(B) Magnified pre-contrast sagittal T1-weighted sequence shows hyperdensity consistent with hemorrhage (thick arrow). (C) Magnified sagittal and (D) axial post-contrast T1-weighted MRI sequences show mild contrast enhancement of CM (thick arrows). MRI: magnetic resonance imaging; CM: cavernous malformation. Courtesy of Glenn A Tung, MD, FACR. Graphic 139103 Version 1.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 27/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate MRI of a cerebral cavernous malformation with old hemorrhage A dark hemosiderin ring around the cavernous malformation is evident on this T-2 weighted MR image, suggestive of old hemorrhage. MRI: magnetic resonance imaging. Courtesy of Guy Rordorf, MD. Graphic 68000 Version 5.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 28/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate Cerebral cavernous malformations (CCM) on CT and MRI sequences SWI is very sensitive to slow-flow vascular malformations such as CCM, as in this child with a large left temporal CCM (dashed arrows), with a characteristic "popcorn" appearance on CT and MRI. There are typical internal calcifications on CT (A), hyperintense subacute blood products on T1-weighted imaging (B), mild internal enhancement on postcontrast T1-weighted imaging (C), and peripheral hypointense hemosiderin on FLAIR (D) and T2-weighted imaging (E). The lesion appears larger on SWI (F) due to blooming artifact. More important, additional smaller CCMs are detected (arrows), which indicate that the patient likely has multiple familial CCM syndrome (which can occur in as many as one-third of patients with CCM). SWI parameters are: 3 Tesla, TE = 20 milliseconds, TR = 29 milliseconds, FA = 15 , field of vision 250 mm 188 mm, matrix 448 336, 2 mm thick acquisition displayed with 16 mm minimum intensity projection. SWI: Susceptibility-weighted imaging; CCM: cerebral cavernous malformations; CT: computed tomography; MRI: magnetic resonance imaging; FLAIR: fluid-attenuated inversion recovery; TE: echo time; TR: repetition time; FA: flip angle. https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 29/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate From: Liu C, Li W, Tong KA, et al. Susceptibility-weighted imaging and quantitative susceptibility mapping in the brain. J Magn Reson Imaging 2015; 42(1):23-41. https://onlinelibrary.wiley.com/doi/abs/10.1002/jmri.24768. Copyright 2014 Wiley Periodicals, Inc. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (https://onlinelibrary.wiley.com/). Graphic 122720 Version 1.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 30/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate Sporadic CCM with a DVA Sporadic CCM with a very large DVA. (A) Axial T2 SE of a 26-year-old female patient shows a CCM near the left lateral ventricle. (B) Postgadolinium T1 shows a large DVA involving much of the left frontal lobe. (C and D) SWI demonstrates very clearly the CCM and DVA without gadolinium administration. https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 31/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate CCM: cerebral cavernous malformation; DVA: developmental venous anomaly; SE: spin echo; SWI: susceptibility-weighted imaging. Republished with permission of the American Society of Neuroradiology, from: Petersen TA, Morrison LA, Schrader RM, Hart BL. Familial versus sporadic cavernous malformations: di erences in developmental venous anomaly association and lesion phenotype. AJNR Am J Neuroradiol 2010; 31:377; permission conveyed through Copyright Clearance Center, Inc. Copyright 2010. Graphic 122722 Version 2.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 32/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate Developmental venous anomaly with dystrophic calcification (A) Axial and (B) coronal non-contrast CT images show hyperdense linear calcification in left lateral putamen. (C) Axial and (D) sagittal images from CT angiography show classic caput medusae and dilated vein (circles) characteristic of DVA. https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 33/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate CT: computed tomography; DVA: developmental venous anomaly. Courtesy of Glenn A Tung, MD, FACR. Graphic 139104 Version 1.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 34/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate Left frontal DVA on MRI A DVA accompanied by a small cyst and loco-regional atrophy localized in the left frontal deep and subcortica white matter of a 45-year-old patient with headache. (A) Thin venous stems and veins in the center, leading to the caput medusae imaging on axial contrast- enhanced 3D SPGR maximum intensity projection image, are visualized. (B) Loco-regional atrophy in the frontal lobe and a millimetric cyst (arrow) adjacent to the DVA caput on a coronal contrast-enhanced 3D SPGR image are visualized. 3D SPRG: three-dimensional spoiled gradient recalled echo; DVA: developmental venous anomaly; MRI: magnetic resonance imaging. Reprinted by permission from Springer: Clinical Neuroradiology. G k e E, Acu B, Beyhan M, et al. Magnetic resonance imaging ndings of developmental venous anomalies. Clin Neuroradiol 2014; 24:135. Copyright 2014. https://link.springer.com/journal/62. Graphic 122040 Version 5.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 35/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate Cerebral angiography of a developmental venous anomaly During the late capillary or venous phase of angiography, there is a paucity of normal veins in the region of a developmental venous anomaly and a characteristic "caput medusae" appearance of the radially arranged small medullary veins (arrow). Courtesy of Guy Rordorf, MD. Graphic 56038 Version 4.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 36/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate MRI of brain capillary telangiectasia A brain capillary telangiectasia (circle) seen in the pons on both GRE (A) and SWI (B) and confirmed on postcontrast T1-weighted image (C). GRE: gradient echo; MRI: magnetic resonance imaging; SWI: susceptibility-weighted imaging. Republished with permission of the American Society of Neuroradiology, from: Chaudhry US, De Bruin DE, Policeni BA. Susceptibility- weighted MR imaging: a better technique in the detection of capillary telangiectasia compared with T2* gradient-echo. AJNR Am J Neuroradiol 2014; 35:2302; permission conveyed through Copyright Clearance Center, Inc. Copyright 2014. Graphic 122043 Version 1.0 https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 37/38 7/5/23, 12:27 PM Vascular malformations of the central nervous system - UpToDate Contributor Disclosures Robert J Singer, MD No relevant financial relationship(s) with ineligible companies to disclose. Christopher S Ogilvy, MD Consultant/Advisory Boards: Cerevasc [Hydrocephalus]; Contour [Aneurysms]; Medtronic [Chronic subdural hematoma]. All of the relevant financial relationships listed have been mitigated. Guy Rordorf, MD No relevant financial relationship(s) with ineligible companies to disclose. Jos Biller, MD, FACP, FAAN, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Glenn A Tung, MD, FACR No relevant financial relationship(s) with ineligible companies to disclose. Richard P Goddeau, Jr, DO, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/vascular-malformations-of-the-central-nervous-system/print 38/38