Soft-Tissue Venous Malformations in Adult Patients: Imaging and Therapeutic Issues1
Josée Dubois, MD,
Gilles Soulez, MD,
Vincent L. Oliva, MD,
Marie-Josée Berthiaume, MD,
Chantale Lapierre, MD and
Eric Therasse, MD
1 From the Department of Radiology, Ste-Justine Hospital, 3175 Côte Ste-Catherine, Montréal, Québec, Canada H3T 1C5 (J.D., C.L.); and the Department of Radiology, Centre Hospitalier de l’Université de Montréal, Québec, Canada (G.S., V.L.O., M.J.B., E.T.). Recipient of a Magna Cum Laude award for an education exhibit at the 2000 RSNA scientific assembly. Received February 27, 2001; revision requested May 2 and received June 28; accepted July 2. Address correspondence to J.D. (e-mail: joseedubois@compuserve.com).
View larger version (115K):
[in a new window]
|
Figure 1. Venous malformation of the right parotid gland. Conventional radiograph demonstrates phleboliths (arrows).
|
|
View larger version (131K):
[in a new window]
|
Figure 2a. Venous malformation of the cheek. (a) Gray-scale US image shows hypoechoic structures (arrows). (b) Doppler US image helps confirm the presence of low venous flow within the malformation.
|
|
View larger version (110K):
[in a new window]
|
Figure 2b. Venous malformation of the cheek. (a) Gray-scale US image shows hypoechoic structures (arrows). (b) Doppler US image helps confirm the presence of low venous flow within the malformation.
|
|
View larger version (143K):
[in a new window]
|
Figure 3a. Venous malformation of the right masseter muscle. (a) Contrast material-enhanced CT scan shows a heterogeneous mass of the right masseter muscle with faint peripheral enhancement surrounding hypoattenuating areas. The presence of a phlebolith (arrow) confirms the diagnosis of venous malformation. (b) Fast spin-echo T2-weighted MR image depicts a cavitary lesion with septation. The lesion is clearly hyperintense. (c) Gadolinium-enhanced T1-weighted MR image shows the lesion with partial heterogeneous enhancement, a finding that suggests partial thrombosis of the venous malformation.
|
|
View larger version (150K):
[in a new window]
|
Figure 3b. Venous malformation of the right masseter muscle. (a) Contrast material-enhanced CT scan shows a heterogeneous mass of the right masseter muscle with faint peripheral enhancement surrounding hypoattenuating areas. The presence of a phlebolith (arrow) confirms the diagnosis of venous malformation. (b) Fast spin-echo T2-weighted MR image depicts a cavitary lesion with septation. The lesion is clearly hyperintense. (c) Gadolinium-enhanced T1-weighted MR image shows the lesion with partial heterogeneous enhancement, a finding that suggests partial thrombosis of the venous malformation.
|
|
View larger version (173K):
[in a new window]
|
Figure 3c. Venous malformation of the right masseter muscle. (a) Contrast material-enhanced CT scan shows a heterogeneous mass of the right masseter muscle with faint peripheral enhancement surrounding hypoattenuating areas. The presence of a phlebolith (arrow) confirms the diagnosis of venous malformation. (b) Fast spin-echo T2-weighted MR image depicts a cavitary lesion with septation. The lesion is clearly hyperintense. (c) Gadolinium-enhanced T1-weighted MR image shows the lesion with partial heterogeneous enhancement, a finding that suggests partial thrombosis of the venous malformation.
|
|
View larger version (131K):
[in a new window]
|
Figure 4. Venous malformation of the left thigh. CT scan demonstrates a heterogeneous lesion in the vastus lateralis muscle. The hypoattenuating peripheral portion of the lesion (arrows) suggests the presence of fat.
|
|
View larger version (122K):
[in a new window]
|
Figure 5a. Venous malformation of the right plantar region. (a) Spin-echo T1-weighted MR image shows diffuse enlargement of the medial plantar muscles. The lesion is hypointense and is difficult to differentiate from the normal muscular structures. (b) STIR T2-weighted image (512 matrix) clearly demonstrates the malformation within the plantar muscles. (c, d) Unenhanced (c) and contrast-enhanced (d) coronal T1-weighted images show perfusion of the malformation, which involves the first three layers of the plantar muscles.
|
|
View larger version (109K):
[in a new window]
|
Figure 5b. Venous malformation of the right plantar region. (a) Spin-echo T1-weighted MR image shows diffuse enlargement of the medial plantar muscles. The lesion is hypointense and is difficult to differentiate from the normal muscular structures. (b) STIR T2-weighted image (512 matrix) clearly demonstrates the malformation within the plantar muscles. (c, d) Unenhanced (c) and contrast-enhanced (d) coronal T1-weighted images show perfusion of the malformation, which involves the first three layers of the plantar muscles.
|
|
View larger version (129K):
[in a new window]
|
Figure 5c. Venous malformation of the right plantar region. (a) Spin-echo T1-weighted MR image shows diffuse enlargement of the medial plantar muscles. The lesion is hypointense and is difficult to differentiate from the normal muscular structures. (b) STIR T2-weighted image (512 matrix) clearly demonstrates the malformation within the plantar muscles. (c, d) Unenhanced (c) and contrast-enhanced (d) coronal T1-weighted images show perfusion of the malformation, which involves the first three layers of the plantar muscles.
|
|
View larger version (103K):
[in a new window]
|
Figure 5d. Venous malformation of the right plantar region. (a) Spin-echo T1-weighted MR image shows diffuse enlargement of the medial plantar muscles. The lesion is hypointense and is difficult to differentiate from the normal muscular structures. (b) STIR T2-weighted image (512 matrix) clearly demonstrates the malformation within the plantar muscles. (c, d) Unenhanced (c) and contrast-enhanced (d) coronal T1-weighted images show perfusion of the malformation, which involves the first three layers of the plantar muscles.
|
|
View larger version (142K):
[in a new window]
|
Figure 6. Venous malformation of the right parotid gland. Gradient-echo T2*-weighted MR image clearly demonstrates a malformation within the right parotid gland with extension into the right parapharyngeal space. Phleboliths are well visualized as areas of hypointensity (arrows).
|
|
View larger version (147K):
[in a new window]
|
Figure 7a. Venous malformation of the right thigh. (a) Coronal STIR MR image demonstrates dysmorphic veins (arrows). (b, c) Gadolinium-enhanced MR phlebograms obtained with three-dimensional FISP show dysmorphic veins in the territory of the deep femoral vein (arrows).
|
|
View larger version (75K):
[in a new window]
|
Figure 7b. Venous malformation of the right thigh. (a) Coronal STIR MR image demonstrates dysmorphic veins (arrows). (b, c) Gadolinium-enhanced MR phlebograms obtained with three-dimensional FISP show dysmorphic veins in the territory of the deep femoral vein (arrows).
|
|
View larger version (55K):
[in a new window]
|
Figure 7c. Venous malformation of the right thigh. (a) Coronal STIR MR image demonstrates dysmorphic veins (arrows). (b, c) Gadolinium-enhanced MR phlebograms obtained with three-dimensional FISP show dysmorphic veins in the territory of the deep femoral vein (arrows).
|
|
View larger version (67K):
[in a new window]
|
Figure 8a. Venous malformation of the left arm. (a) Clinical photograph of the left arm demonstrates a soft-tissue lump. The bluish discoloration of the overlying skin suggests a venous malformation. (b) Sagittal spin-echo T1-weighted MR image reveals infiltration of the subcutaneous fat by a low-signal-intensity mass. Dysmorphic veins are present in the vicinity of the mass (arrow).
|
|
View larger version (91K):
[in a new window]
|
Figure 8b. Venous malformation of the left arm. (a) Clinical photograph of the left arm demonstrates a soft-tissue lump. The bluish discoloration of the overlying skin suggests a venous malformation. (b) Sagittal spin-echo T1-weighted MR image reveals infiltration of the subcutaneous fat by a low-signal-intensity mass. Dysmorphic veins are present in the vicinity of the mass (arrow).
|
|
View larger version (103K):
[in a new window]
|
Figure 9. Venous malformation of the hand. T2-weighted MR image shows dysmorphic veins (arrows).
|
|
View larger version (132K):
[in a new window]
|
Figure 10a. Venous malformation with extension. (a) Axial T1-weighted MR image shows a venous malformation infiltrating the fat surrounding the femoral vessel in the right inguinal region (arrows). (b) On a STIR T2-weighted MR image, the malformation is clearly demonstrated in the inguinal region (arrow). Involvement of the parametrium is also noted.
|
|
View larger version (124K):
[in a new window]
|
Figure 10b. Venous malformation with extension. (a) Axial T1-weighted MR image shows a venous malformation infiltrating the fat surrounding the femoral vessel in the right inguinal region (arrows). (b) On a STIR T2-weighted MR image, the malformation is clearly demonstrated in the inguinal region (arrow). Involvement of the parametrium is also noted.
|
|
View larger version (132K):
[in a new window]
|
Figure 11a. Venous malformation of the elbow. (a) Spin-echo T1-weighted MR image shows an isointense mass (arrowheads) infiltrating the periarticular fat and the triceps muscle. Subtle infiltration of the subcortical bone medulla is also seen (arrow). (b) Axial T2-weighted MR image clearly demonstrates the malformation with involvement of the distal humeral bone and infiltration of the olecranon fossa and the distal portion of the triceps muscle. (c) Gadolinium-enhanced T1-weighted MR image demonstrates perfusion of the entire malformation.
|
|
View larger version (94K):
[in a new window]
|
Figure 11b. Venous malformation of the elbow. (a) Spin-echo T1-weighted MR image shows an isointense mass (arrowheads) infiltrating the periarticular fat and the triceps muscle. Subtle infiltration of the subcortical bone medulla is also seen (arrow). (b) Axial T2-weighted MR image clearly demonstrates the malformation with involvement of the distal humeral bone and infiltration of the olecranon fossa and the distal portion of the triceps muscle. (c) Gadolinium-enhanced T1-weighted MR image demonstrates perfusion of the entire malformation.
|
|
View larger version (108K):
[in a new window]
|
Figure 11c. Venous malformation of the elbow. (a) Spin-echo T1-weighted MR image shows an isointense mass (arrowheads) infiltrating the periarticular fat and the triceps muscle. Subtle infiltration of the subcortical bone medulla is also seen (arrow). (b) Axial T2-weighted MR image clearly demonstrates the malformation with involvement of the distal humeral bone and infiltration of the olecranon fossa and the distal portion of the triceps muscle. (c) Gadolinium-enhanced T1-weighted MR image demonstrates perfusion of the entire malformation.
|
|
View larger version (92K):
[in a new window]
|
Figure 12a. Venous malformation in a middle-aged woman with dysphagia and dysphonia. (a) Sagittal T2-weighted MR image shows a large venous malformation of the cervical prevertebral region inducing compression of the pharynx. (b) T1-weighted MR image obtained after three sessions of sclerotherapy with alcoholic solution of zein and alcohol reveals significant shrinkage of the malformation, which now demonstrates heterogeneous signal intensity with small hyperintense areas. This finding may be related to recent thrombosis. (c) Gadolinium-enhanced MR image shows the malformation with heterogeneous enhancement (arrows). This finding may be related to a posttherapeutic inflammatory reaction and to residual perfusion of the malformation.
|
|
View larger version (95K):
[in a new window]
|
Figure 12b. Venous malformation in a middle-aged woman with dysphagia and dysphonia. (a) Sagittal T2-weighted MR image shows a large venous malformation of the cervical prevertebral region inducing compression of the pharynx. (b) T1-weighted MR image obtained after three sessions of sclerotherapy with alcoholic solution of zein and alcohol reveals significant shrinkage of the malformation, which now demonstrates heterogeneous signal intensity with small hyperintense areas. This finding may be related to recent thrombosis. (c) Gadolinium-enhanced MR image shows the malformation with heterogeneous enhancement (arrows). This finding may be related to a posttherapeutic inflammatory reaction and to residual perfusion of the malformation.
|
|
View larger version (101K):
[in a new window]
|
Figure 12c. Venous malformation in a middle-aged woman with dysphagia and dysphonia. (a) Sagittal T2-weighted MR image shows a large venous malformation of the cervical prevertebral region inducing compression of the pharynx. (b) T1-weighted MR image obtained after three sessions of sclerotherapy with alcoholic solution of zein and alcohol reveals significant shrinkage of the malformation, which now demonstrates heterogeneous signal intensity with small hyperintense areas. This finding may be related to recent thrombosis. (c) Gadolinium-enhanced MR image shows the malformation with heterogeneous enhancement (arrows). This finding may be related to a posttherapeutic inflammatory reaction and to residual perfusion of the malformation.
|
|
View larger version (127K):
[in a new window]
|
Figure 13. CT scan demonstrates direct needle puncture of the venous malformation in the same patient as in Figure 12.
|
|
View larger version (118K):
[in a new window]
|
Figure 14a. Direct phlebography and sclerotherapy of a venous malformation of the foot. (a) Clinical photograph shows a sclerotherapeutic procedure. Because the lesion was superficial, we used a 21-gauge butterfly needle. Venous return was observed, confirming the proper positioning of the needle. (b) Direct phlebogram demonstrates a venous malformation with a cavitary portion (straight arrow) and drainage into dysmorphic veins (curved arrow).
|
|
View larger version (162K):
[in a new window]
|
Figure 14b. Direct phlebography and sclerotherapy of a venous malformation of the foot. (a) Clinical photograph shows a sclerotherapeutic procedure. Because the lesion was superficial, we used a 21-gauge butterfly needle. Venous return was observed, confirming the proper positioning of the needle. (b) Direct phlebogram demonstrates a venous malformation with a cavitary portion (straight arrow) and drainage into dysmorphic veins (curved arrow).
|
|
View larger version (128K):
[in a new window]
|
Figure 15. Venous malformation of the elbow. Direct phlebogram demonstrates a venous malformation with a cavitary pattern.
|
|
View larger version (159K):
[in a new window]
|
Figure 16. Venous malformation of the right thigh. Direct phlebogram demonstrates a venous malformation with a spongy pattern.
|
|
View larger version (97K):
[in a new window]
|
Figure 17. Venous malformation of the hand. Direct phlebogram demonstrates a venous malformation with dysmorphic veins and early drainage.
|
|
View larger version (111K):
[in a new window]
|
Figure 18. Venous malformation of the anterior portion of the elbow. Peripheral phlebogram demonstrates a malformation and its venous drainage.
|
|
View larger version (169K):
[in a new window]
|
Figure 19a. Complex venous malformation of the temporal area. (a) External carotid angiogram demonstrates progressive filling of venous structures. (b) Delayed-phase angiogram shows stagnation of the contrast material in the venous lakes. Because no washout of the dysmorphic veins was observed, the term microfistula is probably not appropriate. This malformation demonstrated high venous flow at Doppler US. Arterial embolization was performed to decrease the flow, followed by direct embolization with alcohol.
|
|
View larger version (171K):
[in a new window]
|
Figure 19b. Complex venous malformation of the temporal area. (a) External carotid angiogram demonstrates progressive filling of venous structures. (b) Delayed-phase angiogram shows stagnation of the contrast material in the venous lakes. Because no washout of the dysmorphic veins was observed, the term microfistula is probably not appropriate. This malformation demonstrated high venous flow at Doppler US. Arterial embolization was performed to decrease the flow, followed by direct embolization with alcohol.
|
|
Copyright © 2001 by the Radiological Society of North America.
