Malformaciones cavernosas intracraneales: espectro de manifestaciones neurorradiológicas / Cerebral cavernous malformations: spectrum of neuroradiological findings

Las malformaciones cavernosas (cavernomas) son lesiones hamartomatosas formadas por espacios vasculares sinusoidales sin parénquima cerebral entre ellos. Las crisis son su presentación clínica más habitual. Son lesiones dinámicas en las cuales se producen cambios a lo largo del tiempo. La mayoría son de localización supratentorial, pero hasta un 20% de los casos se presentan en la fosa posterior. Tanto en la tomografía computarizada como en la resonancia magnética (RM) su presentación típica es como una lesión redondeada u ovoidea, bien definida, sin o con un mínimo efecto masa o edema, y con poco o ningún realce. Su apariencia en la RM dependerá del estadio de la hemorragia, siendo la secuencia más sensible el eco de gradiente T2. El cavernoma no es visible en la arteriografía. No obstante, ésta puede demostrar una anomalía del desarrollo venoso asociada. Los cavernomas pueden presentar características atípicas en cuanto a su tamaño, apariencia, localización y número (AU)

Cavernous malformations (cavernomas) are hamartomatous lesions formed by sinusoidal vascular spaces, with no cerebral parenchyma between them. Seizures are the most usual clinical presentation. They are dynamic lesions, producing changes throughout their evolution. The majority are located in the supratentorial region, but up to 20% of cases they are found in the posterior fossa. In computed tomography (CT) and in magnetic resonance (MR) their typical presentation is as a well defined round or oval lesion, with or without a minimal mass effect or oedema, with little or no contrast enhancement. Their appearance in MRI will depend on the stage of the haemorrhage, a T2 echo gradient being the most sensitive sequence. Angiography do not usually detect cavernomas. However, it may demonstrate a venous developmental anomaly. Cavernomas may present with atypical characteristics, as regards their size, appearance, location and number (AU)

Cerebral cavernous malformations: spectrum of neuroradiological findings.

Cavernous malformations (cavernomas) are hamartomatous lesions formed by sinusoidal vascular spaces, with no cerebral parenchyma between them. Seizures are the most usual clinical presentation. They are dynamic lesions, producing changes throughout their evolution. The majority are located in the supratentorial region, but up to 20% of cases they are found in the posterior fossa. In computed tomography (CT) and in magnetic resonance (MR) their typical presentation is as a well defined round or oval lesion, with or without a minimal mass effect or oedema, with little or no contrast enhancement. Their appearance in MRI will depend on the stage of the haemorrhage, a T2 echo gradient being the most sensitive sequence. Angiography do not usually detect cavernomas. However, it may demonstrate a venous developmental anomaly. Cavernomas may present with atypical characteristics, as regards their size, appearance, location and number.

[Two cases of brain haemorrhage secondary to developmental venous anomaly thrombosis. Bibliographic review]. / Hemorragia intracerebral secundaria a trombosis espontánea de una anomalíavenosa del desarrollo: 2 casos y revisión de la literatura.

We report two cases of intracraneal brain haemorrhage secondary to developmental venous anomaly trombosis recently treated at our Department. First patient was a 28-year old woman on oral contraceptive treatment for a month who was referred to our Department with sudden-onset conscious level deterioration after presenting 24 hours previously with headache, vomits and hemiparesis. Computed Tomography revealed a predominant hypodense area containing hyperdense foci causing mild mass effect and midline-shift in keeping with a haemorrhagic infarction occupying almost completely the right frontal lobe. On CT, magnetic resonance (MR) and magnetic resonance angiography (MRA) there was a prominent tubular structure adjacent to the hematoma in keeping with a partly thrombosed vessel. Urgent craniotomy and partial hematoma evacuation was performed. Digital subtraction angiography confirmed the presence of a filling defect within the draining vein of a typical caputmedusae pattern developmental venous anomaly (DVA). Systemic anticoagulation was started and four days after surgery sedation was reversed and the patient awoke with normal conscious level although mild (4/5) hemiparesis persisted. Second patient was a 38-year old male evaluated in the Emergency Department due to tonic-clonic seizures in the left side followed by altered sensation in the same distribution. Initial CT revealed an intracranial bleed. After contrast administration there was an anomalous vessel in the same location that was confirmed angiographically represented a partly thrombosed DVA. Conservative management was favoured and the patient was discharged from hospital without clinical neurological deficits.

Hemorragia intracerebral secundaria a trombosis espontánea de una anomalíavenosa del desarrollo: 2 casos y revisión de la literatura / Two cases of brain haemorrhage secondary to developmental venous anomaly trombosis. Bibliographic

Presentamos dos casos de hemorragia cerebral secundaria a la trombosis de una anomalía venosa del desarrollo (AVD) recientemente tratados en nuestro servicio. La primera paciente era una mujer de 28 años que tomaba anticonceptivos orales desde hacía un mes, que ingresó tras deterioro agudo del nivel de conciencia precedido de hemiparesia, cefalea y vómitos de 24 horas de evolución. La tomografía computarizada (TC) realizada al ingreso demostró una imagen hipodensa con áreas de hiperdensidad en su interior y que ejercía efecto masa con desviación de la línea media. La lesión era sugestiva de un infarto hemorrágico que ocupaba casi la totalidad del lóbulo frontal derecho. Tanto en la TC, la resonancia magnética (RM) y la angioRM destacaba la existencia de una estructura tubular en el interior del hematoma compatible con un vaso con un trombo en su interior. La paciente fue sometida a una craneotomía urgente con evacuación parcial del hematoma. La arteriografía confirmó la existencia de un drenaje venoso anómalo (DVA) con un defecto de replección en su interior en el que desembocaba un penacho de venas con el patrón típico de "Cabeza de Medusa" por lo que, ante la sospecha de trombosis venosa, se procedió a la anticoagulación sistémica de la paciente. A los 4 días de la intervención se procede a la retirada progresiva de la sedación y de la intubación presentando la paciente un GCS de 15 con leve hemiparesia izquierda 4/5. El segundo caso fue un varón de 38 años que ingresó por un cuadro de crisis comicial tónico-clónica en hemicuerpo izquierdo seguida por una sensación de disestesia en la misma localización. La TC inicial mostraba una imagen de hemorragia intracraneal en la cual, al inyectar contraste, se apreciaba una imagen de vaso anómalo dilatado que, en el estudio angiográfico, resultó corresponder a un anomalía del desarrollo venoso trombosada. Se adoptó una actitud expectante con seguimiento angiográfico periódico de la lesión. El paciente fue dado de alta sin déficits neurológicos (AU)

We report two cases of intracraneal brain haemorrhage secondary to developmental venous anomaly trombosis recently treated at our Department. First patient was a 28-year old woman on oral contraceptive treatment for a month who was referred to our Department with sudden-onset conscious level deterioration after presenting 24 hours previously with headache, vomits and hemiparesis. Computed Tomography revealed a predominant hypodense area containing hyperdense foci causing mild mass effect and midline-shift in keeping with a haemorrhagic infarction occupying almost completely the right frontal lobe. On CT, magnetic resonance (MR) and magnetic resonance angiography (MRA) there was a prominent tubular structure adjacent to the hematoma in keeping with a partly thrombosed vessel. Urgent craniotomy and partial hematoma evacuation was performed. Digital subtraction angiography confirmed the presence of a filling defect within the draining vein of a typical caputmedusae pattern developmental venous anomaly (DVA). Systemic anticoagulation was started and four days after surgery sedation was reversed and the patient awoke with normal conscious level although mild (4/5) hemiparesis persisted. Second patient was a 38-year old male evaluated in the Emergency Department due to tonic-clonic seizures in the left side followed by altered sensation in the same distribution. Initial CT revealed an intracranial bleed. After contrast administration there was an anomalous vessel in the same location that was confirmed angiographically represented a partly thrombosed DVA. Conservative management was favoured and the patient was discharged from hospital without clinical neurological deficits (AU)

Concomitant endovascular treatment of concomitant extracranial carotid stenosis and intracranial aneurysm. Our experience.

SUMMARY: Angioplasty and stenting are emerging alternative treatments to endarterectomy for carotid stenosis. The increasing number of procedures performed carries an increased diagnosis rate of associated asymptomatic intracranial aneurysms, resulting in a clinical and therapeutic dilemma, not fully solved in the literature. When an incidental lesion is found, the first question is whether it is necessary to treat it or not? If treatment is decided, the next question is which should be treated first, the intra or the extracranial lesion? We review our experience and the literature and discuss our preferred approach of single-procedure carotid stenting and aneurysm coiling, which we believe is feasible, safe and effective constituting an option when confronted with this difficult therapeutic dilemma.