Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Vascular Malformations Of CNS Radiology

7,334 views

Published on

Vascular malformations of cns including highand low flow shunts - AVM , dural av fistula , vein of galen malformation , venous malformation , sinus pericranii , cavernous malformation , capillary telangiectasia

Published in: Health & Medicine
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Dating direct: ❶❶❶ http://bit.ly/2F90ZZC ❶❶❶
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Sex in your area is here: ❶❶❶ http://bit.ly/2F90ZZC ❶❶❶
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Vascular Malformations Of CNS Radiology

  1. 1. VASCULAR MALFORMATIONS OF CNS Dr Roshan Valentine PG Resident-Radiology St Johns Medical College Bangalore
  2. 2. INTRODUCTION • Heterogenous group of disorders • Morphogenetic errors affecting arteries , veins or various combinations of vessels
  3. 3. CLASSIFICATION HISTOPATHOLOGY AVM Venous angioma Capillary telangiectasia Cavernous malformation
  4. 4. CLASSIFICATION FUNCTIONAL AV SHUNTING AVM Dural Av fistula VOG malformation WITHOUT AV SHUNTING Venous angioma Capillary telangiectasia Cavernous malformation Sinus pericranii
  5. 5. 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
  6. 6. AV MALFORMATION PATHOLOGY • LOCATION: supratentorial(85%) • SIZE : 2-6cms in diameter • NUMBER : solitary (<2%multiple) • Multiple when a/w syndromes HHT , Wyburn-Mason syndrome
  7. 7. AV MALFORMATION PATHOLOGY GROSS : 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
  8. 8. 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
  9. 9. AV MALFORMATION
  10. 10. AV MALFORMATION PROGNOSIS • All are potentially hazardous • Lifelong risk of H’age- 2-4% every year cumulative • Spontaneous regression – rare and unpredictable
  11. 11. AV MALFORMATION IMAGING GENERAL FEATURE • 3 components – Feeding arteries – Central Nidus – Draining veins
  12. 12. AV MALFORMATION IMAGING CT • 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
  13. 13. 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)
  14. 14. AV MALFORMATION ANGIOGRAPHY • Internal angioarchitecture best depiction • Depicts 3 components of AVM – Enlarged arteries+/- aneurysm – Nidus – Early draining veins
  15. 15. AV MALFORMATION ANGIOGRAPHY Feeding arteries • Dilated and tortuous • Flow related angiopathy – dilatation , stenosis or thrombosis • Pedicle aneurysm(10-15%cases)
  16. 16. AV MALFORMATION ANGIOGRAPHY Nidus • Tightly packed tangle of abnormal arteries and veins with no intervening capillary bed/brain parenchym • Intranidal aneurysm(50% cases)
  17. 17. AV MALFORMATION ANGIOGRAPHY Draining 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
  18. 18. AV MALFORMATION TREATMENT • Complete obliteration of nidus for cure • Traditonal Rx – Surgical excision for nidus • Acute and emergent surgical intervention – in life threatening ICH
  19. 19. AV MALFORMATION STEREOTACTIC RADIOSURGERY • Focussed irradiation to nidus • Indication – Unresectable because of location – Size < 3.5cms • Adv : Non invasive • Disadv :Effect takes years Risk of h’age till it disappears completely
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. DURAL AV FISTULA PATHOLOGY GROSS : 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
  24. 24. 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
  25. 25. DURAL AV FISTULA CLINICAL FEATURE PROGNOSIS • 98% w/o cortical venous drainage - benign course • Malignant dAVF – aggressive clinical course with H’age and ND • Multiple dAVF – poor clinical prognosis
  26. 26. DURAL AV FISTULA TREATMENT • Conservative – Observation +/- carotid compression technique If 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
  27. 27. DURAL AV FISTULA-IMAGING GENERAL FEATURES • Mostly in posterior fossa and skull base • MC – TS-SigS junction
  28. 28. 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
  29. 29. DURAL AV FISTULA-IMAGING
  30. 30. 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
  31. 31. DURAL AV FISTULA-IMAGING
  32. 32. 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
  33. 33. 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
  34. 34. DURAL AV FISTULA
  35. 35. DURAL AV FISTULA-IMAGING
  36. 36. 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
  37. 37. 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
  38. 38. CAROTID CAVERNOUS FISTULA PATHOLOGY • GROSS – Dilated CS (Direct CCF) – Enlarged crack like vessels(Indirect)
  39. 39. CAROTID CAVERNOUS FISTULA CLINICAL FEATURES DIRECT INDIRECT EPIDEMIOLOGY Less common More common DEMOGRAPHICS M=F Any age Women 40-60yrs PRESENTATION Bruit Pulsatile xophthalmos Orbital edema ↓vision Glaucoma Painless proptosis Vision changes TREATMENT Fistula closure by transarterial transfistula detachable balloon embolisation Conservative Superselectiv eembolisation
  40. 40. CAROTID CAVERNOUS FISTULA-IMAGING GENERAL FEATURES • Presence of AV shunting within cavernous sinus • Based on degree of shunt – subtle to striking
  41. 41. CAROTID CAVERNOUS FISTULA-IMAGING CT FINDINGS • Mild or striking proptosis • Prominent CS • Enlarged SOV • Enlarged EOM CECT • Enalrged SOV and CS
  42. 42. CAROTID CAVERNOUS FISTULA-IMAGING MRI • T1 – Bulging SOV and CS with flow voids • T2 – Asymmetric flow related signal loss in the affected veins
  43. 43. CAROTID CAVERNOUS FISTULA-IMAGING ANGIOGRAPHY DIRECT CCF • Rapid flow with early opacification of CS • Fistula may be noted in ICA segment INDIRECT 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
  44. 44. CAROTID CAVERNOUS FISTULA-IMAGING
  45. 45. 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
  46. 46. 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
  47. 47. 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 and intracatable CCF
  48. 48. 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
  49. 49. 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
  50. 50. VGAM – IMAGING MRI • Enlarged serpentine arterial feeders adjacent to the lesion
  51. 51. VGAM – IMAGING ANGIOGRAPHY 2 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
  52. 52. VGAM – IMAGING
  53. 53. VGAM – IMAGING ULTRASOUND • Antenatally • Hypoechoic to mildle echogenic midline mass behinf the third ventricle • CDFI : Bidirectional turbulent flow
  54. 54. CVMS WITHOUT AV SHUNTING
  55. 55. 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
  56. 56. DEVELOPMENTAL VENOUS ANOMALY CLINICAL FEATURES • Usually asymptomatic • Headache/seizures • H’age with FND ( if a/w cavernous malformation) • MC vascular malformation at autopsy
  57. 57. DEVELOPMENTAL VENOUS ANOMALY TREATMENT • Solitary DVA – no Rx • Histologically mixed – based on coexisting lesion
  58. 58. DEVELOPMENTAL VENOUS ANOMALY IMAGING • Location : MC near the frontal horn of ventricle • Size < 3cm • Usually solitary
  59. 59. DEVELOPMENTAL VENOUS ANOMALY NECT • Normal , enlarged draining vein may appear hyperdense CECT • Numerous linear or punctate enhancing foci and converge on single enlarged tubular draining vein
  60. 60. DEVELOPMENTAL VENOUS ANOMALY
  61. 61. 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
  62. 62. DEVELOPMENTAL VENOUS ANOMALY
  63. 63. DEVELOPMENTAL VENOUS ANOMALY • MRA – Arterial phase usually normal • MRV – MEDUSA HEAD drainage pattern
  64. 64. DEVELOPMENTAL VENOUS ANOMALY ANGIOGRAPHIC FINDINGS • Normal arterial and capillary phase • Venous phase – Medusa head appearance
  65. 65. 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
  66. 66. 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 )
  67. 67. CAVERNOUS MALFORMATION
  68. 68. 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
  69. 69. CAVERNOUS MALFORMATION TREATMENT OPTIONS • Total surgical removal via microsurgical resexn – for symptomatic lesions with recurrent H’age • Stereotactic Radiosx = for inaccessible lesions
  70. 70. CAVERNOUS MALFORMATION IMAGING CT – Hyperdense lesion with scatteres intralesional calcification
  71. 71. CAVERNOUS MALFORMATION-IMAGING MRI MR – DIAGNOSTIC Focal central heterogeneity(varying hemorrhage within caverns)- POPCORN appearance on T2WI Circumferential hypointense ring of hemosiderin form around high intense central areas
  72. 72. CAVERNOUS MALFORMATION-IMAGING ANGIOGRAPHY • No identifiable feeding arteries/veins • Negative unless mixed with other lesions
  73. 73. 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)
  74. 74. CAPILLARY TELANGIECTASIA CLINICAL FEATURES • Peak Presentation : 30-40 years • Usually silent, discovered incicdentally at imaging
  75. 75. CAPILLARY TELANGIECTASIA IMAGING • Usually <1cm CT – Usually Normal MR • 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
  76. 76. CAPILLARY TELANGIECTASIA
  77. 77. CAPILLARY TELANGIECTASIA
  78. 78. SINUS PERICRANII • Large transcalvarial communication between intra and extra-cranial venous drainage system • Mostly congenital • May be a/w other dva
  79. 79. 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
  80. 80. SINUS PERICRANII TREATMENT • Surgical removal of extracranial component- cosmetic purpose
  81. 81. SINUS PERICRANII- IMAGING CT NECT • Iso to hyperdense • Typically well demarcated calvarial defect CECT • Strong uniform enhancement
  82. 82. SINUS PERICRANII-IMAGING MRI • T1WI – iso • T2WI- Hyperintense ANGIOGRAM • 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
  83. 83. ENDOVASCULAR MANAGEMENT of CVM EMBOLIC AGENTS USED Liquid agents Acrylic glue • Chemically N-butyl cyanoacrylate • Polymerises on contact with hydroxyl ions in blood • Induces vasculitis and thereby thrombosis of AVM
  84. 84. 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
  85. 85. ENDOVASCULAR MANAGEMENT of CVM PARTICULATE AGENTS SILICONE SPHERES • First agents ever used • Mixed with Ba to make it radiopaque • Increased rebleeding rate
  86. 86. ENDOVASCULAR MANAGEMENT of CVM BALLOONS • Silicone or latex made • Occlude large AVM feeding arteries/high flow fistula • Replaced by coils POLY VINYL ALCOHOL • Delivered via guide wire dependent catheters(~500mics) • Flow dependent catheters (<350mics) • Clumping of particles causing slowing and then thrombosis
  87. 87. 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

×