Case Studies #1                                          Case Studies #2              Case Studies #3

Click Case# (or image) for more information / diagnostic work-up & treatment
 
Case#1: Upper Lip lesion, was born with this lesion, soft, not painful Diagnosis: Capillary Venous Malformation. Although this malformation was initially considered a venous malformation based on history, clinical presentation and MRI, arteriography showed that the malformation has multiple tiny feeding arteries with multiple draining veins resulting in relatively rapid arteriovenous shunt (similar to AVMs). The final diagnosis was capillary venous malformation (CVM). Treatment: This lesion was embolized two times with poor response. The lesion was subsequently removed surgically. For more details, click here.
Case#2: Pulsatile lesion on the outer side of the foot, painful, first noted several years ago Imaging Studies: T2 weighted MRI image shows some abnormal signal around the 5th metatarsal bone, inconclusive Gradient echo image shows a few bright signals in the area, suggestive a high-flow lesion (AVM); Arteriogram revealed an AVM lesion, arterial feeders are from the anterior tibial artery; Diagnosis: AVM (Arteriovenous Malformation)Treatment: Transcatheter embolization. No complication. For more details, click here.
Case#3: Pain and swelling in the upper calf area in a young female. MRI findings suggested an AVM lesion.; Diagnosis: AVM; Treatment: Transcatheter embolization. Images show an AVM lesion in the upper calf with intense contrast enhancement of the AVM nidus. This is a high-flow vascular anomaly (vascular birthmark) draining into the deep venous system. There are multiple small arterial feeders seen; Selective catheterization of one of the arterial feeders and selective arteriograms show rapid arteriovenous blood flow and tortuous vasculature in the nidus area. This vascular bed was subsequently embolized with absolute alcohol; Direct percutaneous puncture of the varicoid aneurysmal venous lesion and contrast injection and coil embolization of the venous abnormality; on post-embo image the lesion is no longer fills with contrast and the extremity arteries are widely patent. For more info, click here.
Case#4: Pain and small bluish skin discoloration in the elbow region. Imaging Studies: T2 weighted axial MRI image shows a typical venous malformation (low-flow vascular birthmark) located superficially just under the skin. The underlying muscle groups appear normal. Direct contrast injection into the malformation outlines the small venous anomaly and also demonstrates venous drainage pathways of the lesion. Diagnosis: Venous Malformation; Treatment: This lesion can be treated surgically or by percutaneous means (Sclerotherapy). Sclerotherapy was selected in this case and a tiny amount of sclerosant agent was used. Good results and no complication. For more info, click here.
Case#5: Painful calf / knee without obvious skin abnormalities. Failed surgical excision history.  Imaging Studies: MRI T2 weighted axial image shows a typical venous malformation (low-flow vascular birthmark) involving the muscle groups in the back of the knee. Post-contrast MR images demonstrate characteristic inhomogeneous, but intense contrast enhancement.  Arteriogram was performed at different institution earlier. In general, arteriography is not needed for venous malformations and these lesions can not be treated with transcatheter embolization. Arterial phase of the study shows no arterial abnormalities. However, delayed phase (venous phase) demonstrates the malformation with scattered inhomogeneous filling of the lesion with the contrast material. Diagnosis: Venus Malformation (failed surgical excision); Treatment: This lesion can not be treated surgically due to the fact that the muscles are involved with this malformation extensively. However, this lesion can be treated with percutaneous means (Sclerotherapy).  Click here for more info.
Case#6: Superficial skin lesion in the upper extremity. Gradually growing, but not painful. Imaging Studies: No imaging studies were performed. MRI is the ideal imaging modality if diagnostic work-up is indicated. ultrasonography is commonly performed for these patients, but it is unnecessary in many patients and also may cause diagnostic dilemma if a sonographer is not familiar with these malformations. Also, CT or plain radiography have limited value in the diagnostic work-up and are not indicated. Diagnosis: Infantile Hemangioma; Treatment:  Treatment is not needed. Please click here to see therapeutic strategies for hemangiomas. Click here for more info about this case. 
Case#7: Focal neck enlargement in an infant. MRI T2 weighted coronal images show a typical mixed form (macrocystic and microcystic) lymphatic malformation (low-flow vascular birthmark). These lesions are commonly called cystic hygroma. Please note that there is signal abnormalities in the lower section of the tongue. Tongue involvement is relatively common in lymphatic malformations of the head and neck.  These low-flow malformations do not demonstrate contrast enhancement on post-contrast scans (not shown). Diagnosis: Lymphatic Malformation (Cystic Hygroma); Treatment: This lesion can not be excised completely (surgically). In this patient, most appropriate therapeutic approach would be direct percutaneous sclerosant injection (sclerotherapy). Click here for more information about this case. 
Case#8: Small painful skin lesion and painful calf in a young boy.  There is a small vascular lesion with a few tiny arterial feeding arteries from the peroneal artery (arteriography). There is not obvious rapid filling of the veins to suggest arteriovenous malformation. However, in early phases of AVM, this may be seen. This is more suggestive of a benign intramuscular hemangioma tumor. Selective injection of the arterial feeder outlining the lesion with a relatively rapid filling of the regional draining veins. This lesion was treated with transcatheter embolization using small particles. Port-embolization arteriography shows no residual lesion after the embolization. Click here for more information.
Case#9: Painful right hip and pulsatile soft tissue swelling in a young female. X-ray: Increased trabeculation and a cystic bone lesion in the proximal femur. MRI: T1 weighted image shows flow related signal loss (dark signal) in the area, suggestive of a high-flow malformation (vascular birthmark). Conventional Arteriogram (Angiography) (3rd and 4th images): Obvious increased vascularity is seen in the area with an aneurysmal venous abnormality and large draining veins. Diagnosis: AVM. Discussion: Arteriovenous malformations are high-flow vascular birthmarks and commonly involve the soft tissues, and in some cases, they may involve the bones. Bone changes related to AVM are not well documented in the literature. This case clearly demonstrates possible bony changes due to high-flow nature of these anomalies. Currently, it is unclear if these bone changes may cause significant weakening.
Case#10: Small soft tissue swelling in the thumb Diagnosis: Infantile hemangioma. MRI is limited in this case; because the area of interest (hand / thumb) is a small body part and the lesion is also small in size. In most larger infantile hemangiomas, MRI can be more helpful in terms of confirming the suspected diagnosis and also to outline the margins of the malformation. Most large infantile hemangiomas demonstrates relatively homogeneous contrast enhancement and some small fast-flow vascularity in the periphery of the mass, as well as in the surrounding soft tissues. Overall, rare possibilities (e.g., malignancy) can not be entirely excluded in this case based on this MR scan. Final decision should be made based on clinical history and assessment.
 

 

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