The role of dynamic contrast-enhanced magnetic resonance imaging in the diagnosis and management of patients with vascular malformations

Abstract

Vascular malformations are uncommon but may confer significant morbidity. Limitations in diagnosis and treatment result from inadequate classification schema and diagnostic algorithms. The crucial distinction is between high-flow and low-flow lesions because this informs prognosis and treatment. This study assessed the utility of dynamic contrast-enhanced magnetic resonance imaging (dceMRI) in distinguishing high-flow from low-flow lesions, a technique that has previously not been widely applied or evaluated in this patient population. A prospective database of all patients referred to the multidisciplinary vascular malformation team at our institution was reviewed from January 2006 to June 2010. dceMRI was obtained on each patient to determine flow characteristics and lesion extent. Additional studies were used as indicated. Catheter-based arteriography was performed when high-flow lesions were identified with the intention of intervening or to distinguish between high-flow and low-flow lesions when MRI was indeterminate. A triage algorithm was used to stratify patients and formulate therapeutic goals. We analyzed the accuracy of dceMRI in identifying high-flow and low-flow lesions. The study included 122 patients (aged <1 to 70 years) comprising 52 males (42.6%) and 70 females (57.4%). Pain (72 patients; 59%) and swelling (88 patients; 72.1%) were the most common presenting symptoms. All patients underwent dceMRI. Of these, 68 had confirmatory imaging (n = 15) or intervention (n = 53). The dceMRI was able to definitively and correctly distinguish high-flow from low-flow lesions in 57 studies, for an accuracy rate of 83.8%. In the remaining 11 studies, dceMRI correctly queried flow status but not definitively, and confirmatory angiography was required. Using a diagnostic tool designed to identify key clinical characteristics, we were able to successfully distinguish between high-flow and low-flow vascular malformations using dceMRI alone in 83.8% of patients, minimizing the need for unnecessary invasive catheter-based procedures.