Dentomaxillofacial Radiology (2003) 32, 333–336 q 2003 The British Institute of Radiology http://dmfr.birjournals.org
SHORT COMMUNICATION
MRI findings in lingual venous malformations A Lo Casto*,1, S Salerno1, F Cannizzaro1, A Caronia1, F Bencivinni1, F Barbiera1, M Rossello2 and G La Tona1 1 2
Dipartimento di Biotecnologie Mediche e Medicina Legale, Sezione di Scienze Radiologiche, Universita` di Palermo, Italy; Dipartimento di Scienze Radiologiche, ARNAS Civico, Palermo, Italy
Objectives: To describe the plain and enhanced MRI findings of lingual venous malformations and to discuss the importance of contrast medium in the differential diagnosis of high intensity lesions of the tongue on T2 weighted images. Methods: The clinical records and MR images of eight patients affected by a lingual venous malformation were retrospectively reviewed. Patients presented with a palpable submucosal bluishred soft mass in the tongue. MRI examinations were performed on a 0.5 T superconducting unit. Plain and enhanced SE (spin echo) T1 weighted and FSE (fast spin echo) T2 weighted images were acquired in axial, sagittal and coronal planes. Axial SPGR (spoiled gradient recalled echo) T1 weighted images were also obtained before and after intravenous (iv) injection of paramagnetic contrast medium. Results: Five of eight venous malformations were located at the tip of the tongue. The other three involved the whole tongue and had an extralingual extent; two extended into the submandibular space and one into the glossoepiglottic valleculae. The largest diameter ranged from 2.5 cm to 8 cm. All lingual venous malformations presented as lobulated masses that were slightly hyperintense or isointense on T1 weighted images and highly hyperintense on T2 weighted images with respect to normal tongue and/or surrounding muscles. They showed a slow and homogeneous filling following iv injection of contrast medium. Millimetre-sized hypointense foci and linear hypointense strands were sometimes noticed, which were owing to phleboliths, flow void or septation. Conclusion: Knowledge of MRI findings of lingual venous malformations is useful for differential diagnosis with other high intensity lingual lesions on T2 weighted images. This discrimination is achievable using iv paramagnetic contrast medium. Dentomaxillofacial Radiology (2003) 32, 333–336. doi: 10.1259/dmfr/73824372 Keywords: tongue; arteriovenous malformations; MRI Introduction Endothelial malformations are the most frequent congenital benign tumours. Diagnosis is based on their history of temporal growth and inspection.1 Imaging is used to characterize these lesions and to evaluate their extent. Among various imaging techniques, MRI has demonstrated superior soft tissue contrast resolution.2 Only a few sporadic cases of endothelial malformations of the tongue studied by MRI have been previously reported,3 – 5 and only in one case has there been a wider series using contrastenhanced MRI, affirming the value of contrast medium in differentiating between haemangioma and lymphangioma.2 In this paper, the authors retrospectively reviewed the plain and contrast-enhanced MRI findings observed in eight patients affected by a lingual venous malformation, *Correspondence to: Prof. Antonio Lo Casto, Via Tevere, 7, 90144 Palermo, Italy; E-mail:
[email protected] Received 1 July 2002; revised 19 July 2002; accepted 30 January 2003
discussing the importance of the use of contrast medium in the differential diagnosis with other high intensity lingual lesions on T2 weighted images. Materials and methods The clinical records and MR images of eight patients (four males and four females; age range 11 – 50 years) affected by a venous malformation of the tongue were reviewed retrospectively and in consensus by three of the authors (ALC, SS, FB). A palpable submucosal bluish-red soft mass, which was poorly defined and readily blanched with compression, was present in the tongue of all the patients. Patients with larger masses complained of swallowing, chewing and speaking difficulties, whereas smaller lesions caused only a chewing problem. Haemorrhage had not occurred in any of the patients. MRI examinations were performed on a 0.5 T superconducting unit (Vectra GE
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Medical Systems, Milwaukee, WI) using a head coil. SE (spin echo) T1 weighted (TR/TE 400 – 480 ms/18 – 20 ms) and FSE (fast spin echo) T2 weighted (TR/TE 3800 – 4080 ms/120 ms) images were acquired in the axial, sagittal and coronal planes. Other parameters were: slice thickness 3 – 4 mm; gap 1 mm; 3 NEX; matrix 256 £ 160 – 192; field of view (FOV) 24 cm. Axial SPGR (spoiled gradient recalled echo) T1 weighted (TR/TE 45 ms/15 ms; flip angle 458; slice thickness 5 mm; 1 NEX; matrix 256 £ 128; FOV 24 cm) images were also obtained before and at 15 s, 30 s, 45 s, 1 min, 3 min, 5 min, 10 min and 15 min after injection of a paramagnetic contrast medium
(0.1 mmol kg21 Multihance; Bracco, Milano, Italy). After these acquisitions, the SE T1 weighted sequence described above was repeated. The following criteria were considered in reviewing MR images for identification of lingual venous malformations: location within the tongue and eventual extralingual extent; shape; size (i.e. largest diameter); and signal behaviour on plain and enhanced sequences. Results Five of eight venous malformations were located at the tip of the tongue (Figure 1). The other three involved the
Figure 1 Venous malformation of the tip of the tongue. (a) SE (spin echo) T1 weighted axial image (TR/TE 480/20 ms). An oval area, slightly hyperintense with respect to the rest of the tongue (arrowhead), is appreciable at the tip of the tongue. (b) FSE (fast spin echo) T2 weighted axial image (TR/TE 4080/120 ms) at the same level as (a). The lesion is homogeneously hyperintense with lobulated margins (arrowhead). (c) Plain and (d) enhanced SPGR (spoiled gradient recalled echo) T1 weighted axial images (TR/TE 45/15 ms; flip angle 458). The lesion shows slow filling 3 min following intravenous contrast medium administration. (e) Enhanced SE T1 weighted axial image (TR/TE 480/20 ms) at the same level as (a). The lesion is homogeneously enhanced Dentomaxillofacial Radiology
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whole tongue and had an extralingual extent; two of them extended into the submandibular space and one extended into the glossoepiglottic valleculae (Figure 2). All venous malformations of the tongue presented as lobulated masses that were slightly hyperintense or isointense on T1 weighted images (Figure 1) and highly hyperintense on T2 weighted images with respect to the normal tongue and/or surrounding muscles (Figures 1 and 2). They showed slow and homogeneous filling on SPGR and SE T1 weighted images following iv contrast medium
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administration (Figure 1). Millimetre-sized hypointense foci and linear strands were sometimes noticed (Figure 2). The range of largest diameter of the venous malformations was between 2.5 cm and 8 cm.
Discussion Endothelial malformations were classified in 1982 by Mulliken and Glowacki6 into two large groups,
Figure 2 Venous malformation of the whole tongue. (a) FSE (fast spin echo) T2 weighted sagittal image (TR/TE 3800/120 ms). A hyperintense lesion is located in the bulk of the tongue. (b) Plain and (c) enhanced SE (spin echo) T1 weighted axial images (TR/TE 480/20 ms) at corresponding levels. The mass shows homogeneous enhancement with some hypointense septa. (d) FSE T2 weighted coronal image (TR/TE 3800/120 ms). An extension of the mass reaches the submandibular space (arrowhead). (e) FSE T2 weighted axial image (TR/TE 4080/120 ms) at a more caudal level than (b) and (c). A posterior extension of the mass at the level of glossoepiglottic valleculae is demonstrated (arrowhead) Dentomaxillofacial Radiology
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haemangiomas and vascular malformations, on the basis of their natural history, cellular turnover and histology. Vascular malformations were distinguished into another two groups, high flow vascular lesions with arterial component, and low flow vascular lesions without arterial component, such as lymphatic and venous malformations.6 Clinically, vascular malformations of the tongue appear as submucosal bluish-red masses, which are soft, poorly defined and readily blanch with compression. Patients affected by vascular malformations may complain of recurrent bleeding and symptoms related to the size of the lesion, such as difficulty in breathing, chewing, swallowing or speaking. Despite their benign histological nature, vascular malformations of the tongue may produce devastating deformities or lethal complications, including compression of vital structures, consumptive coagulopathy such as Kasabach – Merritt syndrome, fissure formation, ulceration, bleeding, regional gigantism as well as a detrimental psychological impact.1,4,5,7 MRI is an important non-invasive technique in the diagnosis and definition of oral and maxillofacial venous malformations and evaluation of adjacent soft tissues, providing direct sagittal and coronal images. Previous reports have shown the superiority of MRI over CT and ultrasound in delineating the extent of these lesions,2 as confirmed in our series, where extralingual involvement of the submandibular space and glossoepiglottic valleculae was readily demonstrated. MR signal behaviour of venous malformations of the tongue on plain images is quite characteristic but is non-specific: with respect to muscles, venous malformations show an isointensity or slight hyperintensity on T1 weighted images, and high hyperintensity due to the presence of enlarged venous lakes (slow-flowing blood) on T2 weighted images.1,2,3 – 5,8,9 On contrast-enhanced T1 weighted images, a slow and homogeneous increase of signal intensity occurs. Although the use of contrast medium does not improve the determination of presence, location and extent of the lesion, it is important for the differential diagnosis with other focal masses of the tongue.1,3,8,10 Signal homogeneity on both T1 and T2
sequences is sometimes interrupted by small hypointense foci and linear strands that correspond to phleboliths, flow void or septal partitions.11 Other lesions of the tongue share the high intensity on T2 weighted images with venous malformations, such as ranula, thyroglossal duct cyst, abscess, malignant lesions such as squamous cell carcinoma and adenocarcinoma, high flow vascular malformations and haemangiomas. Use of contrast medium is important for differential diagnosis with all these lesions because of the typical slow and homogeneous filling of the venous malformations. On post-contrast images, ranula, lymphangioma, abscess and thyroglossal duct cyst show enhancement only of the peripheral wall, and also of septa for lymphangioma. Malignancies of the tongue usually enhance following gadolinium injection; however, they usually enhance only mildly and their greater bulks may enhance heterogeneously because of the presence of necrosis.1,3,12,13 On MRI, high flow vascular malformations appear as a tangle of multiple flow voids that indicate high flow on gradient echo images, and have a salt and pepper appearance on T2 weighted and post-contrast images. Although these lesions can be associated with surrounding oedema or fibrofatty stroma, usually no focal discrete soft tissue mass is found.1 Sometimes deep haemangiomas and venous malformations are difficult to distinguish; the diagnosis may be oriented for venous malformations by the presence of enlarged venous lakes, seen as discrete areas of homogeneous high signal on T2 weighted images, while for haemangiomas the diagnosis may be oriented by the presence of fibrofatty infiltration due to early involution of the lesion that occurs in adolescence.11 In conclusion, knowledge of MRI findings in lingual venous malformations is useful for differential diagnosis with other focal lingual lesions that also show high intensity on T2 weighted images. This discrimination is achievable using contrast medium on dynamic T1 weighted images, which allows visualization of the typical slow and homogeneous filling.
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