Time-Resolved Magnetic Resonance Angiography in the Evaluation of Intracranial Vascular Lesions and Tumors: A Pictorial Essay of Our Experience  Ming-Cheng Liu, MD, Hung-Chieh Chen, MD, Chen-Hao Wu, MD, PhD, Wen-Hsien Chen, MD, Yuang-Seng Tsuei, MD, Clayton Chi- Chang Chen, MD  Canadian Association of Radiologists Journal  Volume 66, Issue 4, Pages 385-392 (November 2015) DOI: 10.1016/j.carj.2015.05.001 Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 1 A small arteriovenous malformation (AVM) with superficial venous drainage, Spetzler-Martin grade II, in a 50-year-old man. (A) Coronal time-resolved magnetic resonance angiography (TR MRA) image shows the right parietal AVM with a nidus (arrow) supplied by branches derived from the right anterior and middle cerebral arteries. Sagittal (B) early and (C) late arterial and (D) venous phase TR MRA images show the AVM nidus (arrow) in the right parietal lobe. Superficial venous drainage occurs via a dilated cortical vein into the superior sagittal sinus (arrow head). (E) Follow-up DSA image of the right internal carotid artery (frontal projection) shows the AVM nidus (arrow). (F-H) Sequential DSA images (lateral projection) show the nidus (arrow) and superficial venous drainage (arrow head). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 2 A small arteriovenous malformation (AVM) with superficial and deep venous drainage, Spetzler-Martin grade III, in a 21-year-old man. (A) Coronal time-resolved magnetic resonance angiography (TR MRA) image shows the left frontal AVM with a nidus (arrow) supplied by branches derived from the left anterior and middle cerebral arteries. Sagittal (B) early and (C) late arterial and (D) venous phase TR MRA images show the AVM nidus (arrow) in the left frontal lobe. Superficial venous drainage occurs via a dilated cortical vein (arrow head) into the superior sagittal sinus. Deep venous drainage occurs via the internal cerebral vein (arrow with dashed line) into the straight sinus. (E) Follow-up DSA image of the left internal carotid artery (frontal projection) shows the AVM nidus (arrow). (F-H) Sequential DSA images (lateral projection) show the nidus (arrow), superficial (arrow head), and deep venous drainage (arrow with dashed line). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 3 Medium-sized arteriovenous malformation (AVM) with superficial and deep venous drainage, Spetzler-Martin grade IV, in a 44-year-old woman. (A) Coronal time-resolved magnetic resonance angiography (TR MRA) image shows the right deeper AVM with a nidus (arrow) supplied by branches deriving from the right anterior and middle cerebral arteries. Sagittal (B) early and (C) late arterial and (D) venous phase TR MRA images show the AVM nidus (arrow) in the right basal ganglion and external capsule. Superficial venous drainage occurs via a dilated cortical vein (arrow head) and a focal venous ectasia (asterisk) into the superior sagittal sinus. Deep venous drainage occurs via the internal cerebral vein (arrow with dashed line) into the straight sinus. (E) Follow-up DSA image of the right common carotid artery (frontal projection) shows the AVM nidus (arrow). (F-H) Sequential DSA images (lateral projection) show the nidus (arrow), superficial venous drainage (arrow head), focal ectasia (asterisk), and deep venous drainage (arrow with dashed line). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 4 Dural arteriovenous fistulas (DAVF), type I, in a 54-year-old woman. (A) Sagittal time-resolved magnetic resonance angiography (TR MRA) image shows a DAVF at the right transverse-sigmoid sinus junction (arrow) that is supplied by small branches of the right external carotid artery. (B-D) Coronal (B) early and (C) late arterial and (D) venous phase TR MRA images show a DAVF (arrow) at the right transverse-sigmoid sinus junction with antegrade venous drainage into the right sigmoid sinus. (E) Follow-up DSA image of the right common carotid artery (lateral projection) shows a DAVF (arrow) and its supplying arteries. (F-H) Sequential DSA images (frontal projection) show the DAVF (arrow). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 5 Dural arteriovenous fistulas (DAVF), type IIa+b, in a 63-year-old man. (A) Sagittal time-resolved magnetic resonance angiography (TR MRA) image shows a left temporal DAVF (arrow) that is supplied by branches deriving from the left external carotid artery and the meningohypophyseal trunk of the left internal carotid artery. Coronal (B) early and (C) late arterial and (D) venous phase TR MRA images show a DAVF (asterisk) in the left temporal region. The impaired antegrade venous drainage is due to occlusion of the left sigmoid sinus that results in retrograde venous drainage via the right transverse sinus (arrow with dashed line) into the right internal jugular vein and the left vein of Labbe (arrow) into the superior sagittal sinus. (E) Follow-up DSA image of the left common carotid artery (lateral projection) shows the DAVF (arrow). (F-H) Sequential DSA images (frontal projection) show the DAVF (asterisk), retrograde sinus drainage (arrow with dashed line), and cortical venous drainage (arrow). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 6 Dural arteriovenous fistulas (DAVF), type III, in an 80-year-old man. (A) Coronal time-resolved magnetic resonance angiography (TR MRA) image shows a faint left-sided occipital DAVF. Sagittal (B) early and (C) late arterial and (D) venous phase TR MRA images show the DAVF (arrow) in the left occipital region, which is supplied by the left occipital artery. The venous drainage of the DAVF (arrow) occurs via an engorged cortical vein (arrow head) into the vein of Galen and antegrade flow into the straight sinus (arrow with dashed line). (E) Follow-up DSA image of the left common carotid artery (frontal projection) shows the DAVF. (F-H) Sequential DSA images (lateral projection) show the DAVF (arrow), arterial supply from the left occipital and tentorial (open arrow) arteries, direct cortical venous drainage (arrow head), and antegrade flow of the straight sinus (arrow with dashed line). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 7 Moyamoya disease in a 19-year-old woman. (A) Coronal time-resolved magnetic resonance angiography (TR MRA) image shows nearly total occlusion of the bilateral supraclinoid internal carotid arteries (ICAs) (arrows). Sagittal (B) early and (C) late arterial and (D) venous phase TR MRA images show stenosis in the terminal portion of the ICAs (arrow) and the proximal portion of the bilateral anterior and middle cerebral arteries. Numerous faint and tortuous Moyamoya vessels and subcortical collateral circulation (arrow with dashed line) are observed. (E) Follow-up DSA image of the right internal carotid artery (frontal projection) shows the nearly total occluded ICA (arrow). (F-H) Sequential DSA images (lateral projection) show the stenotic ICA (arrow) and numerous faint parietal subcortical collaterals (arrow with dashed line). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 8 Direct-type (Barrow type A) carotid cavernous fistula in an 18-year-old man. (A) Coronal early arterial phase time-resolved magnetic resonance angiography (TR MRA) image shows opacification of the left cavernous sinus (arrow). Sagittal (B) early, (C) middle, and (D) late arterial phase TR MRA images show the early opacification of the engorged left superior ophthalmic vein (SOV) (arrow) with superficial venous drainage via a dilated facial vein (arrow head). (E) Follow-up DSA image of the left common carotid artery (frontal projection) shows the early opacification of the left cavernous sinus (arrow). (F-H) Sequential DSA images (lateral projection) show the early opacification of the engorged left SOV (arrow), dilated facial vein (arrow head), and prominent inferior petrosal sinus (arrow with dashed line). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 9 Indirect-type (Barrow type D) carotid cavernous fistula (CCF) in a 63-year-old woman. (A) Coronal arterial phase time-resolved magnetic resonance angiography (TR MRA) image shows early opacification of the left cavernous sinus (arrow). Sagittal (B) early, (C) middle, and (D) late arterial phase TR MRA images show the early opacification of the left cavernous sinus (arrow) and the left superior ophthalmic vein (SOV) (arrow head). (E) Follow-up DSA image of the left common carotid artery (frontal projection) shows the early opacification of the left cavernous sinus (arrow). (F-H) Sequential DSA images (lateral projection) show a CCF draining into the left cavernous sinus (arrow) and the SOV (arrow head) with feeders from dural branches of the internal and external carotid arteries. Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 10 Falx meningioma in a 42-year-old woman. Coronal time-resolved magnetic resonance angiography (TR MRA) images in the (A) early and (B) late arterial and (C) venous phases show a strongly enhancing mass in the left frontal lobe. The tumor is supplied by branches deriving from the left anterior cerebral artery (arrow head) and the left middle meningeal artery (arrow). Sagittal image in the (D) venous phase shows the tumor is compressing the anterior segment of the superior sagittal sinus (SSS). Follow-up DSA images of the (E) left common carotid, (F) left external carotid, and (G) left internal carotid arteries (frontal projection) show the tumor stain in the left frontal lobe; blood is supplied by branches derived from the left anterior cerebral artery (arrow head), the left middle meningeal artery (arrow), and the anterior falx artery (open arrow). DSA image of the (H) left internal carotid arteries (lateral projection) shows the tumor is compressing the anterior segment of the SSS. Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions

Figure 11 Hemangioblastoma in a 21-year-old man. Coronal time-resolved magnetic resonance angiography (TR MRA) images in the (A) early and (B) late arterial and (C) venous phases show an enhancing lesion (arrow) in the left posterior fossa that is not visible in the early arterial phase. (D) Sagittal TR MRA image in the late arterial phase shows the enhancing lesion with a blood supply from the left posterior inferior cerebellar artery (arrow head). (E-G) Follow-up DSA images of the left vertebral artery (frontal projection) shows the tumor stain appearing in the (F) late arterial phase and persisting in the (G) venous phase. (H) A sagittal postcontrast T1-weighted image shows a strongly enhancing nodule in the posterior region of the medulla (arrow). Canadian Association of Radiologists Journal 2015 66, 385-392DOI: (10.1016/j.carj.2015.05.001) Copyright © 2015 Canadian Association of Radiologists Terms and Conditions