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Intracranial Arteriovenous Shunting Detection with Arterial Spin-Labeling and Susceptibility-Weighted Imaging: Potential Pitfall of a Venous Predominant Parenchymal Arteriovenous Malformation

Intracranial Arteriovenous Shunting Detection with Arterial Spin-Labeling and... LETTERS Intracranial Arteriovenous Shunting Detection with Arterial Spin-Labeling and Susceptibility-Weighted Imaging: Potential Pitfall of a Venous Predominant Parenchymal Arteriovenous Malformation 1 4 read with great interest the study of Hodel et al, which demon- dilated medullary veins. These lesions consistently showed a ca- Istrated that the combined use of arterial spin-labeling (ASL) put medusa appearance very similar to the appearance of DVAs, and susceptibility-weighted imaging was significantly more sen- with the absence of enlarged arterial feeders and lack of a typical sitive and equally specific compared with conventional angio- AVM nidus. graphic MR imaging for the detection of arteriovenous shunting. In summary, a lesion with increased signal intensity on an ASL In Fig 2 of this article, a lesion with increased signal intensity on map is suspicious for arteriovenous shunting, and a caput medusa ASL images was subsequently confirmed as a developmental ve- appearance on the venous phase of a cerebral angiogram is not nous anomaly (DVA) based on the presence of a classic umbrella- sufficient to make the diagnosis of DVA. Careful attention to the shaped appearance on the venous phase cerebral angiogram. arterial phase of the angiogram would be prudent to exclude a Most DVAs are not associated with perfusion changes on ASL venous-predominant parenchymal arteriovenous malformation. imaging. In a large study of 652 DVAs, only a minority of DVAs (8%) demonstrated signal abnormalities on ASL maps, and in- REFERENCES trinsically increased ASL signal or increased signal in a draining 1. Hodel J, Leclerc X, Kalsoum E, et al. Intracranial arteriovenous vein associated with a DVA are potentially imaging biomarkers of shunting: detection with arterial spin-labeling and susceptibility- 2,3 arteriovenous shunting. It may be argued that the presence of a weighted imaging combined. AJNR Am J Neuroradiol 2017;38:71–76 typical venous phase cerebral angiogram with a caput medusa CrossRef Medline 2. Iv M, Fischbein NJ, Zaharchuk G. Association of developmental ve- appearance will confirm the DVA. However, direct arteriovenous nous anomalies with perfusion abnormalities on arterial spin label- shunting into dilated medullary veins characteristic of a DVA ing and bolus perfusion-weighted imaging. J Neuroimaging 2015;25: without a typical nidus has been repeatedly reported in the liter- 243–50 CrossRef Medline ature. These arterialized DVAs have been described with various 3. Nabavizadeh SA, Mamourian AC, Vossough A, et al. The many faces terminology, but Im et al proposed the name of “venous-pre- of cerebral developmental venous anomaly and its mimicks: spec- trum of imaging findings. J Neuroimaging 2016;26:463–72 CrossRef dominant parenchymal AVMs” on the basis of clinical, angio- Medline graphic, surgical, and histologic findings in a series of 15 cases. Of 4. Im SH, Han MH, Kwon BJ, et al. Venous-predominant parenchymal note, the cerebral angiograms of these lesions demonstrated an arteriovenous malformation: a rare subtype with venous drainage abnormal blush in the early arterial phase, followed by diffuse pattern mimicking developmental venous anomaly. J Neurosurg vascular and capillary parenchymal staining in the mid-arterial 2008;108:1142–47 CrossRef Medline X S.A. Nabavizadeh phase and immediate drainage into a network of radially arranged Department of Radiology Hospital of University of Pennsylvania Perelman School of Medicine at the University of Pennsylvania http://dx.doi.org/10.3174/ajnr.A5108 Philadelphia, Pennsylvania E32 Letters May 2017 www.ajnr.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Neuroradiology American Journal of Neuroradiology

Intracranial Arteriovenous Shunting Detection with Arterial Spin-Labeling and Susceptibility-Weighted Imaging: Potential Pitfall of a Venous Predominant Parenchymal Arteriovenous Malformation

Nabavizadeh, S.A.
American Journal of Neuroradiology , Volume 38 (5) – May 1, 2017
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Publisher
American Journal of Neuroradiology
Copyright
© 2017 by American Journal of Neuroradiology
ISSN
0195-6108
eISSN
1936-959X
DOI
10.3174/ajnr.A5108
Publisher site
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Abstract

LETTERS Intracranial Arteriovenous Shunting Detection with Arterial Spin-Labeling and Susceptibility-Weighted Imaging: Potential Pitfall of a Venous Predominant Parenchymal Arteriovenous Malformation 1 4 read with great interest the study of Hodel et al, which demon- dilated medullary veins. These lesions consistently showed a ca- Istrated that the combined use of arterial spin-labeling (ASL) put medusa appearance very similar to the appearance of DVAs, and susceptibility-weighted imaging was significantly more sen- with the absence of enlarged arterial feeders and lack of a typical sitive and equally specific compared with conventional angio- AVM nidus. graphic MR imaging for the detection of arteriovenous shunting. In summary, a lesion with increased signal intensity on an ASL In Fig 2 of this article, a lesion with increased signal intensity on map is suspicious for arteriovenous shunting, and a caput medusa ASL images was subsequently confirmed as a developmental ve- appearance on the venous phase of a cerebral angiogram is not nous anomaly (DVA) based on the presence of a classic umbrella- sufficient to make the diagnosis of DVA. Careful attention to the shaped appearance on the venous phase cerebral angiogram. arterial phase of the angiogram would be prudent to exclude a Most DVAs are not associated with perfusion changes on ASL venous-predominant parenchymal arteriovenous malformation. imaging. In a large study of 652 DVAs, only a minority of DVAs (8%) demonstrated signal abnormalities on ASL maps, and in- REFERENCES trinsically increased ASL signal or increased signal in a draining 1. Hodel J, Leclerc X, Kalsoum E, et al. Intracranial arteriovenous vein associated with a DVA are potentially imaging biomarkers of shunting: detection with arterial spin-labeling and susceptibility- 2,3 arteriovenous shunting. It may be argued that the presence of a weighted imaging combined. AJNR Am J Neuroradiol 2017;38:71–76 typical venous phase cerebral angiogram with a caput medusa CrossRef Medline 2. Iv M, Fischbein NJ, Zaharchuk G. Association of developmental ve- appearance will confirm the DVA. However, direct arteriovenous nous anomalies with perfusion abnormalities on arterial spin label- shunting into dilated medullary veins characteristic of a DVA ing and bolus perfusion-weighted imaging. J Neuroimaging 2015;25: without a typical nidus has been repeatedly reported in the liter- 243–50 CrossRef Medline ature. These arterialized DVAs have been described with various 3. Nabavizadeh SA, Mamourian AC, Vossough A, et al. The many faces terminology, but Im et al proposed the name of “venous-pre- of cerebral developmental venous anomaly and its mimicks: spec- trum of imaging findings. J Neuroimaging 2016;26:463–72 CrossRef dominant parenchymal AVMs” on the basis of clinical, angio- Medline graphic, surgical, and histologic findings in a series of 15 cases. Of 4. Im SH, Han MH, Kwon BJ, et al. Venous-predominant parenchymal note, the cerebral angiograms of these lesions demonstrated an arteriovenous malformation: a rare subtype with venous drainage abnormal blush in the early arterial phase, followed by diffuse pattern mimicking developmental venous anomaly. J Neurosurg vascular and capillary parenchymal staining in the mid-arterial 2008;108:1142–47 CrossRef Medline X S.A. Nabavizadeh phase and immediate drainage into a network of radially arranged Department of Radiology Hospital of University of Pennsylvania Perelman School of Medicine at the University of Pennsylvania http://dx.doi.org/10.3174/ajnr.A5108 Philadelphia, Pennsylvania E32 Letters May 2017 www.ajnr.org

Journal

American Journal of Neuroradiology – American Journal of Neuroradiology

Published: May 1, 2017

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