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MR Evaluation of Developmental Venous Anomalies: Medullary Venous Anatomy of Venous Angiomas

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MR Evaluation of Developmental Venous Anomalies: Medullary Venous Anatomy of Venous Angiomas MR Evaluation of Developmental Venous Anomalies: Medullary Venous Anatomy of Venous Angiomas Charles Lee, Michael A. Pennington, and Charles M. Kenney III PURPOSE: To present characteristic MR findings of developmental venous anomalies (DVAs) in terms of location of caput and draining veins, to correlate these findings with normal medullary venous anatomy, and to suggest an approach to the evaluation of DVAs by means of MR imaging. METHODS: We reviewed the contrast-enhanced MR examinations of 61 patients with DVA, which were selected from 4624 consecutive cranial MR examinations. Site of the DVA and size and direction of draining veins were recorded. RESULTS: Seventy-two DVAs with 78 draining veins were located: 18 were juxtacortical, 13 were subcortical, and 41 were periventricular or deep. Twenty-six of the DVA caputs were frontal, 16 were parietal, 13 were in the brachium pontis/ dentate, seven were in the temporal lobe, three were in the cerebellar hemisphere, three were in the occipital lobe, three were in the basal ganglia, and one was in the pons. The draining veins were superficial in 29 cases and deep in 49. Of the 36 supratentorial deep draining veins, 16 were in the trigone/occipital horn, 11 were in the mid-body of the lateral ventricle, seven were in the frontal horn, and two were in the temporal horn. Among the 14 infratentorial deep draining veins, five were in the lateral recess of the fourth ventricle, four were anterior transpontine veins, three were lateral transpontine veins, and two were precentral cerebellar veins. CONCLUSION: The DVA caputs and their draining veins occurred in typical locations that could be predicted from the normal medullary venous anatomy, with the frontal, parietal, and brachium pontis/dentate being the most common locations. Drainage can occur in superficial cortical veins or sinuses or in deep ventricular veins or in both, no matter where the caput is located. Whether drainage was superficial or deep could not be predicted on the basis of the site of the DVA caput. Contrast-enhanced T1-weighted MR images showed the DVAs best, but diagnosis could be made from T2-weighted MR images. Index terms: Angioma; Brain, anatomy; Brain, magnetic resonance; Veins, abnormalities and anomalies AJNR Am J Neuroradiol 17:61–70, January 1996 Developmental venous anomalies (DVAs), DVAs (1). Contrast-enhanced computed to- also known as venous angiomas, are becoming mography (CT), which is no doubt responsible the most commonly encountered intracranial for the recent increase in the number of reported vascular lesion in central nervous system imag- cases of DVA, is yielding to the far superior ing (1). Most DVAs are asymptomatic or un- imaging ability of magnetic resonance (MR) as complicated, and surgery is no longer consid- it becomes routinely available. MR imaging is ered necessary. Although cerebral angiography thus becoming the primary study of choice and is the definitive study of choice, it, too, is no the means by which diagnosis of DVA is veri- longer judged necessary with uncomplicated fied. Although the exact pathogenesis of DVA is unknown, there appears to be a congenital ba- Received February 10, 1995; accepted after revision July 7. sis (2–4). DVAs can be found in children in From the Department of Radiology, University of Kentucky Medical whom absence of normal draining veins are Center, Lexington. Address reprint requests to Charles Lee, MD, Department of Radiology, seen in the region of the DVA verified by au- University of Kentucky Medical Center, 800 Rose St, HX-3150, Lexington, topsy, surgery, or angiography. The DVA and KY 40536. its draining vein become a compensatory ve- AJNR 17:61–70, Jan 1996 0195-6108/96/1701–0061 nous drainage system (5). Because no angioma q American Society of Neuroradiology or malformation is present with DVA, Lasjau- 61 62 LEE AJNR: 17, January 1996 nias et al proposed the name be changed from views beyond the standard, routine cerebral study were not venous angioma to developmental venous obtained. anomalies (6). These authors believed that DVA DVAs were defined as vascular lesions with multiple represented nonpathologic variations of venous enlarged vessels converging on a single (sometimes mul- tiple) dilated parenchymal vessel. Without cerebral an- drainage. giography it was difficult to determine whether the en- Currently, DVA is thought to represent a pri- larged vessel was arterial or venous; however, the location mary dysplasia of capillaries and small transce- of the vessels and their proximity to and junction with rebral veins (7) or a compensatory mechanism known venous structures suggested that they were indeed caused by an intrauterine accident resulting in venous structures, and probably medullary veins. The thrombosis of normal venous pathways (8). Be- classical fan-shaped caput medusae was not always ap- cause dilated medullary veins can be found with parent in each case, with the multiple vessels appearing as glioblastomas, Huang et al proposed that these linear, curvilinear, or dotlike structures, depending on the vessels may arise from reactivation of embry- orientation of the vessel with respect to the plane of imag- onic or fetal vascular remnants in response to ing. an increase in vascularity supplying the tumor The DVAs were also classified by location as juxtacor- tical, subcortical, and deep, according to Valavanis et al or in response to hypoplasia or aplasia of the (2). Juxtacortical (or superficial) was defined as within the normal venous structures caused by a throm- gray matter or at the gray-white junction. Subcortical was botic intrauterine event (3). defined as below the juxtacortical region but not adjacent The purpose of this article is to present our to the ventricular wall. Deep (or periventricular) was de- findings with MR imaging of DVA and to com- fined as adjacent to the lateral, third, or fourth ventricle or pare our experience with that of others. We dis- within the center of the structure, such as the pons. Su- cuss the normal medullary venous anatomy of pratentorial deep DVAs were defined as being adjacent to the cerebrum and cerebellum as it relates to the frontal horn, the mid-body of the lateral ventricle, the DVA and present the characteristic locations of temporal horn, the trigone, or the occipital horn. Infraten- the caput medusae and draining veins. Because torial deep DVAs were those adjacent to the fourth ventri- most DVAs are uncomplicated and MR is usu- cle within the brachium pontis or dentate nucleus. The terminal or draining vein to which the caput medu- ally the imaging technique of choice, we also sae joins was classified as either a deep or superficial suggest a diagnostic approach using MR imag- draining vein. In the supratentorial compartment, superfi- ing. cial draining veins were identified as those that joined either a cortical vein or the sagittal sinus. Deep draining veins were identified as those that joined the subependy- Materials and Methods mal veins of the lateral ventricles and ultimately the vein of We reviewed and recorded the MR findings in 61 pa- Galen. In the infratentorial compartment, superficial drain- tients with DVA culled from 4624 consecutive contrast- ing veins were identified as those that joined the cerebellar enhanced cerebral MR examinations performed on a 1.5-T hemispheric veins, superior and inferior vermian veins, MR unit. Either 0.1 mmol/kg gadopentetate dimeglumine transverse or sigmoid sinus, and torcula. Deep draining or 0.1 mmol/kg or 0.3 mmol/kg gadoteridol was given to veins were those that joined the subependymal veins of the each patient. Standard T1- and T2-weighted spin-echo fourth ventricle and thus either the anterior or lateral tran- pulse sequences were used. First-order-motion compen- spontine veins, or laterally and inferiorly to the veins of the sation or gradient-moment nulling was routinely used for lateral recess of the fourth ventricle, or superiorly to the all MR images. Of the 61 patients, 28 had coronal images precentral cerebellar vein. in addition to the usual transaxial images. Another 14 patients had two-dimensional time-of-flight MR angiogra- Results phy done for reasons other than verifying the DVA. Con- trast-enhanced CT scans were obtained in 18 of the 61 Sixty-one patients had a total of 72 DVAs and patients and cerebral angiograms were obtained in six 78 draining veins. Twenty-nine patients were patients for reasons other than verifying the presence of male and 32 were female; ages ranged from 4 DVA. months to 71 years (mean age, 37 years). All cases of DVA were identified retrospectively from Seven were children younger than 10 years old dictated reports. A second review was conducted to elim- and six were teenagers. Fifty-one patients had inate questionable DVA and other anomalies that did not fit the diagnostic criteria for DVA. Therefore, a true preva- single DVAs, nine patients had two DVAs, and lence figure may not be valid, because some of the DVAs one patient had three DVAs. Fifty-four DVAs may not have been reported initially and thus may have were supratentorial and 18 were infratentorial. been missed in the retrospective review. Because the ma- Thirty-five were on the right side, 31 on the left jority of the DVAs were incidental findings, additional side, and three were bilateral. AJNR: 17, January 1996 DEVELOPMENTAL VENOUS ANOMALIES 63 There were 18 juxtacortical, 13 subcortical, face or deep into the subependymal veins in the and 41 periventricular or deep DVAs, located in walls of the ventricles. the frontal (n 5 26), parietal (n 5 16), brachium In 1968 Constans et al (10) provided radio- pontis/dentate (n 5 13), temporal (n 5 7), cer- logic description of two cases of DVA. Since ebellar hemisphere (n 5 3), occipital (n 5 3), then, numerous radiographic studies of DVA basal ganglia (n 5 3), and pontine (n 5 1) have been reported (1, 2, 6–8, 10–15).
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