Case Studies #2                                       Case Studies #1              Case Studies #3
Click Case# (or image) for more information / diagnostic work-up & treatment
Case#11: Small -Moderate venous malformation (hemangioma) in the elbow, History of failed surgical excision. Arteriogram (Arteriography) demonstrated delayed opacification with no arterial involvement.  T2 weighted MRI axial images through the elbow demonstrate hyperintense (bright) lesion in the muscles extending into the subcutaneous area. The lesion is located around the brachial artery and major nerves which makes surgical excision very difficult, if not impossible (without major sequela).  Venous access is usually maintained and is used for flushing the deep veins during the procedure so that potential sclerosant drainage into the deep venous system would not cause thrombosis (deep vein thrombosis).  With adequate venous outflow control, sclerosant agent mixed with contrast material (ethiodol) is then injected into the malformation under careful fluoroscopic control. 
  Case#12: Pain in the calf, young female patient. No skin lesion. TOF MRA (actually MRV or MR venography) shows obvious relatively large caliber vasculature in the lateral calf demonstrating strong venous flow (directed back to the heart). Contrast-enhanced MRA demonstrating early opacification of the vasculature (arteries and veins) in the diseased leg. Based on these MR findings, arteriovenous fistula (AVF) is suspected. AVM is much less likely. Surgical ligation is favored over transcatheter embolization in this case due to short communicating arteriovenous channel. Embolization would be a risky intervention in this case. 
Case#13: Congenital lesion in the thigh, noted at birth.  Differential should include congenital hemangioma (or rapidly involuting congenital hemangioma - RICH) and congenital sarcoma. Congenital sarcoma (fibrosarcoma) is probably less common than RICH.  Biopsy of the lesion may be needed in selected cases. Platelet count and thyroid hormone levels needs to be checked. Imaging findings of this condition may be quite confusing; probably this has caused unnecessary interventions in many patients throughout the country. If needed, transcatheter embolization is the treatment of choice to close off some of the arterial feeders, and surgery is required in small number of patients. 
Case#14: AVM in the calf with multiple embolization procedures. 


Arteriogram demonstrated a residual AVM nidus was noted below the knee. selective contrast injections in the small arterial feeders demonstrated AV connections (early venous opacification is obvious). The AVM nidus was then embolized with particles - embospheres using a microcatheter system. Follow-up arteriogram showed no significant residual abnormal AV connection and patent runoff arteries. For further information on transcatheter embolization click here.
Case#15: Spinal Hemangioma



Due to unusual skin lesion (? pseudo-port-wine stain), Cobb disease is suspected. CTA was performed (not shown here) which did not show any high-flow anomaly and demonstrated above detailed soft tissue abnormality. This abnormality showed inhomogenous subtle contrast enhancement. Based on these findings, low-dose radiotherapy is recommended for her pain. CT imaging after therapy to decide the degree of involvement of the vertebral bodies. If the vertebral bodies appear weak at that point (prone to compression fracture), vertebroplasty will be considered to lower the risk of vertebral collapse (which would cause acute cord compression in this patient). Diagnosis: Spinal (vertebra) venous malformation ("hemangioma") with extraosseous soft tissue component.
Case#16: Forearm venous malformation causing significant pain.


T1W axial image through the proximal forearm (near the elbow) shows a heterogeneous mass-like lesion involving the muscle groups. The bright portion of the lesion represents fatty tissue, and gray color portion represent a vascular portion of the malformation. Fat-suppressed T1W image following intravenous contrast injection demonstrates a typical contrast enhancement pattern in association with suppression of the fatty signal.  This is a nice example to demonstrate the fact that significant number vascular anomalies demonstrates increased fatty tissue. A radiographic image (during sclerotherapy) outlines the lesion with rounded filling defects representing phleboliths. Management in these patients does not differ from other low-flow venous or lymphatic lesions. This patient was successfully treated with sclerotherapy

Case#17: Hemangioma overlying the lumbosacral spine 8 year old girl, born with a hemangioma at the base of her spine; described as "it is only on the surface and doesn't effect her nervous system. The docs did the "wait and see" and after 8 years, the redness is all but gone. The "swell" seems to be getting larger. Is this a secondary abnormality (fibrofatty tissue) or something else, like a tumor? No one seems to know anything here about these vascular birthmarks". MRI was performed to evaluate the underlying spinal structures and lipomyelomeningocele diagnosis was made. 
Case#18: Forehead infantile hemangioma in a 9 weeks old babygirl 9 week old girl with a red somewhat raised lesion on her forehead. First noticed at birth by the Paediatrician. At that stage it was just a faint mark. By 4 weeks the lesion was starting to bubble and go dark red. It has continued to grow since and is now flatter in appearance along with dark blackish spots. There is normal skin around the lesion that is also raised...
Case#19: Swelling in the neck "diagnosed with cystic hygroma at the age of 2 months after a knot came up on the left side of his neck... referred to a surgeon. Observation is suggested.  it went down significantly in a month..  At about 1 year, another mass came up in the same site. It was determined that it was a swollen lymph node and not a recurrence of the cystic hygroma.. more
Case#20: Liver hemangioma was diagnosed incidentally Ultrasound (US) examination of a 55 year old patient with some abdominal discomfort showed a small lesion in the liver. The appearance of the lesion was suggestive of benign hepatic cavernous hemangioma (venous malformation), but not characteristic. The patient was significantly concerned for a possibility of hepatic metastatic disease due to past medical history of colon carcinoma (surgically removed several years ago with no known metastases). Therefore, further imaging was performed.



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