fully 3 weeks after the onset.

LESSONS

DVAs may predispose to ischemic stroke due to thrombosis and hypercoagulation, although it is rare. It is necessary to consider the possibility of ischemic stroke due to minor head trauma, even without factors causing hypercoagulation.

Intracranial venous malformations: Incidence and characterization in a large pediatric cohort

BACKGROUND

Significant advances have been reported recently in the genetic and mechanistic characterization of extracranial venous malformations. However, intracranial purely venous malformations (icVM) analogous to those outside the CNS have not been systematically described.

PURPOSE

We sought to ascertain whether such an entity as icVM could in fact be identified, distinct from previously described CNS venous anomalies and analogous to extracranial venous malformations.

METHODS

Our prospectively collected pediatric cerebrovascular database was reviewed to identify patients with icVM; 1458 consecutive angiograms and/or angiographic interventions performed on 706 children at our institution from October, 2006 through May, 2019 were evaluated, in addition to outside imaging studies on 192 additional patients sent to our Vascular Anomalies Center for cerebrovascular review during the same time period. Thus, the cohort consisted of 898 children.

RESULTS

Nineteen of 898 patients (2.1%) were found to harbor icVM, including 9 (47.3%) with sinus pericranii, 15 (78.9%) with associated large, complex extracranial venous malformations, and 3 (15.7%) with neurocognitive delay. There was no intracranial hemorrhage or venous hypertension seen in the cohort. Asymptomatic venous thrombosis in the superior sagittal sinus was seen in three patients.

CONCLUSION

Venous malformations, both extracranial and icVM, share many characteristics that are distinct from developmental venous anomalies. icVM were not associated with venous hypertension. The underlying genetic mutations involved in the development of icVM, germ-line or somatic, remain to be elucidated, but may very well involve shared mechanisms and pathways with extracranial venous malformations.

A review of extraaxial developmental venous anomalies of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, venous varices or aneurysmal malformations, and enlarged emissary veins

This paper is a narrative review of extraaxial developmental venous anomalies (eDVAs) of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, enlarged emissary veins, and venous varices or aneurysmal malformations. The article highlights the natural history, anatomy, embryology, imaging, clinical implications, and neurosurgical significance of these lesions, which the authors believe represent a continuum, with different entities characterized by distinct embryopathologic features. The indications and surgical management options are discussed for these individual intracranial pathologies with relevant illustrations, and a novel classification is proposed for persistent falcine sinus (PFS). The role of neurointervention and/or microsurgery in specific cases such as sinus pericranii and enlarged emissary veins of the skull is highlighted. A better understanding of the pathophysiology and developmental anatomy of these lesions can reduce treatment morbidity and mortality. Some patients, including those with vein of Galen malformations (VOGMs), can present with the added systemic morbidity of a high-output cardiac failure. Although VOGM is the most studied and classified of the above-mentioned eDVAs, the authors believe that grouping the former with the other venous anomalies/abnormalities listed above would enable the clinician to convey the exact morphophysiological configuration of these lesions, predict their natural history with respect to evolving venous hypertension or stroke, and extrapolate invaluable insights from VOGM treatment to the treatment of other eDVAs. In recent years, many of these symptomatic venous malformations have been treated with endovascular interventions, although these techniques are still being refined. The authors highlight the broad concept of eDVAs and hope that this work will serve as a basis for future studies investigating the role of evolving focal venous hypertension/global intracranial hypertension and possibilities of fetal surgical intervention in these cases.

A Rare Case of Supratentorial Cavernous Angioma Associated with Arterialized Developmental Venous Anomaly

The association of cavernous malformations and developmental venous anomalies (DVA) is well known, but the presence of arterial fistulous connection with the main venous collector has been reported in the literature only once. We report the unusual case of a hemorrhagic cavernous angioma associated with DVA characterized by a fine arterial supply to the main venous collector. During surgery, after the excision of the cavernous angioma, few small arterial feeders were found entering the main channel of the venous developmental anomaly. The presence of an arterial fistulous connection with the main venous collector of a DVA may be a possible mechanism involved in a higher bleeding potential of cavernous angioma.

Aqueductal Developmental Venous Anomaly Presenting with Mimic Symptoms of Idiopathic Normal Pressure Hydrocephalus in an Elderly Patient: A Case Report

Developmental venous anomalies (DVAs) are generally asymptomatic; however, they can sometimes cause central nervous disorders. Aqueductal stenosis caused by DVAs is so rare that only 14 cases have been reported to date. Moreover, most patients are children or young adults, presenting with headaches or consciousness disturbances, associated with raised intracranial pressure. Here, we report on an 83-year-old man presenting with mimic symptoms of idiopathic normal pressure hydrocephalus (cognitive disorder, gait disturbance, and urinary urgency: Hakim’s triad) because of obstructive hydrocephalus caused by a DVA located in the aqueduct. Endoscopic third ventriculostomy (ETV) was performed to relieve his symptoms, and the opening pressure of the lateral ventricle was recorded to be 10 cm-H₂O. Endoscopic examination of the intraventricular system clearly revealed a vein within the aqueduct converging with the adjacent subependymal vessels. These findings were compatible with the characteristics of DVAs. His symptoms improved after the ETV. This case suggested that DVAs within the aqueduct, despite of their congenital nature, could give rise to decompensated obstructive hydrocephalus even in elderly patients, resulting in Hakim’s triad.

Restrictive cerebral cortical venopathy: A new clinicopathological entity

We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child's presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.

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.

Hybrid surgery for an arteriovenous malformation fed by an accessory middle cerebral artery and drained by a developmental venous anomaly: A case report and literature review

An accessory middle cerebral artery (AMCA), which mainly acts in the collateral circulation of the middle cerebral artery (MCA), is a rare anatomic malformation. Similar to other intracranial vessels, cerebrovascular disease can occur in the AMCA. However, the development of an arteriovenous malformation (AVM) in the AMCA is very rare, especially in conjuction with developmental venous anomalies (DVAs). Here, a rare case of an AMCA combined with an AVM and a DVA was reported. The patient was a 47-year-old female with intracranial hemorrhage at symptom onset. CT and MRI showed lesions in the left Sylvian fissure and insula accompanied by hemorrhage. DSA suggested a left AMCA; an AVM of the AMCA was located in the deep Sylvian fissure. The AVM was diffusely developed and drained into the DVA. The operation was performed in a hybrid operating room. The major feeding artery of the AVM, which was derived from the AMCA, was clipped, then the AVM and DVA were subsequently removed. Intraoperative DSA showed that the AVM and DVA were radically removed. A pathological examination confirmed the presence of an AVM. The patient recovered well and was discharged. Therefore, as highlighted in this case report, rare AVMs can be found in AMCAs and can even occur simultaneously with a DVA. Hybrid surgical treatment can be used to remove AVMs and can lead to an improved prognosis.

Clinical and Arterial Spin Labeling Brain MRI Features of Transitional Venous Anomalies

BACKGROUND AND PURPOSE

Transitional venous anomalies (TVAs) are rare cerebrovascular lesions that resemble developmental venous anomalies (DVAs), but demonstrate early arteriovenous shunting on digital subtraction angiography (DSA) without the parenchymal nidus of arteriovenous malformations (AVMs). We investigate whether arterial spin labeling (ASL) magnetic resonance imaging (MRI) can distinguish brain TVAs from DVAs and guide their clinical management.

METHODS

We conducted a single-center retrospective review of patients with brain parenchymal DVA-like lesions with increased ASL signal on MRI. Clinical histories and follow-up information were obtained. Two readers assessed ASL signal location relative to the vascular lesion on MRI and, if available, the presence of arteriovenous shunting on DSA.

RESULTS

Thirty patients with DVA-like lesions with increased ASL signal were identified. Clinical symptoms prompted MRI evaluation in 83%. Symptoms did not localize to the venous anomaly in 90%. Ten percent presented with acute symptoms, only one of whom presented with hemorrhage. ASL signal in relation to the venous anomaly was identified in: 50% in the adjacent parenchyma, 33% in the lesion, 7% in a distal draining vein/sinus, and 10% in at least two of these sites. Follow-up DSA confirmed arteriovenous shunting in 71% of ASL-positive venous anomalies. Interrater agreement was very good (κ = .81-1.0, P < .001).

CONCLUSION

A DVA-like lesion with increased ASL signal likely represents a TVA with arteriovenous shunting. Our study indicates that these lesions are usually incidentally detected and have a lower risk of hemorrhage than AVMs. ASL-MRI may be a useful tool to identify TVAs and guide further management of patients with TVAs.

Developmental venous anomalies

Developmental venous anomalies (DVAs) are relatively common lesions, present in up to 3% of the population. The defining characteristic of these lesions is the confluence of radially oriented veins into a single dilated venous channel. DVAs are also known as cerebral venous angiomas, cerebral venous malformations, and cerebral venous medullary malformations. They are the most common type of cerebral vascular malformation found on autopsy studies, and they are often encountered as incidental findings on neuroimaging studies. DVAs are congenital lesions thought to arise from aberrations that occur during venous development, but continue to provide the normal venous drainage to the cerebral territory in which they reside. Although the natural history of DVAs is benign, they may be associated with cavernous malformations or other vascular abnormalities, which can lead to hemorrhage in the vicinity of the DVA. Surgical or endovascular obliteration of DVAs carries a significant risk of venous infarction; thus, conservative management is the treatment of choice for patients with these lesions.

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.

Association between trauma and acute hemorrhage of cavernous malformations in children: report of 3 cases

OBJECTIVE Cavernous hemangiomas are benign congenital vascular abnormalities. Intracerebral cavernous hemangiomas have an appreciable risk of spontaneous hemorrhage. Little is known as to whether head trauma increases the risk of bleeding for these lesions. In this study, the authors present a case series of 3 patients with posttraumatic nonspontaneous hemorrhage of intracerebral cavernous malformations (CMs). For the first time, to the authors' knowledge, they propose that trauma might constitute a risk factor for acute hemorrhage in intracerebral cavernomas. METHODS The authors reviewed the charts of all patients with a new diagnosis of intracerebral cavernoma at their pediatric hospital between 2010 and 2014. Patients with a history of head trauma prior to presentation were subsequently studied to identify features common to these posttraumatic, hemorrhage-prone lesions. RESULTS A history of head trauma was identified in 3 of 19 cases. These 3 patients presented with seizures and/or headaches and were found to have acute hemorrhage within a cavernous hemangioma. None of these patients had any history of abnormal neurological symptoms. All 3 abnormal vascular lesions had associated developmental venous anomalies (DVAs). The 3 patients underwent resection of their respective vascular abnormalities, and the diagnosis of cavernous hemangioma was confirmed with postsurgical tissue pathology. All 3 patients had complete resolution of symptoms following complete excision of their lesions. CONCLUSIONS Trauma may represent a risk factor for acute hemorrhage in patients with CMs. The presence of associated DVAs may represent a risk factor for posttraumatic hemorrhage of cavernomas. Excision should be considered in such cases, if feasible.

De novo formation of cerebral cavernous malformation adjacent to existing developmental venous anomaly - an effect of change in venous pressure associated with management of a complex dural arterio-venous fistula

This is a case report of de novo development of two cerebral cavernous malformations adjacent to existing developmental venous anomalies. The development of cavernomas was noted over a follow-up period of 10 years. These developments happened during the course of staged endovascular management of a complex dural arterio-venous fistula along the right sphenoid wing. The patient presented with a proptosis secondary to lympho-haemangiomatous lesion of the fronto-orbital region and a high-flow right sphenoid wing dural arterio-venous fistula. During the initial period of conservative management of the dural arterio-venous fistula, he developed de novo cavernous malformations in the left mesial temporal lobe adjacent to a developmental venous anomaly in the temporal lobe, and along with this there was engorgement of deep veins related to another existing developmental venous anomaly in the brainstem. Later during the course of endovascular treatment of the dural arterio-venous fistula, a large brainstem cavernoma developed adjacent to the brainstem developmental venous anomaly. This case report discusses the cause-effect relationship of venous pressure changes related to management of dural arterio-venous fistula and de novo formation of cerebral cavernous malformations adjacent to existing developmental venous anomalies.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing-like attacks in a pediatric patient found to have a pontine capillary telangiectasia and developmental venous anomaly: A case report exploring the root of the problem

Introduction Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)-like attacks are rarely reported in the pediatric population and may remain undiagnosed and under-investigated as a result. Case presentation We present a case of a 15-year-old male with intermittent, episodic, right-sided brief headaches most in keeping with SUNCT, initially diagnosed as paroxysmal hemicrania, but with no response to indomethacin. The pain was likewise not responsive to typical migraine treatments or steroids. Management and outcome Contrast-enhanced magnetic resonance imaging demonstrated a right pontine capillary telangiectasia with an associated developmental venous anomaly that was adjacent to the root of the right trigeminal nerve. Differential diagnosis included first division trigeminal neuralgia with autonomic features. The patient's pain was partially alleviated by oxygen administration and responded well to carbamazepine; he remained pain free on carbamazepine a year later. Conclusion This case highlights the diagnostic dilemma of differentiating SUNCT from trigeminal neuralgia with autonomic features, both of which are rare diagnoses in pediatric patients, and the importance of appropriate neuroimaging to rule out secondary causes in patients presenting with trigeminal autonomic cephalalgias, recognizing that abnormalities identified on neuroimaging, such as vessels adjacent to the trigeminal nerve, may not be causative findings.

Isolated giant cerebral varix - A diagnostic and therapeutic challenge: A case report

Background:

Isolated giant cerebral varix (IGV) is an uncommon vascular lesion that represents a diagnostic challenge and requires dynamic vascular studies for its characterization. The IGV is considered a benign, low-flow venous lesion with very low risk of bleeding that might cause secondary symptoms mainly due to compression of the adjacent parenchyma.

Case Description:

A 12-year-old female patient with non-contributory medical history presented with headache for the last 2 months. Upon admission, her neurological examination was unremarkable. Magnetic resonance imaging (MRI) and computed tomography angiography (CTA) images demonstrated a large varicose dilation of the superficial Sylvian vein, located anterior to the left temporal pole, with no evidence of abnormal arteriovenous connections or tumoral lesions. This finding was considered incidental and unrelated to her symptoms. In this case, we considered that the combination of CTA and MRIs was enough to establish an accurate diagnosis, excluding the need to perform invasive imaging studies. Taking into account these considerations, the patient was managed with conservative treatment and has been followed up for 1 year, remaining asymptomatic.

Conclusion:

Cerebral IGVs are rare vascular lesions that are treated conservatively when asymptomatic and surgically in the case of rupture or compression of adjacent structures. Given our observation of a high unlikelihood of vascular connections to arteries, and the information obtained with non-invasive imaging techniques such as CTA and MRI was enough to make a clinical decision and avoid the evaluation with invasive procedures.

Spontaneous Thrombosis and Subsequent Recanalization of a Developmental Venous Anomaly

Developmental venous anomalies (DVA) are among the most common congenital malformations of the cerebral angioarchitecture. Spontaneous thrombosis of this entity is rare, and our review of the literature found only 31 reported cases of symptomatic spontaneous thrombosis of developmental venous anomalies. Here, we report a unique case describing the spontaneous thrombosis of a DVA leading to venous infarction and subsequent recanalization. The patient was a previously healthy 21-year-old male who presented with an acute onset of partial seizures. Following negative hypercoagulability studies and along with CT (computed tomography) and MR (magnetic resonance) imaging, the patient was treated with anticoagulant therapy and demonstrated complete functional recovery. Knowledge from our literature review of similar cases combined with the experience gained from this patient’s treatment leads us to suggest that spontaneous DVA thrombosis and venous infarction generally has a good outcome despite initially devastating neurologic deficits. Additionally, the rarity of spontaneous DVA thromboses lends itself to the need to identify possible predisposing risk factors, chief amongst these being hypercoagulopathies.

Long-term treatment outcome of venous-predominant arteriovenous malformation

OBJECTIVE

Treatment strategies for venous-predominant arteriovenous malformation (vp-AVM) remain unclear due to the limited number of cases and a lack of long-term outcomes. The purpose of this study was to report the authors' experience with treatment outcomes with a review of the pertinent literature in patients with vp-AVM.

METHODS

Medical and radiological data from 1998 to 2011 were retrospectively evaluated. The degree of the arteriovenous (AV) shunt was categorized into 2 groups, a high- and low-flow AV shunt based on the angiographic findings.

RESULTS

Sixteen patients with a mean age of 45.3 years (range 16-78 years) and a mean follow-up of 79.9 months (range 25-264 months) were examined. Symptomatic lesions were noted in 13 patients: intracranial hemorrhage (ICH) in 9, seizure in 1, and headache in 3. A high-flow shunt was observed on angiography in 13 patients. Among these 13 patients, 12 patients were symptomatic. Nine patients presenting with ICH underwent hematoma removal with additional Gamma Knife surgery (GKS; n = 4), GKS only (n = 2), or conservative treatment (n = 3). The 3 asymptomatic patients received conservative treatment, and 1 rebleeding episode was observed. Seven of 8 patients who underwent GKS as an initial or secondary treatment modality experienced a marked reduction in the AV shunt on follow-up angiography, but complete obliteration was not observed.

CONCLUSIONS

Poor lesion localization makes a vp-AVM challenging to treat. Symptomatic patients with a high-flow shunt are supposedly best treated with GKS, despite the fact that only 87.5% of the vp-AVMs treated this way showed a reduction in the malformation volume, and none were cured.

Exercise Induced Transient Neurological Deficit in a Patient with Cerebellar Developmental Venous Anomaly

BACKGROUND

The association of venous angiomas or developmental venous anomalies (DVA) with transient neurological deficit is rare. We present a rare case of a cerebellar developmental venous anomaly resulting in transient neurological deficits.

CASE DESCRIPTION

A 58-year-old man with recurrent left sided facial dysesthesia, hemiparesis, and mild difficulty ambulating after exercise. A similar episode was experienced six months earlier under the same circumstances. Computed tomographic (CT) scan demonstrated an ill-defined hyperdensity in the right cerebellar hemisphere. Cerebral angiography demonstrated a venous angioma that dilated with valsalva maneuver.

CONCLUSION

We report the first case of a cerebellar venous angioma causing exercise induced transient neurologically deficits. Limiting strenuous exercise may be needed to avoid symptom recurrence. Further research is warranted on the hemodynamic effects of intracranial DVA's.

Complex Partial Epilepsy Associated with Temporal Lobe Developmental Venous Anomaly

BACKGROUND

Developmental venous anomalies (DVA) are found incidentally but sometimes patients with these anomalies present with varying degrees of neurologic manifestations.

OBJECTIVE

We report a patient with early onset complex partial epilepsy and associated DVA and discuss the natural history, neuroimaging and clinical characteristics, and management.

CASE DESCRIPTION

A 21-year-old man presented with a history of complex partial epilepsy with secondary generalization which started at the age of 4 years. An electroencephalogram (EEG) was performed which demonstrated spike and wave discharges predominantly in the left frontotemporal region. A magnetic resonance imaging (MRI) was performed which demonstrated a linear flow void suggestive of a DVA. The angiogram demonstrated DVA that connected with the left transverse venous sinus and an anastomotic vein between the straight sinus and the transverse venous sinus traversing the brain parenchyma. He was started on carbamezipine for the treatment of complex partial seizures.

CONCLUSIONS

Temporal lobe DVA may be associated with complex partial seizures and can be diagnosed by MRI and angiographic findings.

Trigeminal Neuralgia due to an Isolated Cerebral Varix: Case Report

Intracranial isolated varix is a very rare entity. Although it is usually asymptomatic, there are reports on symptomatic cases with hemorrhage or mass effect that mostly relate to arteriovenous fistulas or arteriovenous malformations. We present an extremely rare case of trigeminal neuralgia caused by an isolated varix. A 55-year-old woman had been experiencing right trigeminal neuralgia for 3 years. Computed tomography and magnetic resonance imaging revealed an enhanced mass lesion on the root entry zone of the right trigeminal nerve. Angiograms confirmed the mass was a varix arising on the vein connecting the basal vein of Rosenthal and the superior petrosal vein. Preoperative three-dimensional (3D) imaging clearly depicted the anatomical relation of the varix, adjacent vessels, and trigeminal nerve, which helped plan operative procedures. The varix with its parent vein was successfully transposed from the nerve without sacrificing any veins. Her pain disappeared immediately after the surgery and did not recur during a 30-month follow-up period. The 3D image contributed to making an accurate and safer operative plan especially for this rare case.

Epileptogenic developmental venous anomaly: insights from simultaneous EEG/fMRI

Developmental venous anomalies (DVAs) are associated with epileptic seizures; however, the role of DVA in the epileptogenesis is still not established. Simultaneous interictal electroencephalogram/functional magnetic resonance imaging (EEG/fMRI) recordings provide supplementary information to electroclinical data about the epileptic generators, and thus aid in the differentiation of clinically equivocal epilepsy syndromes. The main objective of our study was to characterize the epileptic network in a patient with DVA and epilepsy by simultaneous EEG/fMRI recordings. A 17-year-old woman with recently emerging generalized tonic-clonic seizures, and atypical generalized discharges, was investigated using simultaneous EEG/fMRI at the university hospital. Previous high-resolution MRI showed no structural abnormalities, except a DVA in the right frontal operculum. Interictal EEG recordings showed atypical generalized discharges, corresponding to positive focal blood oxygen level dependent (BOLD) correlates in the right frontal operculum, a region drained by the DVA. Additionally, widespread cortical bilateral negative BOLD correlates in the frontal and parietal lobes were delineated, resembling a generalized epileptic network. The EEG/fMRI recordings support a right frontal lobe epilepsy, originating in the vicinity of the DVA, propagating rapidly to both frontal and parietal lobes, as expressed on the scalp EEG by secondary bilateral synchrony. The DVA may be causative of focal epilepsies in cases where no concomitant epileptogenic lesions can be detected. Advanced imaging techniques, such as simultaneous EEG/fMRI, may thus aid in the differentiation of clinically equivocal epilepsy syndromes.

Thrombosis of a developmental venous anomaly in inflammatory bowel disease: case report and radiologic follow-up

Developmental venous anomalies (DVAs) are benign embryologic vascular variants, and before the advent of computed tomography and magnetic resonance imaging were supposed to be rare conditions. Usually, DVAs are asymptomatic and accidentally discovered during routine brain imaging studies, but sometimes they can be the cause of disabling neurologic symptoms. We describe the clinical and neuroradiologic follow-up of a 62-year-old man with a history of inflammatory bowel disease (IBD) presenting with new onset epilepsy and intracranial hemorrhage caused by thrombosis of a DVA who fully recovered after treatment with oral anticoagulant therapy. Patients with IBD have an increased risk of thrombosis because of inflammatory activity and the hypercoagulable state. Here we describe the first case of DVA thrombosis in a patient with IBD, and we show clinical and neuroradiologic follow-up after anticoagulant therapy.