Cerebral cavernous malformations: Spectrum of neuroradiological

Transcription

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Radiología. 2012;54(5):401---409
www.elsevier.es/rx
UPDATE IN RADIOLOGY
Cerebral cavernous malformations: Spectrum of neuroradiological
findings夽
J.J. Cortés Vela a,∗ , L. Concepción Aramendía b , F. Ballenilla Marco b , J.I. Gallego León b ,
J. González-Spínola San Gil a
a
b
Servicio de Radiodiagnóstico, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
Servicio de Radiodiagnóstico, Hospital General de Alicante, Alicante, Spain
Received 7 February 2011; accepted 18 September 2011
KEYWORDS
Cavernoma;
Cavernous angioma;
Cavernous
haemangioma;
Multiple
cavernomatosis;
Computed
tomography;
Magnetic resonance;
Angiography
PALABRAS CLAVE
Cavernoma;
Angioma cavernoso;
Hemangioma
cavernoso;
Cavernomatosis
múltiple;
Tomografía
computarizada;
Abstract 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 magnetic resonance
imaging (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.
© 2011 SERAM. Published by Elsevier España, S.L. All rights reserved.
Malformaciones cavernosas intracraneales: espectro de manifestaciones
neurorradiológicas
Resumen 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
夽 Please cite this article as: Cortés Vela JJ, et al. Malformaciones cavernosas intracraneales: espectro de manifestaciones
neurorradiológicas. Radiología. 2012. doi:10.1016/j.rx.2011.09.016.
∗ Corresponding author.
E-mail address: jesusjcortes@hotmail.com (J.J. Cortés Vela).
2173-5107/$ – see front matter © 2011 SERAM. Published by Elsevier España, S.L. All rights reserved.
402
Resonancia
magnética;
Arteriografía
J.J. Cortés Vela et al.
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.
© 2011 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction and epidemiology
Cavernomas are non-encapsulated, well-defined, vascular
hamartomatous lesions formed by sinusoidal vascular spaces
with no cerebral parenchyma between them. They are
one of the four major types of vascular malformations of
the central nervous system, together with developmental
venous anomalies, arteriovenous malformations, and capillary telangiectasias.1 The literature offers a wide range of
synonyms of cavernoma, such as cavernous angioma, cavernous malformations, and angiographically occult vascular
malformation. Although cavernomas were first classified as
a rare condition, they are now becoming a more and more
common finding in neuroimaging studies, particularly after
the advent of magnetic resonance imaging (MRI).
Since they are normally asymptomatic, their actual incidence is not well known. According to series of autopsies,
carvernomas occur in about 0.4% of subjects, accounting for
5---13% of all cerebral vascular malformations, and are only
second to venous developmental anomalies in incidence.2
Cavernomas occur equally in males and females and usually
appear between the second and fifth decade of life.3
All cavernomas were initially thought to have a congenital cause. However, it has been shown that they are
dynamic lesions that undergo changes overtime (de novo
appearance, growth, size reduction).4 On some occasions,
carcinomas disappear after a hemorrhage.5 Several factors
associated with de novo formation of carcinoma have been
reported6 : previous cranial irradiation, infection of specific viruses, influence of hormones, genetic causes, seeding
along the needle track during biopsy, and venous developmental anomalies.7 The association of cavernoma and
developmental venous anomaly should be considered since
both disorders co-occur in about 30% of cases according to
the medical literature.8 In this respect, it would be very useful to complete the radiological studies with the injection of
intravenous contrast material because, unlike cavernoma,
developmental venous anomaly shows intense enhancement
(Fig. 1). There are also studies reporting the rare association between cavernoma, developmental venous anomaly,
and capillary telangiectasia as spectrum of one same disorder. Capillary telangiectasia is best detected following
intravenous contrast administration.9 Based on a number of
histological and immunohistochemical studies, a theory has
been suggested for cavernoma formation in case of previous
developmental venous anomaly10,11 (Fig. 2).
Recent genetic studies have provided evidence of dysfunction of specific genes involved in angiogenesis in
patients with inherited forms of cerebral cavernomas.
These genes encode proteins that interact at the junction of endothelial cells. These patients would present with
increased vascular permeability caused by the absence or
dysfunction of the junctions between the endothelial cells.
Three genes associated with familial forms of cerebral cavernoma have been identified to date. These genes have
been named after the abbreviation CCM (cerebral cavernous
malformations): CCM1 (KRIT1), CCM2 (MGC4607), and CCM3
(PDCD10). Of all three, gen CCM3 is associated with a higher
risk of hemorrhage, and thus, with appearance of the disease
at an earlier age.12
Histological features
On histological examination, cavernomas are composed of
dilated vascular channels variable in size lined by a thin and
Figure 1 Cavernoma in the left cerebellar hemisphere with associated developmental venous anomaly whose collecting vein
drains into the left transverse sinus. (a) and b) T2-weighted cranial MR image and T2 gradient-echo cranial MR image in the axial
plane. Cavernoma in the left cerebellar hemisphere. An associated developmental venous anomaly can be guessed in (a). (c) Axial
T1-weighted sequence clearly shows enhancement of the developmental venous anomaly and absence of enhancement of the
cavernoma after administration of intravenous gadolinium.
Cerebral cavernous malformations: Spectrum of neuroradiological findings
403
Theory of cavernoma formation
Stenosis of collecting vein from the developmental venous anomaly
Increased pressure in the capillary bed
Microhemorrhages and red blood cell extravasation
Fibroblastic and endothelial proliferation
Cavernoma formation
Figure 2 Theory suggested for cavernoma formation in the
setting of a previous developmental anomaly.
weak epithelium that lacks elastic and muscular layers predisposing to hemorrhage. The channels are surrounded by a
reactive collagenous matrix. There might be internal calcifications. The main histologic feature of cavernomas is the
absence of cerebral parenchyma between the interstices of
the lesions, which distinguishes cavernomas from capillary
telangiectasias.10
Macroscopically, cavernomas are bluish nodules containing areas of bleeding at different stages. Due to recurrent
bleeding, carvernomas are surrounded by a pseudocapsule
of gliotic brain that is stained with hemosiderin (Fig. 3). As
will be discussed below, all these histologic features condition the radiological appearance of cavernomas.
Clinical manifestations
Cavernomas may affect any part of the brain and their clinical manifestations mainly depend on their localization.
Supratentorial cavernomas are the most common,
accounting for approximately 80% of cases. They mainly
affect the subcortical region and the frontal and temporal lobes are the most commonly affected (Fig. 4). Seizures
are the most frequent clinical manifestation of cavernomas,
generally associated with hemorrhages. However, they can
also be associated with headaches, other focal neurological
deficits, and hemorrhages.3,13
Figure 4 Axial T2-weighted MR image shows a typical cavernoma located in the subcortical area of the left frontal lobe.
In the posterior fossa, cavernomas mostly affect the protuberance and cerebellar hemispheres (Fig. 5) and their
common manifestations are focal neurological deficits, such
as anomalies in the pairs of cranial nerves and changes
in sensitivity and ataxia. The first clinical manifestations
of intraventricular cavernomas (very rare) usually involve
intracranial hypertension caused by obstruction of the cerebrospinal fluid due to recurrent hemorrhages.14
A number of factors have been reported that modify the
natural history and behaviour of these lesions, increasing
the risk of hemorrhage, and thus, conditioning more aggressive clinical presentations (multiple lesions, female sex,
CCM3 genotype, diagnosis before 35 years of age, infratentorial location, association with a developmental venous
anomaly, and lesions >1 cm in diameter15 ).
According to the series, up to 40% of cavernomas are
asymptomatic and incidentally discovered during radiological examinations.2,3,15
Figure 3 Histologic features of the cavernoma. (a) Microscopic histologic section dyed with hematoxylin---eosin showing congestive
dilated vascular lumina with frequent signs of thrombosis, adjacent cerebral parenchyma with reactive gliosis, and hemosiderin
depositions. (b) Macro photography of the same lesion shows a bluish nodule with hemorrhages at different stages.
404
Figure 5 (a) Axial T2 gradient-echo MRI sequence shows a cavernoma centered in the protuberance. (b) Coronal T2-weighted MR
image shows a small cavernoma in the left cerebellar hemisphere.
Typical radiological features
Computerized tomography (CT), with or without contrast
administration, detects only 30---50% of lesions, leading to
underdiagnosis of the disease if CT is the only imaging
modality used.16 Cavernomas usually manifest as highdensity and well-defined lesions rounded or ovoid in shape,
sometimes with internal calcifications. The surrounding
brain parenchyma usually remains normal. There is usually
minimal or no mass effect on the adjacent structures and
no vasogenic edema associated. Mild or no enhancement
is observed following intravenous contrast administration17
(Fig. 6).
MRI is the primary imaging technique for cavernoma diagnosis and evaluation, showing a clearly higher sensitivity
than CT. The appearance of cavernomas varies depending on the stage of the hemorrhage.17 The most common
finding of uncomplicated cavernomas is known as popcorn
lesion involving a nucleus with heterogeneous signal in
T1- and T2-weighted images (due to thrombosis, hemorrhage, fibrosis, and calcification) surrounded by a complete
hemosiderin ring with lower signal intensity in T2-weighted
sequences (Fig. 7). The most sensitive sequence to detect
Figure 6 Cavernoma located in the right suprasylvian area,
a typical CT image. (a) Unenhanced axial CT. (b) Similar axial
image after contrast injection shows a well-defined, highdensity, rounded lesion with no associated edema or mass effect
and no enhancement after contrast administration.
cavernomas is T2-weighted gradient-echo sequences.18 The
lesion is said to bloom (it is more clearly visualized) due to
magnetic susceptibility effects caused by hemoglobin degradation products. It has recently been demonstrated that
MRI performed with high-field (3T) systems provide better morphological characterization of these lesions, while
new susceptibility-weighted imaging (SWI) is more sensitive
Figure 7 Cavernoma located in the right suprasylvian area,
a typical MR image (the same case as in Fig. 6). (a) and
(b) Axial T1- and T2-weighted RM images, respectively, show the
typical popcorn appearance of a cavernoma with hypointense
peripheral rim in T2-weighted sequence. (c) Note the blooming
in the axial T2-weighted gradient-echo sequence.
405
Figure 8 Left parietal cavernoma with associated developmental venous anomaly. (a) Coronal T1-weighted MR image after
administration of intravenous gadolinium showing both the cavernoma and the enhancing developmental venous anomaly. (b) The
arteriography clearly shows the anatomy of the developmental venous anomaly, whereas the cavernoma remains occult.
to detect small lesions than conventional sequences.19
As with CT, the surrounding parenchyma is usually normal and the mass effect, edema, and enhancement
following administration of intravenous gadolinium rarely
occur.
Arteriography is indicated when there are doubts about
the causes of cerebral haemorrhage, when the diagnosis
of cavernoma cannot be reliably made using CT or MRI,
with a view to ruling out an arteriovenous malformation
as the cause of hemorrhage. Arteriography is not indicated when the MRI shows the typical image of cavernoma.
Cavernomas, thrombosed arteriovenous malformations, and
capillary telangiectasia make up the group of angiographically occult vascular malformations, whose main common
Figure 9 Cavernomas with an atypical radiological appearance. (A) Axial T2-weighted cranial RM image shows a large right
occipital cavernoma with vasogenic edema and a mild mass effect on the occipital horn of the right lateral ventricle. (b) Coronal
T2-weighted RM image shows a cavernoma in the right hemi-protuberance with signs of recent haemorrhage. The image also shows a
fluid-fluid level inside the cavernoma, loss of the peripheral low-intensity rim, vasogenic edema, and mass effect on the IV ventricle.
(c) and (d) Axial T2-weighted gradient-echo sequence. Intraventricular haemorrhage caused by previous bleeding of a cavernoma
located adjacent to the occipital horn of the right lateral ventricle.
406
feature is the absence of vascular anomalies due to slow
blood flow. This is by far the most common feature.20,21 Arteriography is very sensitive to demonstrate developmental
venous anomalies associated with cavernomas (Fig. 8), but
MRI scanning following intravenous contrast administration
is reliable enough to rule it out.
Atypical radiological features
Cavernomas may present with atypical radiological features
in terms of appearance, size, location, and number.17
In case of recent hemorrhage, which usually co-occurs
with clinical manifestations, cavernomas may lack its typical appearance in the different imaging modalities showing
atypical characteristics such as associated vasogenic edema,
mass effect on adjacent structures, loss of the hypointense
peripheral hemosiderin ring, fluid-fluid level, or presence
of perilesional hemorrhage17 (Fig. 9). In these cases, serial
images are useful if the hemorrhage does not undergo
surgery.22,23
When treating a hemorrhagic lesion in the central nervous system with associated edema, Yung et al. demonstrate
that the presence of a hyperintense peripheral rim in T1weighted sequences may be highly suggestive of cavernoma.
This rim was observed in 62% of hemorrhages secondary to
cavernomas, only in 6% of hemorrhages secondary to metastasis and it was not identified in hemorrhages caused by
primary tumours or in primary hemorrhages. For this reason,
the presence of this rim in a haemorrhage in the central nervous system suggests that a cavernoma is highly likely to be
the cause of the hemorrhage.24
Figure 10 Axial T2-weighted gradient-echo sequence. Giant
cavernoma that takes most of the left occipital lobe. In spite of
its large size, this cavernoma shows no edema or mass effect
on the adjacent structures.
Most cavernomas present with a size <3 cm and many of
them are millimetric. Nevertheless, large lesions or the socalled giant cavernomas may occur25 (Fig. 10).
Cavernomas have been reported in many different locations. They may be found in the spinal cord, most commonly
Figure 11 Fusiform cavernoma in the cervical spinal cord, which extends from C2 to C5 (a, b, and c) but it is angiographically
occult (arrows in d).
407
Figure 12 Typical multiple cavernomatosis. (a) T1-weighted sequence. (b) T2-weighted FLAIR sequence. (c) T2-weighted
sequence. (d) T2-weighted gradient-echo sequence. All sequences are visualized in the axial plane. Note the superior performance of T2-weighted gradient-echo sequence to visualize these lesions (including those that had been previously identified and
many others) due to the magnetic susceptibility artifact secondary to hemoglobin degradation products.
in the cervical region, usually co-occurring with multiple
brain lesions26 (Fig. 11). Subarachnoid, intraventricular, subdural and even extradural lesions as well as lesions in the
sinuses of the dura mater have been reported.27
In approximately 15---20% of cases, more than one lesion
is diagnosed, a phenomenon which is known as multiple
cavernomatosis. These cases are associated with a family history of cavernoma in over 80% of patients, whereas
only 15% of multiple lesions have been reported in cases
with no family history. Multiple lesions involve a higher risk
of bleeding, and thus, they clinically manifest in patients
at an earlier age.28,29 In cases of multiple cavernomas, T2
gradient-echo sequences (and more recently, susceptibilityweighted sequences) usually detect a higher number of
lesions than the rest of sequences due to the blooming
of small lesions by the magnetic susceptibility effect due
to millimetric hemosiderin depositions18 (Fig. 12). Therefore, when punctuate hemosiderin depositions are seen
in T2 gradient-echo sequences, multiple cavernomatosis
should be included in the differential diagnosis, together
with hypertensive angiopathy, amyloid angiopathy, hemorrhagic metastasis, vasculitis of the central nervous system,
hemorrhagic diffuse axonal injury, and radiation-induced
telangiectasia.
Management
Cavernomas associated with epilepsy seizures are normally managed with conservative medical treatment of
antiepileptic drugs. Resection of a cavernoma is indicated
when seizures cannot be controlled with pharmacological treatment, the adverse effects of the drugs are too
serious, or the patient fails to follow the treatment. A
number of studies have reported seizure-free rates of 60%
using pharmacological treatment,30 whereas surgical treatment provides a seizure-free rate of approximately 80%.31
Those lesions that initially manifest with hemorrhage should
be managed with conservative treatment. However, surgical resection should also be considered if the hemorrhage
causes serious neurological signs or symptoms, or if rebleeding occurs.
Surgical treatment is particularly indicated in superficial
and supratentorial lesions that can be easily approached.
408
Biopsy can be performed when diagnosis is not entirely reliable. It should be noted that resection of the entire lesion
is mandatory because partial resection entails a higher
risk of haemorrhage than that associated with conservative
treatment.32
In spite of their difficult surgical approach and risk of
sequelae, brainstem lesions and basal ganglia lesions should
be more aggressively managed since they have a greater
tendency toward bleeding and higher sequela and mortality
rates. There is controversy as to what is the most appropriate therapeutic treatment for these lesions. Surgical
resection should be performed. However, the high morbidity and mortality rates associated have recently given way to
stereotactic radiosurgery as an alternative for treatment of
lesions with difficult surgical approach, with lower morbidity
mortality rates.33
Conclusions
Cavernomas are vascular malformations that the radiologist
usually faces in daily practice. They present with typical
radiological features, especially on MRI, associated with
subacute or chronic blood products. For this reason, T2
gradient-echo sequences are of great help for carvernoma
identification. Cavernomas are quite commonly associated
with developmental venous anomaly, and thus, MRI studies
are necessary for better visualization. However, cavernomas
may manifest with atypical features, usually associated with
recent hemorrhage. In these cases, follow-up is very useful
to confirm diagnosis. Knowledge of these features is crucial
to make a correct diagnosis, which enables optimization of
the different treatment strategies.
Authorship
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Responsible for the integrity of the study: JJCV.
Conception of the study: JJCV, LCA, FBM and JIGL.
Design of the study: JJCV, LCA, FBM and JIGL.
Acquisition of data: JJCV.
Analysis and interpretation of data: JJCV, LCA, FBM and
JIGL.
Statistical analysis: N/A.
Bibliographic search: JJCV, LCA, FBM, JIGL and JGSSG.
Drafting of the paper: JJCV, LCA, FBM, JIGL and JGSSG.
Critical review with intellectually relevant contributions: JJCV, LCA, FBM, JIGL and JGSSG
Approval of the final version: JJCV, LCA, FBM, JIGL and
JGSSG.
Conflict of interest
The authors declare not having any conflict of interest.
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Cerebral cavernous malformations: Spectrum of neuroradiological

Transcription

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