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Mixed Vascular Malformation

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0:01

So here's an example of a diffuse

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abnormality involving the oral tongue and

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then extending into the floor of the mouth.

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So when we look at the non-contrast T1

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weighted images, we can see this intermediate

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signal mass that's involving the oral tongue on

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the sagittal images, the T2 weighted images.

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This defines the extent of this abnormality.

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When you give contrast, you can see that there

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is patchy enhancement to this diffuse abnormality,

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indicating that there is a vascular supply.

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Now, could this be a very

0:31

aggressive squamous cell carcinoma?

0:33

I assume it's possible, but in general, squamous cell

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carcinomas don't present at this extensive stage.

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So this was a younger patient, and

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the patient had a known congenital

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malformation involved in the oral tongue

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in the oral cavity.

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So now we have a congenital malformation,

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and the issue is how do we classify this?

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Well, the way that I classify it,

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again, to get us through 80% of these,

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is that we divide these into four areas.

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There is arterial, there is venous, there

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is capillary, and then there is lymphatic.

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So if we understand the four rings,

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if you will, the Olympic rings,

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and we look at various components of

1:14

these within various malformations,

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this will again, will get us through

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about 80% of the common vascular lesions

1:20

that we'll be seeing in our practice.

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So how do we dissect this case?

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Well, the first thing that we do is we

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look at the T2 weighted sequences,

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which is located at the top left.

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And when we look at the T2 weighted sequences, we

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can see that there's areas of increased T2 signal.

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So when we see these areas of

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increased T2 signal, that tells us

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that there is a lymphatic

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component to this malformation.

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The next thing that we look at is we can see

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this abnormality is involving muscle, and not

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only is it involving muscle, when we look at

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the coronal T2 weighted images, we can see

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these focal areas of diminished signal, and

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these focal areas of diminished signal are phleboliths.

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So in venous malformations, the characteristic

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findings for venous malformations

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are muscle involvement and phleboliths.

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So now we know that we have a venous malformation.

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Now, in one of the other earlier cases we

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showed, we saw components of a lymphatic

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component and a venous component, and that was

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referred to as a veno-lymphatic malformation.

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That case did not have any appreciable enhancement.

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But when we look at the contrast-enhanced

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T1 weighted images, we can see that

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there's quite a bit of enhancement.

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And in fact, when we look at this, a lot of this

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is some, a little bit of fine linear enhancement,

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suggesting that there's a capillary component.

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So now we have a capillary component.

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The fourth component is arterial.

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And in order to have an arterial component, then

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that is the classic arteriovenous malformation.

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In general, if you have an arteriovenous

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malformation, you don't have enlargement of the

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soft tissues, but instead you tend to have atrophy.

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Why?

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Because normally an artery goes to

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a capillary, it goes to the vein.

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The capillaries allow nutrient exchange

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with the surrounding soft tissues.

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If you have a direct communication

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between an artery and a vein, you don't

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have the capillaries, and as a result,

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there's no way for the nutrients to diffuse out into

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the soft tissues and nourish those soft tissues.

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And if there's not enough nutrients, then all of

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a sudden the soft tissues retract—the atrophy.

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So instead of having a lot of soft

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tissues, you have smaller soft tissues.

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So that's why this does not have

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an arterial component to it.

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In general, when we classify vascular malformations,

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if there's two components—a lymphatic and

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venous—this is a veno-lymphatic malformation.

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If it's capillary and venous, it's

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a capillary-venous malformation.

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If it's lymphatic and capillaries,

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it's a capillary-lymphatic malformation.

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But if there are greater than

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two components, as is seen here,

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this is what we refer to as a mixed vascular

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malformation. So this construct will get you

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through the majority of congenital vascular

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malformations that you'll encounter

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involving the extracranial head and neck.

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In order to confirm this diagnosis, we performed

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a time-resolved MR angiography, and what the

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time-resolved MR angiography demonstrates is

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that there is diffuse enhancement involving

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this large vascular malformation

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involving the oral tongue, but notice

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how there's not large vessels feeding it.

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Rather, this is more of a diffuse capillary

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blush as opposed to large vessels.

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So that's why the differential diagnosis here would

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include a component of a capillary malformation, a

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lymphatic malformation, and a venous malformation.

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And because there are more than two components, we

4:53

would classify this as a mixed vascular malformation.

Report

Description

Faculty

Suresh K Mukherji, MD, FACR, MBA

Clinical Professor, University of Illinois & Rutgers University. Faculty, Michigan State University. Director Head & Neck Radiology, ProScan Imaging

Tags

Vascular

Oral Cavity/Oropharynx

Neuroradiology

Neuro

MRI

Head and Neck

Congenital

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