C V M - JULY.pptx

8/16/2019 C V M - JULY.pptx

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DEFINITION

• Cerebrovascular malforma!o"s #CVMs$ area %eero&e"eous &rou's of (!sor(ers %are'rese" mor'%o&e"e!c errors a)ec!"&

arer!es* ca'!llar!es* ve!"s or var!ouscomb!"a!o" of vessels+

• Develo'me" of %e %uma" feal vasculars,sem occurs v!a o relae( 'rocesses.

/+ Vasculo&e"es!s+

0+ A"&!o&e"es!s+



CLASSIFICATION

HISTO1ATHOLO2ICAL CLASSIFICATION

#/$ arer!ove"ous malforma!o"s#AVMs$#0$ ve"ous a"&!omas #(evelo'me"al

ve"ous a"omal!es$

#3$ ca'!llar, ela"&!ecas!as+#4$ caver"ous malforma!o"s+

FUNCTIONAL CLASSIFICATION

#/$CVMs %a (!s'la, arer!ove"ouss%u"!"&+

#0$CVMs !%ou AV s%u"!"& .



Arteriovenous Malformation

• Arer!ove"ous malforma!o" #AVM$ !s a !&%l, 'ac5e(6s"arl7 of %!"-alle( vessels !% (!rec arer!al ove"ous s%u"!"&+ T%ere !s "o !"erve"!"& ca'!llar, be(+Mos bra!" AVMs #BAVMs$ are 'are"c%,mal les!o"s a"(

are also calle( 6'!al AVMs7• AVMs are co"&e"!al (efecs of vascular (evelo'me"

c%aracer!8e( b, (,sre&ulae( a"&!o&e"es!s+

• Mos AVMs are sol!ar,+ Mul!'le AVMs are almosala,s s,"(rom!c+ Commo" assoc!a!o"s !"clu(ehereditary hemorrhagic telangiectasia (HHT, alsoknown as Rendu-Osler-Weber disease) andWyburn mason syndrome.

• Over !" o# $%&s are su'ratentorial, located in

the cerebral hemis'heres. Only !" are #ound inthe 'oser!or fossa++



7-1. Graphic depicts AVM nidus with intranidal aneurysm ,feeding artery (pedicle!" aneurysm and enlarged drainingveins .





7-#. $%&' scan (upper left" and &'A images in a patientwith spontaneous cereellar hemorrhage demonstratean underlying AVM . Appro)imately 1*+ of AVMs are



7-*A. A)ial '1 in a /-yearold man with headache

shows a classic wedge-shaped left parietal AVM withmultiple serpentine 0ow voids! . A few linear foci of '1shortening represent thromosed vessels within thenidus.

7-*. '/ in the same patient nicely demonstrates the

wedge of 0ow voids! . 'he road ase toward thecorte) with ape) pointing toward the lateral ventricle is



-!*. +$R scan demonstrates minimal hy'erintensitywithin and around the $%& , suggesting small #oci o# glioticbrain. -!. T */ scan shows some linear and ser'entineareas o# enhancement that are mostly in draining veins.



-!0. ateral 1$ shows enlarged &*$, $*$ #eeding vesselswith a tangle o# smaller vessels in the wedgesha'ed nidus .+aint o'aci2cation o# the su'erior sagittal sinus re'resentsarteriovenous shunting o# contrast.-!+. ate arterial 'hase o# the 1$ shows the nidus and

3early draining4 veins em'tying into the 111 . 5o dee'venous drainage was identi2ed. 1'et6ler-&artin grade 7





-8*. T<= >R0 shows no gross evidence o# hemorrhage. -8. T */ +1 scan shows that the ser'entine 3:ow voids4enhance strongly, uni#ormly.



1?0T@0R-&$RT5 $%& >R$5>1*$0

•1i6e

• Small #9 3 cm$ : /

• Me(!um #3-; cm$ : 0

•

Lar&e #< ; cm$ : 3• 0loAuence o# $dBacent ;rain

• No"elo=ue" : >

•

Elo=ue" : /• %enous rainage

• Su'er?c!al o"l, : >

•

Dee' com'o"e" : /



cerebral 'roli#erative angio'athy

-$. 1$ o# selective internal carotid angiogram in a 'atientwith cerebral 'roli#erative angio'athy shows innumerable

dilated vascular s'aces with no dominant #eeding arteries.



DURAL AV FISTULA

-C. >ra'hic de'icts d$%+ with thrombosed transversesinus with multi'le tiny arteriovenous in the dural wall .

esion is mostly su''lied by transosseous #eeders #rom



-. ;one *T in the 'atient with tinnitus shows multi'leenlarged transosseous vascular channels in the sAuama o#the right occi'ital bone.



-*. *ontrast-enhanced &R$ source image shows duralsinus thrombosis , multi'le enhancing vascular channelscharacteristic o# 'osterior #ossa d$%+. -. &R$ in the same 'atient shows innumerable tiny#eeding arteries su''lying a d$%+ at the transverse-sigmoid sinus Bunction. The sinus has 'artially



7-1/A. 34A of the e)ternal carotid artery in a patient withtinnitus, dAV5 in the occluded transverse sinus supplied ythe middle meningeal artery , transosseous ranches fromthe %&A.



-7$. T<W in a D-year-old man with right-sided trigeminalneuralgia shows a tangle o# vessels in the &eckel cave andcerebello'ontine angle cistern associated with a large 3:owvoid4 .-7;. 1$ o# right *$ angiogram shows that the tangle o#vessels is su''lied by enlarged dural branches o# the *$and 2stuli6es directly into an enlarged 3early draining4



*ognard *lassi2cation

• T%e *ognard classi2cation of (ural arer!ove"ous

?sulas correlaes ve"ous (ra!"a&e 'aer"s !%!"creas!"&l, a&&ress!ve "eurolo&!cal cl!"!cal course+

• ty'e - co"?"e( o s!"us all* ,'!call, afer %rombos!s+

• ty'e

– a - co"?"e( o s!"us !% reu #rero&ra(e$ !"o s!"us bu "ocor!cal ve!"s

– b - (ra!"s !"o s!"us !% reu #rero&ra(e$ !"o cor!cal ve!"s#/>-0> %aemorr%a&e$

• ty'e - (ra!"s (!recl, !"o cor!cal ve!"s #"o !"os!"us$ (ra!"a&e #4> %aemorr%a&e$

• ty'e % - (ra!"s (!recl, !"o cor!cal ve!"s #"o !"o

s!"us$ (ra!"a&e !% ve"ous ecas!a #; %aemorr%a&e$

• ty'e % - s'!"al 'er!me(ullar, ve"ous (ra!"a&e*assoc!ae( !% 'ro&ress!ve m,elo'a%,

http://radiopaedia.org/articles/dural-arteriovenous-fistula









BORDEN CLASSIFICATION• T%e ;orden classi2cation of (ural arer!ove"ous

?sulas #DAVF$ &rou's %ese les!o"s !"o %ree ,'es base(u'o" %e s!e of ve"ous (ra!"a&e a"( %e 'rese"ce or abse"ce

of cor!cal ve"ous (ra!"a&e• ty'e

– (ra!"a&e !"o a me"!"&eal ve!"s* s'!"al e'!(ural ve!"s or !"o a (uralve"ous s!"us

– "ormal a"ero&ra(e o !" bo% %e (ra!"!"& ve!"s a"( o%er ve!"s

(ra!"!"& !"o %e s,sem – e=u!vale" o Co&"ar( ,'e I a"( IIa* !% a favourable "aural

%!sor, 0*4

• ty'e – (ra!"a&e !"o me"!"&eal ve!"s* s'!"al e'!(ural ve!"s or !"o a (ural

ve"ous s!"us

– rero&ra(e o !"o %e "ormal subarac%"o!( ve!"s

– e=u!vale" o Co&"ar( ,'e IIb a"( IIab

• ty'e – (!rec (ra!"a&e !"o subarac%"o!( ve!"s or !"o a" !solae( se&me" of

ve"ous s!"us #%!c% resuls from a %rombos!s o" e!%er s!(es of %e

(ural s!"us se&me"$ – e=u!vale" o Co&"ar( ,'e III* IV a"( V










carotid-cavernous 2stula

-D. *oronal gra'hic de'icts a carotid-cavernous 2stula

(**+). The right cavernous sinus is enlarged by numerousdilated arterial and venous channels.



-8. *linical 'hotogra'h o# a 'atient with a **+ showsnumerous enlarged scleral vessels . -. *0*T scan shows classic 2ndings o# **+. The rightcavernous sinus is enlarged , and the i'silateral su'erioro'hthalmic vein is more than D times the si6e o# the le#tsu'erior o'hthalmic vein .



-. T<W shows ty'ical &R 2ndings o# **+ with anenlarged right cavernous sinus containingnumerousabnormal 3:ow voids4 .-C. ateral 1$ in a case o# direct **+ in a <-year-oldwomanwith multi'le skull base #ractures shows that the

*$ narrows be#ore terminating in a large venous'ouch .High-'ressure venous re:u9 into the su'erior and in#erior



vein o# >alen mal#ormation

-<<. >ra'hic illustrates vein o# >alen mal#ormation. 0nlargedchoroid arteries drain directly into dilated median'rosence'halic vein (&?%) , #alcine sinus . Torcular hero'hili

(venous sinus con:uence) is massively enlarged



-<7. *0*T scan in a newborn demonstrates a massive%>$& draining into an enlarged #alcine sinus, causingobstructive hydroce'halus.



-<D$. 1agittal T<W shows 'rominent arteries su''lying anenlarged median 'rosence'halic vein .5ote enlarged #alcinesinus .



7-/#. 34A in the same patient shows that the VGAM issupplied y multiple direct arterial 2stulas



-<!. 5eonatal transcranial F1 shows a large %>$& 'osterior tothe 7rd ventricle. ?rominent vessel1 with arterial :ow su''lythe lesion.



DEVELO1MENTAL VENOUSANOMAL GVENOUS AN2IOMA

-<8. >ra'hic de'icts %$ with enlarged medullary veinsdraining into a single transmantle collector vein





-<C. T */ &R scans show classic 2ndings o# %$ withenlarged W& veins draining into a large collector vein . Thiswas an incidental 2nding in an asym'tomatic 'atient





15F1 ?0R*R$5

-7D. *oronal gra'hic de'icts a classic sinus 'ericranii (1?)with an e9'anded venous 'ouch under the scal' connectingto the intracranial venous system through a transcalvarialchannel . 1ome 1?s are associated with a develo'mentalvenous anomaly . -7!. 1agittal *T% shows a small sinus 'ericranii connecting

to the su'erior sagittal sinus through an adBacent skull de#ect



-78. *oronal contrastenhanced 1?>R scan shows aclassic sinus 'ericranii that connects to the su'eriorsagittal sinus via a small transcalvarial venous channel .-7. ate venous 'hase 1$ shows angiogra'hic 2ndings

o# sinus 'ericranii with enlarged venous 'ouchesconnectin directl to the su erior sa ittal sinus throu h



CEREBRAL CAVERNOUS MALFORMATION

-7. 1ubacute , classic 3'o'corn ball4 a''earances o# **&s.&icrohemorrhages are seen as multi#ocal 3blooming blackdots



-DG$. 50*T in a 'atient with #amily history o# **& shows

'unctate hy'erdense lesion in the 'osterior limb o# the le#tinternal ca'sule-DG;. 50*T scan obtained 8 years later when the 'atientdevelo'ed acute right hemi'aresis shows that the lesion hasmarkedly enlarged.



-DG*. T<W shows classic 3'o'corn ball4 a''earance withlocules o# blood in dierent stages o# evolution surrounded byhemosiderin rim



-D<$. T<W in a 'atient with multi'le cerebral cavernousmal#ormations shows a large le#t #rontal lesion with a :uid-:uid level . &ulti'le other hy'ointense lesions are 'resent .-D<;. T<= 1W shows innumerable 3blooming black dots4characteristic o# @abramski ty'e D **& ('unctatemicrohemorrhages).T<= scans are much more sensitive than +10 T<W in



• @$;R$&1I *$11+*$TO5 O+ **&s

• Ty'e J 1ubacute hemorrhage

•

H,'er!"e"se o" T/* %,'er-G%,'o!"e"se o" T0

• Ty'e <J ierent age hemorrhages

• Class!c : 6'o'cor" ball7

• M!e( s!&"al !% %,'erG%,'o o" bo% T/a"( T0

• Loo5 for bloo(-?lle( locules !% u!(-u!(

levels• Ty'e 7J *hronic hemorrhage

• Ty'e DJ ?unctate microhemorrhages

• 6Bloom!"& blac5 (os7 o" T0 #2RE* SI$



capillary telangiectasia

7-##. Graphic depicts pontine capillary telangiectasia withtiny dilated capillaries interspersed with normal rain





7-#7&. 58A9 scan shows faint patchy hyperintensity in the pons.7-#73. '/: G9% scan shows suscepti'iity eect with grayishhypointensity in the mid pons.



7-#7%. '1 &; scan shows the rush-lie faint enhancementthat is characteristic of capillary teangiectasia..



CONCLUSION

• Ulra sou"( eam!"a!o" %as a l!m!e( role!" %e (!a&"os!s of CVM+

• CT a"( MRI evalua!o" !s %el'ful !" %e

local!8a!o" of %e malforma!o"+• CTA * MRA a"( 3D reco"sruc!ve !ma&es

&!ve a" !"s!&% abou %e ee" of %emalforma!o"s+

• DSA !s %e &ol( sa"(ar( mo(al!, for %eevalua!o" of maJor!, of %e malforma!o"s+



THANK OU

• TUESDA /4G>G0>/

• DEMO . ANOMAL US2 B DRSIDDA11A

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C V M - JULY.pptx