Angiographically Occult Vascular Malformations Flashcards
Angiographically occult (cryptic) vascular malformations refer to cerebrovascular malformations that are not demonstrable on technically satisfactory catheter angiography. Which of the following are the etiologies of such condition?
● A. Lesions that have hemorrhaged in which bleeding may obliterate the lesion or the clot may temporarily compress the lesion
● B. Sluggish flow of blood within abnormal vessels
● C. Small size of the abnormal vessels
● D. May require very late angiographic films (i.e., delayed films) to visualize due to late filling
● E. All of the above
E. All of the above
Angiographically occult vascular malformation most commonly present with which of the following?
● A. Seizures or headache
● B. Progressive neurologic symptoms
● C. One-sided body weakness
● D. Memory deficit
● E. Urinary incontinence
A. Seizures or headache
Osler Weber Rendu syndrome, also known as hereditary hemorrhagic telangiectasia or capillary telangiectasia, is slightly enlarged capillaries with low flow. It is usually incidentally found at necropsy and has very low risk of hemorrhage (except possibly in brainstem) with intervening neural tissue. Associated cerebrovascular malformations with it include the following except?
● A. AVMs
● B. Vein of Galen malformation
● C. Venous angiomas
● D. Aneurysms
● E. Telangiectasia
B. Vein of Galen malformation
Osler Weber Rendu syndrome may show a well-demarcated homogenous or mottled high density with some form of contrast enhancement on CT of brain. On T2WI, there is found reticulated core of increased and decreased intensity, and a prominent surrounding rim of reduced intensity may be present. What is the most suitable treatment option for this disease?
● A. Surgery is indicated for evacuation of hematoma or for recurrent hemorrhages
● B. Stereotactic radiosurgery is the most suitable option
● C. Embolization is superior to all other modalities
● D. Treatment is only with medication
● E. There is no known treatment for this disease
A. Surgery is indicated for evacuation of hematoma or for recurrent hemorrhages
Cavernous malformation is an angiographically occult lesion with low flow vessels and no intervening neural parenchyma or arteries. What is the study of choice for this lesion (on which it appears as popcorn pattern)?
● A. CT angiography of brain
● B. MRI, especially gradient echo or SWI
● C. Catheter angiogram
● D. CT with IV contrast
● E. PET scan
B. MRI, especially gradient echo or SWI
Cavernoma or cavernous hemangioma or angioma or hemangioma is a well-circumscribed, benign vascular hamartoma consisting of irregular thick and thin-walled sinusoidal vascular channels located within the brain but lacking intervening neural parenchyma, large feeding arteries, or large draining
veins. Structural characteristics of this lesion include which of the following?
● A. Comprised of dilated endothelial lined capillary vessels (caverns) with defective tight junctions
● B. No identifiable arterial feeders on angiography
● C. Often associated with a developmental venous anomaly (DVA)
● D. No functional brain tissue with the encapsulated core
● E. All of the above
E. All of the above
Cavernous malformation constitutes 5 to 13% of CNS vascular malformations. What is the most common location of these lesions?
● A. Brainstem
● B. Supratentorial
● C. Basal ganglia
● D. Spinal cord
● E. Cerebellum
B. Supratentorial
Which of the following is incorrect regarding Zabramski classification of cavernous malformations?
● A. Type 1 is subacute hemorrhage with a rim of hemosiderinladen macrophages and gliotic brain
● B. Type 2 is loculated areas of hemorrhage and thrombus of varying age with a rim of gliotic, hemosiderin-stained brain, with large lesions that may have areas of calcifications
● C. Type 3 is chronic resolved hemorrhage with hemosiderin staining within and around the cavernous malformation
● D. Some lesions in type 4 category were found to be telangiectasia
● E. Type 5 presents with intralesional hemorrhage
E. Type 5 presents with intralesional hemorrhage
Which of the following statements is incorrect regarding surgical management of cavernous malformations (CMs)?
● A. Surgery is not recommended for asymptomatic CMs, especially those that are deep or in eloquent areas or brainstem, or with multiple CMs
● B. Consider surgery for solitary asymptomatic CMs if easily accessible and not in eloquent brain, to prevent future hemorrhage, because of psychological burden, expensive timeconsuming follow-ups, to facilitate lifestyle or career decision, or in patients who might need to be on anticoagulants
● C. Early CM resection is considered (≤ 6 weeks from hemorrhage) in patients with seizures, especially when medically refractory, if the CM is the likely cause of the seizure
● D. Consider surgery in symptomatic easily accessible CMs (surgical morbidity and mortality is equivalent to living with the CM for 1–2 years after a first bleed)
● E. Consider surgery after a symptomatic second bleed in a brainstem cavernous malformation
● F. Consider radiosurgery in solitary CMs with previous symptomatic hemorrhage if the CM is located in eloquent areas that have an unacceptably high risk with surgery
● G. All of the above are correct
G. All of the above are correct
Stereotactic localization or intraoperative ultrasound is particularly helpful in localizing the cavernous malformation. What is the goal of surgery in case of cavernous malformation?
● A. Only decompression
● B. Decompression with removal of hematoma
● C. Complete resection of the lesion
● D. Removing only symptomatic portion of the lesion
● E. None of the above
C. Complete resection of the lesion
The reason for a vascular lesion being angiographically cryptic does not include which of the following?
● A. Lesions that have hemorrhaged
● B. The bleeding may obliterate the lesion
● C. The clot may temporarily compress the lesion
● D. Fast flow
● E. May require delayed film to visualize due to late filling
D. Fast flow
Multiple lesions in hereditary hemorrhagic telangiectasia are not associated with which of the following?
● A. Osler Weber Rendu syndrome
● B. Louis-Barr
● C. Myburn Mason
● D. Sturge Weber
● E. Multiple endocrine neoplasia type I
E. Multiple endocrine neoplasia type I
In hereditary hemorrhagic telangiectasia (HHT), surgery is indicated mainly for which of the following?
● A. Unruptured lesion
● B. Diagnosis
● C. Thalamic location
● D. 1st hemorrhage
● E. Well-controlled seizures
B. Diagnosis
A patient is admitted with seizures and ICH. What is the typical MRI radiologic sign for cavernoma?
● A. Popcorn
● B. Spokes of wheel
● C. Sunburst
● D. Sunset
● E. Caput medusae
A. Popcorn
Which of the following is a risk factor for formation of cavernous malformation?
● A. Trauma
● B. Radiotherapy
● C. Diabetes
● D. Smoking
● E. Ehlers Danlos disease
B. Radiotherapy
