Vascular Anomalies, ISSVA Classification

2 categories: vascular tumors or vascular malformations. Distinction determines therapy.

Vascular Tumors

• infantile hemangiomas: grow rapidly after birth, GLUT1+
• congenital hemangiomas (RICH and NICH): fully mature at birth, GLUT1-
• Tufted angioma
• Kaposiform hemangioendothelioma
• Spindle cell hemangioendotheliomas
• Dermatologic acquired vascular tumors

Vascular malformations (slow)

• capillary malformation (port-wine stain, telangiectasia, angiokeratoma)
• venous malformation
• lymphatic malformation

Vascular malformations (fast)

• arterial malformation
• arteriovenous fistula
• arteriovenous malformation

PDF link

MRI Hand and Wrist anatomy link

A nice PDF link to an old radiographics article diagraming MRI hand and wrist anatomy in a concise fashion: http://radiographics.rsna.org/content/8/6/1171.full.pdf

Red Marrow

• more water content, bright on T2
• amorphous and feathery, flame shaped
• metaphyseal and metadiaphyseal
• smoking and obesity, middle aged females

MRI Appearance of blood and timing

	T1	T2	Time	Blood
It Be	Iso	Bright	<2-4 hrs	OxyHg
IDy	Iso	Dark	1-3d	DeOxyHg
BiDy	Bright	Dark	3-7d	Intracellular MetHg
BaBy	Bright	Bright	1-2 wks	Extracellular MetHg
DooDoo	Dark	Dark	>2 wks	Hemosiderin

Bright on T1

• Blood
• Fat
• Protein
• Melanin
• Contrast

Acute Ischemic Stroke

Cytotoxic edema is cell death with efflux of K and influx of Ca, Na, and water. Edema peaks at day 7.

CT noncontrast

• Hyperdense artery sign on brain windows = thrombus; MCA most common (asymmetric)
• Loss of gray-white matter distinction, loss of insular ribbon;
• Parenchymal hypodensity = edema/cell necrosis
• Gyral swelling = 12-24hrs
• Hemorrhagic transformation = 24-48hrs
• if negative, get MRI

MRI

• Perfusion defect = ADC dark, DWI bright
• Edema = T1 low, T2 high
• if MRI negative and still strong clinical suspicion, do MRA or CTA neck/head

Stroke Timing

Time	CT	MRI
Minutes	no change	absent flow void, arterial enhancement, DWI high
2-6 hrs	hyperdense artery sign, insular ribbon sign	brain swelling (T1), subtle T2 high
6-12 hrs	sulcal effacement, decreased attenuation	T2 high
12-24 hrs	decreased attenuation	T1 low
3-7 d	max swelling
3-21 d	gyral enhancement
30-90 d	encephalomalacia, loss of enhancement

Which vessel territory?

Causes of acute stroke by age group

Pediatrics

• CHD
• Blood dyscrasias
• meningitis
• arterial dissection
• trauma
• extracorporeal membrane oxygenation (ECMO)
• venous thrombosis

Young Adult

• Cardiac emboli
• ASD
• drug abuse
• arterial dissection
• coagulopathy
• venous thrombosis

Elderly

• ASD
• cardiac emboli
• coagulopathy
• amyloid
• vasculitis
• venous thrombosis

L Spine MRI Dictation

Indication: [x].

Technique: An MRI of the lumbar spine was performed utilizing the following sequences: [x]

Comparison: [x]

Findings: Normal lumbar lordosis is preserved. Lumbar vertebral heights and alignment are maintained. No expansile or destructive osseous lesion is seen. No focal disk herniation, spinal canal or neural foramina stenosis is identified. The conus and cauda equina appear normal; the conus terminates at the [x] level. No epidural mass or collection is seen.

Impression: Normal lumbar spine MRI.

Brain MRI Dictation

Indication: [x]

Technique: An MRI of the brain was performed utilizing the following sequences: [x]

Comparison: [x]

Findings: The ventricles and sulci are normal in size and configuration. There is no acute infarct or intracerebral hemorrhage. No extra-axial blood or fluid collection is present. No intracranial mass is identified. The brainstem, posterior fossa and cervical medullary junction are preserved. Normal intracranial intravascular flow voids are seen. The orbits, periorbital and paracavernous spaces are normal. No abnormality of the skull base or calvarium is identified.

Impression: Normal MRI of the brain.

Ankle MRI Dictation

Indication: [x]

Technique: [x]

Comparison: [x]

Findings: The peroneal tendons, medial flexor tendons, and anterior extensor tendons are unremarkable.

The lateral ligamentous structures, including the anterior and posterior tibiofibular and talofibular ligaments, as well as the calcaneofibular ligament, are intact. The deep and superficial deltoid ligaments are normal. The spring and arcuate ligaments are normal. The Achilles tendon, retrocalcaneal and superficial bursae are normal. The plantar fascia is unremarkable.

The talonavicular joint is normal. The cartilage of the tibiotalar and subtalar joints is maintained.

Impression: [x]

Hip MRI Dictation

Clinical statement: [x]

Technique: [x]

Comparison: [x]

Findings: There is no greater trochanteric or iliopsoas bursitis. There is no stress fracture or osteonecrosis .

Images of the hip demonstrate no labral tear. The articular cartilage over the hip joint is maintained. There is no effusion or synovitis .

The fat planes around the sciatic nerves are preserved. The hamstring origins are normal. The sacroilliac joints are unremarkable.

Normal intervertebral T2 disc signal in the lower lumbar discs is maintained. No inguinal hernia or other pelvic pathology is identified.

Impression: [x]

Knee MRI Dictation

Indication: [x]

Technique: [x]

Comparison: [x]

Findings: The anterior and posterior cruciate ligaments are intact, as are the collateral ligament complexes and the insertion of the popliteus tendon.

There is no meniscal tear. The capsular attachments are intact. Evaluation of articular cartilage reveals the cartilage over the femoro-tibial and patello femoral joints to be maintained, without prominent fibrillation or flap.

The quadriceps mechanism is maintained. There is no stress fracture or osteonecrosis .

Impression: [x]

Elbow MRI Dictation

Clinical statement: [x]

Technique: [x]

Comparison: [x]

Findings: The extensor tendons and lateral collateral ligaments, including the ulnar band of the lateral collateral ligament, are maintained. The medial collateral ligament and flexor pronator origin are unremarkable.

As visualized in extension, the ulnar nerve is localized in the ulnar sulcus and the posterior interosseous nerve at the level of the supinator has preserved fat planes. The biceps, triceps, and brachialis insertions are normal. Articular cartilage is maintained.

Impression: [x]

Wrist MRI Dictation

Clinical statement: [x]

Technique: [x]

Comparison: [x]

Findings: The volar extrinsic ligaments are intact (these include the radio- scapho-capitate and radio- luno-triquetral ligaments. The intraosseous scapholunate and lunotriquetral ligaments are maintained. The triangulofibrocartilage complex is preserved (this includes the articular disc, the meniscal homologue, the extensor carpi ulnaris tendon, the volar and dorsal distal radioulnar ligaments, and the ulno-lunate and ulno-triquetral ligaments).

The extensor tendons are unremarkable, without tenosynovitis , tear or degeneration. The contents of the carpal tunnel are preserved. (The carpal tunnel nine tendons, plus the median nerve. Look for aberrent vessels such as a persistent median artery.) Guyon’s canal is unremarkable.

The articular cartilage over the carpus is normal.

Impression: [x]

Shoulder MRI Dictation

Indication: [x]

Technique: [x]

Comparison: [x]

Findings: No fluid signal in the supraspinatus tendon. No rotator cuff tear. Intact biceps labral complex. Normal superior labrum attachment. The anteroinferior labrum is intact. Posterior labrum is normal. Intact subscapularis tendon and biceps tendon. Normal inferior glenohumeral ligament complex. The biceps pulley is intact with normal coracohumeral ligaments and superior glenohumeral ligament complex.

[Mild/moderate/severe] clavicular arthrosis with hypertrophy of the distal clavicle. [Type I/II/III sloping?] acromion. Normal glenoid fossa. Normal marrow signal without fracture or edema.

Impression: [x]