Clinical implications of associated venous drainage in patients with cavernous malformation

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Object. The authors reviewed angiograms obtained in patients with cavernous malformations to identify and characterize coexisting venous drainage.

Methods. Fifty-seven patients with cavernous malformations treated at the authors' institutions between 1994 and 2002 were classified into three groups according to the venous system adjacent to the malformation on angiography studies. In Group A patients (23 patients) the malformations had no venous drainage; in Group B patients (14 patients) the lesions were associated with typical venous malformations; and in Group C patients (20 patients) the lesions had atypical venous drainage (AVD). The risk of hemorrhage based on the type of associated venous drainage was analyzed, and the usefulness of magnetic resonance (MR) imaging compared with digital subtraction (DS) angiography in demonstrating associated AVD was determined.

Fifty-seven patients harbored 67 cavernous malformations: Group A patients had 29 cavernous malformations with no associated venous drainage; Group B patients had 17 lesions associated with venous malformations; and Group C patients harbored 21 lesions, 20 of which manifested AVD. Symptomatic hemorrhage was present in 10 (43.5%) of 23 Group A patients and in 28 (82.4%) of 34 Groups B and C patients. Although high-resolution MR imaging revealed the presence of associated venous malformations in 11 (78.6%) of 14 Group B patients, such studies demonstrated AVD in only two (10%) of 20 Group C patients.

Conclusions. Patients harboring cavernous malformations plus venous malformations or AVD are more likely to present with symptomatic hemorrhage than are patients with cavernous malformation alone. The actual incidence of associated venous drainage may be underestimated when MR imaging alone is used rather than combined with DS angiography.

Article Information

Address reprint requests to: Jun-ichiro Hamada, M.D., Department of Neurosurgery, Graduate Medical Sciences, Kumamoto University, 1—1—1 Honjo, Kumamoto 860-856, Japan. email: jhamada@kaiju.medic.kumamoto-u.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Images obtained in a patient in Group A; that is, one harboring a cavernous malformation with no coexisting venous drainage. Left: Axial T2-weighted MR image demonstrating a cavernous malformation without associated venous drainage. Right: A DS angiogram revealing no coexisting venous drainage.

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    Images obtained in a patient in Group B; that is, one harboring a cavernous malformation together with a venous malformation. Left: A Gd-enhanced T1-weighted MR image displaying a cavernous malformation with an associated typical venous malformation. Right: A DS angiogram demonstrating a collection of dilated medullary veins, the so-called caput medusae, converging in an enlarged transcortical collector draining vein.

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    Images obtained in a patient in Group C; that is, one harboring a lesion with AVD. Left: An MR image demonstrating a lesion with no AVD. Center: A DS angiogram obtained during the arterial phase, demonstrating no arteriovenous malformation or arteriovenous fistula. Right: A DS angiogram obtained during the late venous phase, revealing a cavernous malformation with associated venous drainage different from typical venous malformations. Several tiny vessels (arrowheads) drain into a slightly dilated vein (arrow) without connection to the transcortical venous system.

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