Neurosurgical Consultants: Vascular Malformations: Arteriovenous Malformation

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VENOUS ANGIOMA

Venous Angiomas (Venous Malformations) are the most common type of intracranial vascular malformation with an estimated prevalence of approximately 2.5% of the general population.

A Venous Angioma is characterized by an enlarged collection of veins which, other than their size, are microscopically normal. These enlarged veins receive drainage from adjacent healthy Brain. The veins have a characteristic appearance of a radial arrangement, all converging on an enlarged central venous trunk. This trunk drains into healthy superficial or deep venous systems. Venous Angiomas are not associated with abnormal arteries and are generally regarded as anomalies rather than pathological structures.

Most patients that are identified with Venous Angiomas are consequent to an incidental neuroimaging study.

SYMPTOMS

Most patients with a Venous Angioma are completely asymptomatic and have no need for any treatment.

While it is generally accepted that Venous Angiomas have a very low risk of bleeding, intracranial hemorrhage may be the presenting symptom for a small percentage of patients. Patients may also present with new onset seizure or focal neurological deficit. Posterior Cranial Fossa (back & lowest "chamber" of the interior of the Skull) lesions are more likely to result in some form of neurological deficit.

NEUROIMAGING

Angiograms usually have a "hydra" or "caput medusae" appearance consequent to the image of small radial veins converging on a central draining venous trunk. CT or MRI Scans usually demonstrate a curvilinear structure that resembles the spokes of a wheel.

Figure 1 (Top Left): Gadolinium Enhanced MRI Scan (Axial View) demonstrates a Venous Angioma (Curved Arrows) in the Left Frontal Lobe in a 35 Year old Female.
Figure 2 (Top Right): Close-up View of Same Patient's MRI Scan. The Curved Arrows indicate the venous drainage pattern towards "normal" deep draining veins.
Figure 3 (Left): MRI Scan (Coronal View-Same Patient) The Curved Arrow indicates the deep draining vein associated with the Venous Angioma.
NOTE: THE "LESION" IS NOT CAUSING ANY SYMPTOMS IN THIS PATIENT.

TREATMENT

Venous Angiomas are usually part of the normal venous drainage system for normal Brain. Therefore, surgical removal can lead to a disastrous venous infarction of the surrounding and adjacent brain resulting in significant morbidity and mortality. Excision or ablation of venous Angiomas is to be avoided except for very unusual circumstances.

Surgical intervention may occasionally be appropriate in a patient with a Venous Angioma to remove a clot after a hemorrhage; however, it is more likely that the bleeding originated from a Cavernous Angioma since the two appear to be related pathophysiologically.

In a case of a hemorrhage associated with a Venous Angioma, it is imperative to investigate the patient for an adjacent Cavernous Angioma. If a Cavernous Angioma is found, surgical removal of the clot and the Cavernous Angioma is appropriate while leaving the Venous Angioma.