0:05

So good. What did you think about this case? What did you put down for this one?

0:09

This one I put put, uh, wrong, wrong terminology. I put on, I,

0:14

I comment as a heman, which is the term that never used anymore.

0:19

Well, actually they use the term hemangioma.

0:23

Yeah. But

0:25

I just realize, um,

0:27

hemangiomas are different than low flow vascular malformation. So mm-hmm.

0:32

The one on the left right here demonstrates this mass.

0:37

And this mass is located within the muscle.

0:40

So if the mass is located within the muscle,

0:44

then you start thinking about neoplasms and so on and so forth.

0:47

But if it's soft and fluctuate,

0:49

then you have to think of it as could be some type of vascular malformation or

0:54

is it a hemangioma? So how do we then differentiate? Well,

0:57

the next thing we do is if I look at this and it's high T two signal,

1:01

then the next thing I do is I look at the contrast enhanced study. Now is this,

1:06

is this lesion avidly enhancing with contrast because most hemangiomas avidly

1:11

enhanced with contrast. So is this lesion avidly enhancing with contrast?

1:15

Yes or no?

1:17

No.

1:18

Good. So that tells you it's probably not a hemangioma. Okay? Mm-hmm.

1:23

So now I go back and look at this and I see the high T two signal,

1:27

and then if you look real closely, what do you see here?

1:34

Some hypo intense. Exactly,

1:37

Exactly. And does it look tubular or does it look punctate? Mm-hmm.

1:41

Punctate, we got this one. I thought this is a four point,

1:44

but it doesn't make sense with the post contrast study.

1:47

Exactly, exactly.

1:49

So now if you take a lesion that's in intramuscular

1:54

and then you have, um, multiple olis,

1:59

then what's the most likely vascular malformation that's going to give you that

2:04

combination?

2:06

Weakness malformation,

2:08

Right? Yeah. Now, the terminology that we don't use anymore is cavernoma.

2:12

We used to, we used to use cavernous malformations.

2:15

So maybe you've got hemangiomas and cavernous malformations mixed up,

2:18

but we don't use the term cavernous malformations anymore.

2:22

We use the term venous malformations. So I think you may have said hemangiomas.

2:27

In fact, when you look at these delayed imaging studies,

2:29

I think you can see sort of a,

2:31

this geographic enhancement seen out in the periphery.

2:34

Mm-hmm.

2:35

So the correct diagnosis here would be a venous malformation.

2:41

And here on the sagal, just here,

2:43

you can see the not a lot of avid enhancement there,

2:47

But can it be renal lymphatic malformation because the enhancement is not so

2:52

great?

2:53

Um, yeah, it could be ven lymphatic. I think that's, that's fine. Now,

2:58

the reason, reason why it, so the answer to your question is yes,

3:02

it could be venal lymphatic malformation,

3:04

because the characteristics are also suggest lymphatic malformation because

3:09

it's bright on T two. But I have to admit that if,

3:13

if something is purely intramuscular,

3:15

the characteristics for an intramuscular, if, lemme put it this way,

3:20

if you have a vascular malformation that is intramuscular

3:25

and contained FLTs,

3:27

then that really is very characteristic of a venous malformation.

3:32

Now, if I saw this and then it was extending into multiple spaces

3:38

and it was extending along the fascial planes

3:43

and I saw flits and there was also a muscular component,

3:48

then I would suggest that it's a venal lymphatic malformation. Okay, so let me,

3:53

let me do this. Okay. You know, there the he angios, um,

3:57

and this really is a much longer talk, but the, the he angios, um,

4:02

are two types. There's infantile and congenital.

4:05

And so they kind of start at birth and then they progress.

4:08

So you have the, um, the infantile he angios,

4:13

which begin, at begin at birth, they arise and then they shrink.

4:18

So that's the true infantile. He angios. And then you have congenital he angios,

4:23

which are already present at birth. And if they, um, don't involute,

4:28

they're called a niche non involuting congenital, he angios.

4:32

And if they do enlo, then they're called rapidly involuting, he angios.

4:37

And if they partially involute, then it's called pitch p i c H. Okay?

4:42

But what we're talking about is, um,

4:45

what we're talking about are the vascular malformation.

4:48

So I sort of use the Olympic rings approach. I dunno if you've seen this before,

4:52

but I talk about capillary lymphatic arterial and Venus. Okay?

4:58

So the capillary malformations are sort of the Sturge Weber, uh, types.

5:02

So this was, you probably are old enough to remember Gorbachev maybe,

5:05

but this was the famous,

5:06

most famous capillary malformation in the world for many, many years, right?

5:11

And this is really a clinical diagnosis. And if you do image these,

5:15

you don't really see too much. Basically,

5:18

you can get a little bit of enhancement right here in the subcutaneous tissues.

5:22

So when you actually look at these clinically, you can see that they're,

5:25

they are,

5:25

they are this birthmark and have a little bit of blood flow within them.

5:30

Now the next one is the lymphatic malformation.

5:32

So the lymphatic malformations are also known as cystic hydroma.

5:35

So they basically look like, um, just a water,

5:40

just a water containing structure. Okay?

5:43

Now the lymphatic malformations are felt to, uh,

5:45

felt to arise because the lymphatic and the venous structures arise together.

5:50

So they tend to involve multiple spaces.

5:53

So this is just an example of lymphatic malformation involved in this,

5:57

this submandibular space. And you can also see a little bit of, um,

6:00

some tations here, but notice the septations don't enhance,

6:04

or that's probably indicative of prior hemorrhage or maybe prior trauma or prior

6:08

infection. But notice when we give contrast that they don't enhance.

6:12

And this enhancement right here is just a submandibular gland.

6:16

Now the venous malformations is what I just showed.

6:20

So notice how these malformations are characteristically seen within the

6:24

muscles. And we can also see some flits. So these are the flits on ct,

6:29

and here we can see a lilith on mr.

6:31

And that's actually located within the muscle. And this is, uh,

6:35

just a delayed imaging of a,

6:38

a venous malformation demonstrating this delayed flow right here involving the

6:42

masser muscle. And then the last one is that our,

6:46

the arterial venous malformation of the av fistulas. In fact,

6:49

this is that case I just showed that you saw earlier.

6:52

This was the direct communication between the artery and the vein.

6:57

So my point is,

6:58

is that what we talked about was the characteristic appearance of each one.

7:03

Now, but in real life,

7:04

what ends up happening is that you typically have combinations of these two.

7:08

So if you have a combination of arter and venous and you have an arterial venous

7:12

malformation, but to get to your point, more specifically,

7:17

let's just say if you have lymphatic and venous coming together,

7:20

what would that look like? So this is a lympho venous malformation.

7:24

So what would that look like? Or venal, lymphatic malformation.

7:27

So this is what it would look like. So here we have,

7:29

this is predominantly located intramuscular, right?

7:34

And you can see these little FLTs, right?

7:37

But notice how this lesion is actually extending outside of the muscle.

7:41

So this would be a ven lymphatic malformation. Another example here.

7:46

So this is involving the bator muscle.

7:48

So this tells me there's probably a venal, uh, a um,

7:53

venous malformation component. You can also see the flits here.

7:57

Do you see the flits here, Han? Yes. So that tells you that that again,

8:01

goes along with the venous component, but on the other hand,

8:04

look how high signal it is and notice how it's actually extending into the

8:08

buccal space. And it's extending deeply into the, uh, tego maxillary fissure.

8:13

So because this is involving multiple spaces,

8:15

and that's that lymphatic component. So the fact that it's very, very bright,

8:19

it's fluid involves multiple spaces, and that's the lymphatic component.

8:23

So that's why we would call this Aveeno lymphatic malformation.

8:28

Does that make sense to you?

8:29

Yes.

8:30

Okay.

8:31

If it's just confined to the muscle, most likely it's a venous malformation.

8:36

Yeah. With the relet, yeah.

8:38

Yes.

8:38

And it has to be soft on palpation too, because realize you can have, you know,

8:42

rhabdo my sarcomas or other things that.