Before today’s cases I will review some important terms.
AVMs / CAVMs
CAVMs also known as classic brain AVMs, are a common form of cerebral vascular malformation and are composed of a nidus of vessels through which arteriovenous shunting occur.
Arteriovenous malformations (AVMs)
Cerebral arteriovenous malformations (CAVMs)
When an arteriovenous malformation (AVM) occurs, a tangle of blood vessels directly diverts blood from the arteries to the veins.
1. Cavernous hemangioma
Cavernous hemangioma, also called cavernous angioma, or cavernoma (often when referring to presence in the brain), is a type of blood vessel malformation or hemangioma, where a collection of dilated blood vessels form a tumor.
Because of this malformation, blood flow through the cavities, or caverns, is slow. Additionally, the cells that form the vessels do not form the necessary junctions with surrounding cells. Also, the structural support from the smooth muscle is hindered, causing leakage into the surrounding tissue. It is the leakage of blood, known as a hemorrhage from these vessels that causes a variety of symptoms known to be associated with this disease.
- 65 yo female, brain infarction after aneurysm
– infarction as a complication-
- Cerebral Vasospasm
By definition, cerebral vasospasm is narrowing of a cerebral blood vessel and causes reduced blood flow distally, which may lead to delayed ischemic deficit and cerebral infarction if left untreated.
- Vasospasm can decrease cerebral perfusion to an area, causing ischemia and perhaps infarction, and can lead to further deterioration of neurological function.
Below is example from a journal: Figure 1: CT scan on Day 0 shows subarachnoid hemorrhage with intraventricular and intraparenchymal hemorrhage. CT angio on day 0 showed right middle cerebral artery aneurysm. On day 4 and 10, CT scan showed resolving hematoma without hydrocephalus. On day 13, an infarct was seen in the right basal ganglia with resolving hematoma. On day 16 and 20, bilateral infarcts were seen in both the basal ganglia and internal capsule.
2. We looked at a case of ear pain, but found no abnormailities
3. 78 yo male, head injury after gingival cancer operation, checked for bone fracture in skull, checked for intracranial hemorrhage, older brain – showed lacunar infarction
An intracranial hemorrhage is a type of bleeding that occurs inside the skull (cranium). Bleeding around or within the brain itself is known as a cerebral hemorrhage (or intracerebral hemorrhage). Bleeding caused by a blood vessel in the brain that has leaked or ruptured (torn) is called a hemorrhagic stroke
- due to fibrinoid degeneration.
4. 52 yo female, neuromyolitis optica (autoimmune disease), L4,5 spondylolisthesis, C4,5 & 5,6 dural sac indentation
Dx : The Mayo Clinic proposed a revised set of criteria for diagnosis of Devic’s disease in 2006. Those new guidelines require two absolute criteria plus at least two of three supportive criteria. In 2015 a new review was published by an international panel refining the previous clinical case definition but leaving the main criteria unmodified:
- Brain MRI not meeting criteria for MS at disease onset
- Spinal cord MRI with contiguous T2-weighted signal abnormality extending over three or more vertebral segments, indicating a relatively large lesion in the spinal cord
- NMO-IgG seropositive status (The NMO-IgG test checks the existence of antibodies against the aquaporin 4 antigen.)
Neuromyelitis optica (NMO), also known as Devic’s disease or Devic’s syndrome, is a heterogeneous condition consisting of the simultaneous inflammation and demyelination of the optic nerve (optic neuritis) and the spinal cord (myelitis).
Spondylolisthesis is the forward displacement of a vertebra, especially the fifth lumbar vertebra, most commonly occurring after a fracture. Backward displacement is referred to as retrolisthesis.
5. 35 yo male, skull injury, degenerative change in cervical spine
Sometimes radiologists use templates for reporting. Click below image to see examples:
6. 74 yo male, following surgery for metastatic brain tumor, subdural hematoma, left parietal lobe hemorrhage, intracranial hemorrhage, peripheral edema, internal shift had occurred, – so needs surgery to decompress edema
7. 50 y.o female, fibroadenoma of left breast, lobulated mass, if cannot Dx by MRI, need mammogram as pixels much more detailed, if cannot Dx by MRI, need needle biopsy
Fibroadenoma is the most common benign tumor of the breast. It is the most common breast tumor in women under age 30. A fibroadenomais made up of breast gland tissue and tissue that helps support the breast gland tissue.
Below: The image on the far left is a juvenile fibroadenoma – it is oval in shape and has smooth margins, i.e. typically benign.
The non-enhancing septations are not seen in this case.
The image on the right is another example of a fibroadenoma: a lobulated mass with non-enhancing septations.
Below: a gross specimen of a fibroadenoma. The cut surface has multi-lobulated appearance. Image courtesy of Jean-Christophe Fournet, MD, PhD
8. 87 yo female, ACA aneurysm, cavernous angioma
Cavernous angiomas belong to a group of intracranial vascular malformations that are developmental malformations of the vascular bed. These congenital, abnormal vascular connections frequently enlarge over time. The lesions can occur on a familial basis. Patients may be asymptomatic, although they often present withheadaches, seizures, or small parenchymal hemorrhages. Cavernous angiomas appear in the images below.
Below: Large, right frontal and left occipital cavernous angiomas on a T1-weighted axial MRI. These 2 heterogeneous masses have a reticulated core of high and low signal intensities surrounded by a hypointense rim of hemosiderin.