eMedicine Specialties > Radiology > Brain/Spine
Brain, Venous Vascular Malformations: Imaging
Updated: Apr 21, 2009
Computed Tomography
Findings
Developmental venous anomalies are typically not visible on nonenhanced CT scans but they can be visualized after the administration of contrast medium. They appear as a large vascular structure in the brain parenchyma that drains into the deep or superficial venous system. The smaller surrounding veins are usually arranged in a radial pattern around the central vein. DVAs do not have a surrounding mass effect or edema and the adjacent brain is typically normal.
Degree of Confidence
The typical appearance of a DVA on CT scans is often diagnostic but MRI may be needed in atypical cases, particularly those involving the posterior fossa where CT is limited because of streak artifacts.
False Positives/Negatives
Although arteriovenous malformations can occasionally be mistaken for DVAs on CT scan and vice versa, differentiation between the two is usually not a problem because AVMs have large feeding arteries, tortuous vessels, and abnormal adjacent brain parenchyma that are not observed in DVAs.
Magnetic Resonance Imaging
Brain, venous vascular malformation. Axial T2 image from same patient as Images 5 and 6 shows that the DVA can be subtle. In this patient, the draining vein is large enough to have a flow void on the image. The parenchymal abnormality is typically not visible.
Brain, venous vascular malformation. Axial fluid-attenuated inversion recovery shows some artifactual increased signal within the vessel, which can aid in detection of DVAs on noncontrasted studies.
Brain, venous vascular malformation. On fast low-angle shot images, both the venous cluster and the draining vein may have mild susceptibility artifact (although not as much as hemosiderin) secondary to the deoxyhemoglobin within the slow-flowing veins (arrows).
Brain, venous vascular malformation. Axial T1 postcontrast demonstrates a large DVA originating from the frontal lobe white matter. Note the cluster of small vessels that form the large draining vein.
Brain, venous vascular malformation. Slightly higher image in the same patient as Image 10. The large draining vein is noted to drain into the superior sagittal sinus.
Findings
On contrast-enhanced MRI, the cluster of veins in developmental venous anomalies has a spoke-wheel appearance (see Image 6); the veins are small at the periphery and gradually enlarge as they approach a central draining vein (see Image 1, Image 2). This appearance has been referred to as caput medusa, or the head of Medusa, because of the serpentine appearance of the curvilinear peripheral draining veins. The intervening brain parenchyma is normal; this is a distinguishing characteristic of a DVA. However, two recent studies report parenchymal abnormalities within the drainage territory of most DVAs11,12
Brain, venous vascular malformation. Axial postcontrast image from the same patient as in Image above demonstrates the fine network of feeder veins that converge into the single draining vein.
Brain, venous vascular malformation. Coronal T1-weighted contrast-enhanced image obtained in a patient who had undergone surgery in the past for an arteriovenous malformation (AVM) shows bilateral developmental venous anomalies (DVAs) and the classic caput medusa appearance. Note the signal intensity abnormality in the inferior right cerebellar hemisphere due to the prior surgery.
Brain, venous vascular malformation. Coronal T1-weighted contrast-enhanced image clearly shows the draining vein and associated venous network of a developmental venous anomaly (DVA).
The draining vein has a fairly straight course toward the deep or superficial venous drainage system, depending on the location of the DVA. When it is adjacent to the lateral ventricles, the draining vein usually merges with a subependymal vein, which may be enlarged. Other DVAs may drain into cortical veins or dural sinuses in the supratentorial brain (see Images 10-11). Infratentorial DVAs have a variety of possible drainage pathways without a clearly dominant one.
Brain, venous vascular malformation. Axial proton density–weighted image in the same patient as image 2 demonstrates the high signal intensity of the draining vein, which is typical on images obtained with this sequence. Note the yin-yang appearance of the vessel with an area of decreased signal intensity adjacent to the area with increased signal intensity.
On T2- and proton density–weighted images, the draining vein may demonstrate increased signal intensity, particularly on standard spin-echo images. This appearance is caused by gradient moment nulling. If the vessel is obliquely oriented, a yin-yang symbol appearance may occur because the high signal intensity is misregistered and a signal void appears next to a similarly shaped area of increased signal intensity (see Image 3). In the absence of an accompanying vascular malformation, the surrounding brain tissue should have normal characteristics on T2-weighted images (see Image 7), although a case in which gliosis surrounded a DVA has been reported. Nonenhanced T1 images may show the draining vein as a flow void but DVAs are often difficult to visualize without the use of contrast medium. Fluid-attenuated inversion recovery (FLAIR) images may be relatively normal or can show a subtle increased signal (see Image 8).
Gradient-echo images often show decreased signal intensity in the venous angioma that is not due to hemosiderin but is secondary to the paramagnetic effects of deoxyhemoglobin in the venous blood (see Image 9). Findings on diffusion images are usually normal.
Magnetic resonance (MR) venography is almost never necessary. If obtained, venograms show the draining vein with some of the surrounding radially arranged veins. Because the DVA provides the venous drainage for a section of brain, anatomically normal venous drainage is not present in that area.
Because DVAs are often associated with other CNS vascular lesions (particularly cavernous angiomas), when a DVA is identified, carefully evaluate the brain and obtain gradient-echo (GRE) images (see Image 4). Cavernomas typically appear as focal areas of blood products that often show different stages of evolution (ie, hemosiderin with extracellular methemoglobin). Capillary telangiectasias are small areas of lacelike enhancement that are dark on GRE images without signal intensity abnormality on T2-weighted images. AVMs have enlarged feeding arteries and tortuous vessels with surrounding gliosis.
Degree of Confidence
MRI findings are diagnostic in almost all instances. However, in cases with questionable findings, MR venography usually suggests the diagnosis.
Angiography
Findings
Developmental venous anomalies found on angiograms are almost invariably incidental findings, as they are with newer MRIs, and the diagnosis can be made in almost every instance. When observed, the DVA appears as a blush of contrast enhancement during the venous phase of the study and drains into a large anatomically anomalous vein. In its most frequent location (adjacent to the lateral ventricles), the vein usually drains into a subependymal vein, although superficial drainage also occurs.
Degree of Confidence
A DVA has a characteristic angiographic appearance and should not be confused with an AVM; no early filling occurs with a DVA.
More on Brain, Venous Vascular Malformations |
| Overview: Brain, Venous Vascular Malformations |
 Imaging: Brain, Venous Vascular Malformations |
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References
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Further Reading
Related eMedicine topics
Arteriovenous Malformations
Chiari Malformation
Intracranial Arteriovenous Malformation
Brain, Arteriovenous Malformation
Chiari I Malformation
Chiari II Malformation
Brain, Capillary Telangiectasia
Clinical guidelines
ACR Appropriateness Criteria® cerebrovascular disease. American College of Radiology - Medical Specialty Society. 1996 (revised 2006). 20 pages. NGC:005545
Clinical trials
Diagnosis of Hemangiomas and Vascular Malformations
Influence of MMP on Brain AVM Hemorrhage
Comparison of Abnormal Cortical Development in Brain Malformations on Postmortem Imaging With Autopsy
A Randomized Trial of Unruptured Brain AVMs
Brain Development Research Program
Keywords
venous vascular malformation, brain venous vascular malformation, developmental venous anomaly, DVA, venous angioma, cavernous angioma, arteriovenous malformation, capillary telangiectasia
