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Dynamic MRI for Distinguishing High-Flow from Low-Flow Peripheral Vascular Malformations

Yoshimitsu Ohgiya1,2, Toshi Hashimoto1, Takehiko Gokan1, Shouji Watanabe3, Masayoshi Kuroda3, Masanori Hirose1, Seishi Matsui1, Hiroshi Nobusawa1, Takashi Kitanosono2 and Hirotsugu Munechika1

1 Department of Radiology, Showa University School of Medicine, Tokyo, Japan.
2 Present address: Department of Diagnostic and Interventional Neuroradiology, University of Rochester School of Medicine & Dentistry and University of Rochester Medical Center, 601 Elmwood Ave., PO Box 648, Rochester, NY 14642.
3 Department of Plastic Surgery, Showa University School of Medicine, Tokyo, Japan.



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  		Fig. 1 —Line graph shows changes in mean percentage of enhancement above baseline with each type of vascular malformation on dynamic contrast-enhanced MRI. Mean percentage of enhancement of high-flow vascular malformations ({diamondsuit}) increases rapidly and decreases gradually, and that of low-flow vascular malformations ({blacksquare}) increases gradually. Note: percentage enhancement above baseline = (signal intensity after enhancement – signal intensity before enhancement) / signal intensity before enhancement x 100. Five sec before start of arterial enhancement is defined as 0 sec.

 


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  		Fig. 2A —2-year-old boy with peripheral high-flow vascular malformation. Transverse T2-weighted fast spin-echo MR image (TR/TE, 4,000/96) shows vascular malformation (arrow) in right temporalis region.

 


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  		Fig. 2B —2-year-old boy with peripheral high-flow vascular malformation. Dynamic contrast-enhanced subtraction MR image shows start of arterial enhancement (short arrow) and no lesion enhancement (long arrow) 15 sec after start of IV bolus of gadopentetate dimeglumine.

 


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  		Fig. 2C —2-year-old boy with peripheral high-flow vascular malformation. Dynamic contrast-enhanced subtraction MR image, obtained at same level as B but 5 sec later, shows immediate and intense lesion enhancement (arrow).

 


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  		Fig. 2D —2-year-old boy with peripheral high-flow vascular malformation. Selective angiogram of right superficial temporal artery shows characteristics of high-flow vascular malformation. Note dilatation of afferent arteries (long arrow) followed by early enhancement of enlarged efferent veins (short arrow).

 


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  		Fig. 3A —36-year-old man with peripheral low-flow vascular malformation. Transverse T2-weighted fast spin-echo MR image (TR/TE, 4,700/120) shows vascular malformation (arrow) of left face.

 


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  		Fig. 3B —36-year-old man with peripheral low-flow vascular malformation. Dynamic contrast-enhanced subtraction MR image shows start of arterial enhancement (arrow) 15 sec after start of IV bolus of gadopentetate dimeglumine.

 


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  		Fig. 3C —36-year-old man with peripheral low-flow vascular malformation. Dynamic contrast-enhanced subtraction MR image, obtained at same level as B but 5 sec later, shows slight lesion enhancement (arrow).

 


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  		Fig. 3D —36-year-old man with peripheral low-flow vascular malformation. Dynamic contrast-enhanced subtraction MR image, obtained at same level as B but 75 sec later, shows more intense lesion enhancement (arrow).

 


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  		Fig. 3E —36-year-old man with peripheral low-flow vascular malformation. Venogram shows filling of abnormal venous spaces (arrow).

 


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  		Fig. 4 —Scatterplot of artery–lesion enhancement time for each vascular malformation. All high-flow vascular malformations show an artery–lesion enhancement time of less than 10 sec. High-flow vascular malformations show shorter artery–lesion enhancement time than low-flow malformations, with overlap between the two. Use of a threshold artery–lesion enhancement time of 5 sec would result in 100% (6/6) sensitivity and 60% (6/10) specificity for differentiation of high-flow from low-flow malformations. Note: artery–lesion enhancement time = interval from beginning of enhancement of an arterial branch in vicinity of lesion in same slice to onset of enhancement in lesion. Start of arterial enhancement is defined as 0 sec. Number next to {blacksquare} is number of patients at that enhancement time.

 


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  		Fig. 5 —Scatterplot shows contrast rise time for each vascular malformation. All high-flow vascular malformations show contrast rise time of less than 20 sec. High-flow vascular malformations show shorter contrast rise time than low-flow vascular malformations, with no overlap between the two. Use of threshold contrast rise time of 30 sec would result in 100% (6/6) sensitivity and 100% (10/10) specificity for differentiation of high-flow from low-flow malformations. Note: contrast rise time = time between onset of lesion enhancement and time of maximal percentage of enhancement above baseline within 120 sec. Onset of lesion enhancement is defined as 0 sec. Number next to {blacksquare} is number of patients at that enhancement time.

 

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