Vascular Malformations Of CNS Radiology
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Transcript of Vascular Malformations Of CNS Radiology
VASCULAR MALFORMATIONS OF CNS
Dr Roshan ValentinePG Resident-RadiologySt Johns Medical CollegeBangalore
INTRODUCTION
• Heterogenous group of disorders• Morphogenetic errors affecting arteries , veins or
various combinations of vessels
CLASSIFICATION
HISTOPATHOLOGY
AVM Venous angioma Capillary telangiectasia
Cavernous malformation
CLASSIFICATION
FUNCTIONAL
AV SHUNTING
AVM
Dural Av fistula
VOG malformation
WITHOUT AV SHUNTING
Venous angioma
Capillary telangiectasi
a
Cavernous malformation
Sinus pericranii
AV MALFORMATION
• MC• Usually congenital• Tightly packed thin walled
vessels (NIDUS)• Direct artery to vein shunting• No intervening capillary bed• Most AVMs are parenchymal
lesions – aka PIAL AVMs
AV MALFORMATION
PATHOLOGY• LOCATION: supratentorial(85%)• SIZE : 2-6cms in diameter• NUMBER : solitary (<2%multiple)• Multiple when a/w syndromes HHT , Wyburn-Mason
syndrome
AV MALFORMATION
PATHOLOGYGROSS : Wedge shaped tangled irregulary dilated vessels with varying wall thickness and luminal size
Surrounding brain parenchyma : H’age residue , gliosis,ischemic changes
HPE: well defined elastic lamina(usually absent in venous channels ) with focal areas of wall thinning
AV MALFORMATION
CLINICAL FEATURES• Presentation: 2-4th decade• Headache with H’age – MC • Seizures > hemorrhage(adults )• Seizures < hemorrhage(children )
Nidus – MC site for hemorrhage Location – peri/interventricular /basal ganglia
• Focal neurological deficits(20-25%) STEAL from adjacent normal area Mass effect
AV MALFORMATION
AV MALFORMATION
PROGNOSIS• All are potentially hazardous• Lifelong risk of H’age- 2-4% every year cumulative• Spontaneous regression – rare and unpredictable
AV MALFORMATION
IMAGINGGENERAL FEATURE• 3 components– Feeding arteries– Central Nidus– Draining veins
AV MALFORMATION
IMAGINGCT• NECT
– Normal : Very small AVM– Iso/hyperdense serpentine vessels(BAG
OF WORMS)– Calcification(25-30%)– AVM Bleed – parenchymal , IVH >> SAH– Post embolization: hyperdense embolics
in nidus CECT• Enhanced arterial feeders , nidus and
draining veins
AV MALFORMATION
MR• T1W1 – tightly packed mass or honeycomb of flow
voids• T2W1 – serpiginous honeycomb of flow voids adjacent high signal tissue – gliosis• FLAIR- flow voids +/- surrounding high signal• GRE - blooming (H’agic residua)
AV MALFORMATION
ANGIOGRAPHY• Internal angioarchitecture best depiction• Depicts 3 components of AVM– Enlarged arteries+/- aneurysm– Nidus– Early draining veins
AV MALFORMATION
ANGIOGRAPHYFeeding arteries • Dilated and tortuous • Flow related angiopathy – dilatation , stenosis or
thrombosis• Pedicle aneurysm(10-15%cases)
AV MALFORMATION
ANGIOGRAPHYNidus• Tightly packed tangle of abnormal arteries and veins
with no intervening capillary bed/brain parenchym
• Intranidal aneurysm(50% cases)
AV MALFORMATION
ANGIOGRAPHYDraining Veins• Opacify in mid-late arterial phase(Early draining
vein) • Enlarged , tortuous and may form varices exerting
local mass effect• Stenosis can cause AVM H’age by ↑ intranidal
pressure
AV MALFORMATION
TREATMENT• Complete obliteration of nidus for cure• Traditonal Rx – Surgical excision for nidus• Acute and emergent surgical intervention – in life
threatening ICH
AV MALFORMATION
STEREOTACTIC RADIOSURGERY• Focussed irradiation to nidus• Indication – Unresectable because of location– Size < 3.5cms
• Adv : Non invasive• Disadv :Effect takes yearsRisk of h’age till it disappears completely
AV MALFORMATION
ENDOVASCULAR RX• Adjunct to Sx/ RadioSx• Used in small AVMs or 1-2 feeding arteries• Embolisation – Precedes surgery /radiosx
reduce size of nidus• Complete cure if : small AVM , few feeders , single
draining vein
DURAL AV FISTULA
• 2nd MC CVM with AV shunting• Tiny crack like vessels that
shunt blood b/w meningeal arteries and small venules within dural sinus wall
• ETIOLOGY : Acquired – ↑ angiogenesis within
dural sinus wall after thrombosis
DURAL AV FISTULA
PATHOLOGY• LOCATION: Trans Sinus>Sig sinus>Cav sinus(adults) Sup Sigmoid sinus (Children)• SIZE : Tiny single vessel shunts to massive complex
lesions with multiple feeders• NUMBER : Multiple lesions are uncommon
DURAL AV FISTULA
PATHOLOGYGROSS : Multiple enlarged dural feeders on the wall of thrombosed dural sinus : Fistulas connecting feeders with arterialized draining veins
HPE: irregular intimal thickening with variable loss of internal elastic lamina
DURAL AV FISTULA
CLINICAL FEATURE• Mostly in adults(40-60yrs)• C/F varies wht location and drainage pattern
TS-SigS - Bruit and tinnitus Cav S – Pulsatile proptosis , chemsois , retroorbital
pain• Lesions with cortical venous drainage(Malignant
dAVF) : seizures, dementia , progressive FND
DURAL AV FISTULA
CLINICAL FEATUREPROGNOSIS• 98% w/o cortical venous drainage - benign course• Malignant dAVF – aggressive clinical course with
H’age and ND• Multiple dAVF – poor clinical prognosis
DURAL AV FISTULA
TREATMENT• Conservative – Observation +/- carotid compression
techniqueIf rsk of H’age• Endovascular – Embolisation of arterial feeders with
particulate or liquid agents , coil embolization of venous sinus
• Surgical resection of involved dural venous sinus• Stereotactic RadioSx- 2-3 years for obliteration
DURAL AV FISTULA-IMAGING
GENERAL FEATURES• Mostly in posterior fossa and skull base• MC – TS-SigS junction
DURAL AV FISTULA-IMAGING
CT• Normal to striking• Enlarged dural sinus or draining vein/transosseous
venous channels• Car-Cav fistula : Enlarged SOV • CECT – Enlarged feeding arteries and draining veins Dural sinus may be thrombosed or stenotic
DURAL AV FISTULA-IMAGING
DURAL AV FISTULA-IMAGING
MRI• Dilated cortical vein without nidus adjacent to
normal appearing brain • MC finding – thrombosed dural venous sinus with
flow voids• Thrombus – T1 and T2 isointense typically T2* - blooming
DURAL AV FISTULA-IMAGING
DURAL AV FISTULA-IMAGING
ANGIOGRAPHY• Best imaging tool• DSA with superselective catheterization of dural and
transosseous feeders required• Dural branches – arise from ECA , ICA and vertebral
arteries• Presence of dural sinus thrombosis, flow reversal with
drainage into cortical veins and engorged tortuous pial veins
DURAL AV FISTULA-IMAGING
ANGIOGRAPHY• High flow venopathy can cause stenosis . Occlusion
or hemorrhage• Dysplastic venous pouches may cause H’age• Increased H’age with cortical venous drainage and
dysplastic venous dilatation
DURAL AV FISTULA
DURAL AV FISTULA-IMAGING
CAROTID CAVERNOUS FISTULA
• AV shunting developing within cavernous sinus
• Direct– High Flow– Rupture of cavernous ICA
into CS• Indirect– Slow flow , low pressure– Fistula b/w dural br of ICA
and the CS
CAROTID CAVERNOUS FISTULA
ETIOLOGY• Almost always acquired• Direct– Traumatic: central skull base #– Non-Traumatic: Preexisting cavernous ICA
aneurysm• Indirect– Degenerative – sequelae of dural sinus thrombosis
CAROTID CAVERNOUS FISTULA
PATHOLOGY• GROSS – Dilated CS (Direct CCF)– Enlarged crack like vessels(Indirect)
CAROTID CAVERNOUS FISTULA
CLINICAL FEATURES
DIRECT INDIRECTEPIDEMIOLOGY Less common More common
DEMOGRAPHICS M=FAny age
Women40-60yrs
PRESENTATION BruitPulsatile xophthalmosOrbital edema↓visionGlaucoma
Painless proptosis Vision changes
TREATMENT Fistula closure by transarterial transfistula detachable balloon embolisation
Conservative
Superselectiv eembolisation
CAROTID CAVERNOUS FISTULA-IMAGING
GENERAL FEATURES• Presence of AV shunting within cavernous sinus• Based on degree of shunt – subtle to striking
CAROTID CAVERNOUS FISTULA-IMAGING
CT FINDINGS• Mild or striking proptosis• Prominent CS• Enlarged SOV • Enlarged EOMCECT• Enalrged SOV and CS
CAROTID CAVERNOUS FISTULA-IMAGING
MRI• T1 – Bulging SOV
and CS with flow voids
• T2 – Asymmetric flow related signal loss in the affected veins
CAROTID CAVERNOUS FISTULA-IMAGING
ANGIOGRAPHYDIRECT CCF• Rapid flow with early opacification of CS• Fistula may be noted in ICA segmentINDIRECT CCF• Multiple dural feeders from Cavernous br of ICA and
deep br of ECA(mid meningeal and dist max A)• Anastomoses b/w ICA and ECA feeders are common
CAROTID CAVERNOUS FISTULA-IMAGING
VEIN OF GALEN ANEURYSMAL MALFORMATION
• Direct AV fistula b/w deep choroidal arteries and persistent embryonic precursor of VOG
• Large midline venous pouch behind the 3rd ventricle
• MC extracardiac cause of high-output cardiac failure in newborn
VEIN OF GALEN ANEURYSMAL MALFORMATION
• In normal fetal dvpt : arterial supply of choroid plexus drains via single transient midline vein – median prosencephalic vein
• Internal cerebral vein drains fetal chorid plexus as MPV regresses
• Persistent high flow fistula prevents regression
VEIN OF GALEN ANEURYSMAL MALFORMATION
CLINICAL FEATURES• >30% of symptomatic VM in children• Rare in adults• Neonates – high output CCF with cranial bruit• Older infants – macrocrania + hydrocephalus +/- CCF• Older Children – Developmental delay and seizures• Young adults - Headache• Large VGAMS – cerebral ischemia and dystrophic changes• Left untreated – Die of progressive brain damage andintracatable CCF
VEIN OF GALEN ANEURYSMAL MALFORMATION
TREATMENT • Goal – not anatomic cure of VGAM but control
malformation to allow normal brain dvpt• Staged arterial embolization at 4/5m
VGAM – IMAGING
CT• NECT
– Enlarge dwell delineated hyperdense mass at tentorial apex
– Obstructive hydrocephalus– H’age and calcification
may be present.• CECT – Strong uniform
enhancement
VGAM – IMAGING
MRI• Enlarged serpentine
arterial feeders adjacent to the lesion
VGAM – IMAGING
ANGIOGRAPHY2 forms based on angioarchitecture• Choroidal – Multiple br from pericallosal choroidal and
thalamoperforate arteries drain into dilated midline venous sac
• Mural – single or few enlarged collicular or post choridal arteries drain into sinus wall
• Venous drainage into persistent embryonic FALCINE SINUS
VGAM – IMAGING
VGAM – IMAGING
ULTRASOUND• Antenatally• Hypoechoic to
mildle echogenic midline mass behinf the third ventricle
• CDFI : Bidirectional turbulent flow
CVMS WITHOUT AV SHUNTING
DEVELOPMENTAL VENOUS ANOMALY
• VENOUS ANGIOMA/VENOUS MALFORMATION
• Umbrella shaped CVM with mature venous part.
• No arterial component• May represent anatomic
variant of otherwise normal venous drainage
DEVELOPMENTAL VENOUS ANOMALY
CLINICAL FEATURES• Usually asymptomatic• Headache/seizures• H’age with FND ( if a/w cavernous malformation)• MC vascular malformation at autopsy
DEVELOPMENTAL VENOUS ANOMALY
TREATMENT• Solitary DVA – no Rx• Histologically mixed – based on coexisting lesion
DEVELOPMENTAL VENOUS ANOMALY
IMAGING• Location : MC near the frontal horn of ventricle• Size < 3cm• Usually solitary
DEVELOPMENTAL VENOUS ANOMALY
NECT• Normal , enlarged draining vein may appear
hyperdenseCECT• Numerous linear or punctate enhancing foci and
converge on single enlarged tubular draining vein
DEVELOPMENTAL VENOUS ANOMALY
DEVELOPMENTAL VENOUS ANOMALY
MR• T1 – Normal if DVA is small H’age if mixed malformations• T1 C+ - stellate collection of linear enhancement
structures joining subependymal collector vein.• GRE – if H;age in coexisting cavernous malformation - Occasionally hypo – Not H’age but deoxyHb within venous blood
DEVELOPMENTAL VENOUS ANOMALY
DEVELOPMENTAL VENOUS ANOMALY
• MRA – Arterial phase usually normal• MRV – MEDUSA HEAD drainage pattern
DEVELOPMENTAL VENOUS ANOMALY
ANGIOGRAPHIC FINDINGS• Normal arterial and
capillary phase• Venous phase –
Medusa head appearance
CAVERNOUS MALFORMATION
• CAVERNOUS ANGIOMA/CAVERNOMA
• Characterised by intralesional hemorrhages into thin walled angiogenically immature blood filled locules called CAVERNS
• Well marginated lesion with no normal brain parrenchyma
• Inherited or acquired
CAVERNOUS MALFORMATION
PATHOLOGY• Location : Mostly infratentorial (PONS) • Dark blue well circumscribed lobulated lesion with mulberry like
config• CCMs do not contain brain parenchyma• Adjacent parenchyma: reactive changes , hemosiderin deposition• Dystrophic calcification+• HPE – collagenised sinusoids with NO
MUSCULARIS/ELASTICA(avm has it )
CAVERNOUS MALFORMATION
CAVERNOUS MALFORMATION
CLINICAL FEATURES • 2/3 are soliary • Peak presentn : 40-60yrs• MC presentn : Seizures(50%)>Headache and FND• H’age risk – 0.25-0.75% per year
CAVERNOUS MALFORMATION
TREATMENT OPTIONS• Total surgical removal via microsurgical resexn – for
symptomatic lesions with recurrent H’age• Stereotactic Radiosx = for inaccessible lesions
CAVERNOUS MALFORMATION
IMAGINGCT – Hyperdense lesion with scatteres intralesional calcification
CAVERNOUS MALFORMATION-IMAGING
MRIMR – DIAGNOSTIC
Focal central heterogeneity(varying hemorrhage within caverns)- POPCORN appearance on T2WI Circumferential hypointense ring of hemosiderin form around high intense central areas
CAVERNOUS MALFORMATION-IMAGING
ANGIOGRAPHY• No identifiable feeding arteries/veins• Negative unless mixed with other lesions
CAPILLARY TELANGIECTASIA
• CAPILLARY ANGIOMA• Collection of enlarged thin
walled vessels resembling capillaries.
• Vessels surrounded by normal brain parenchyma
• Probably congenital lesions• MC sites : Pons , cerebellum(can
occur anywhere)
CAPILLARY TELANGIECTASIA
CLINICAL FEATURES• Peak Presentation : 30-40 years• Usually silent, discovered incicdentally at imaging
CAPILLARY TELANGIECTASIA
IMAGING• Usually <1cmCT – Usually NormalMR• T1W1 –usually normal• T2 – 50% normal - 50 % show stippled foci of hyperintensity• T2* - Best sequence for
demonstrating the lesion(poorly delineated greyish hypointensity)
• T1+C – BRUSH LIKE
CAPILLARY TELANGIECTASIA
CAPILLARY TELANGIECTASIA
SINUS PERICRANII
• Large transcalvarial communication between intra and extra-cranial venous drainage system
• Mostly congenital• May be a/w other
dva
SINUS PERICRANII
CLINICAL FEATURES• Rare• Children and young adults• NON TENDER NON PULSATILE BLUISH
COMORESSIBLE SCALP MASS• Increase in size with Valsalva• Reduce on upright position
SINUS PERICRANII
TREATMENT• Surgical removal of extracranial component-
cosmetic purpose
SINUS PERICRANII- IMAGING
CT NECT• Iso to hyperdense • Typically well demarcated
calvarial defectCECT• Strong uniform
enhancement
SINUS PERICRANII-IMAGING
MRI• T1WI – iso• T2WI- HyperintenseANGIOGRAM• Arterial and capillary phase
normal• Venous phase – Visualised on
late venous phase mostly• Contrast accumulating within
the lesion and adjacent to the skull defect with pericranial scalp vein
ENDOVASCULAR MANAGEMENT of CVM
EMBOLIC AGENTS USEDLiquid agents Acrylic glue• Chemically N-butyl
cyanoacrylate• Polymerises on contact
with hydroxyl ions in blood• Induces vasculitis and
thereby thrombosis of AVM
ENDOVASCULAR MANAGEMENT of CVM
ONYX• Ethylene vinyl alcohol polymer• Mixed with dimethyl sulfoxide (DMSO)• On mixing it forms a soft spongy polymer• Its more effective than acrylic glue
ENDOVASCULAR MANAGEMENT of CVM
PARTICULATE AGENTSSILICONE SPHERES• First agents ever used• Mixed with Ba to make it radiopaque• Increased rebleeding rate
ENDOVASCULAR MANAGEMENT of CVM
BALLOONS• Silicone or latex made• Occlude large AVM feeding arteries/high flow fistula• Replaced by coilsPOLY VINYL ALCOHOL• Delivered via guide wire dependent catheters(~500mics)• Flow dependent catheters (<350mics)• Clumping of particles causing slowing and then thrombosis
ENDOVASCULAR MANAGEMENT of CVM
MICROCOILS• Used along with
embolic agents• They reduce the flow
in rapid av shunts• Also in treatment of
intracranial aneurysm a/w AVMs