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. Author manuscript; available in PMC: 2018 May 1.
Published in final edited form as: Clin Nucl Med. 2017 May;42(5):e275–e276. doi: 10.1097/RLU.0000000000001637

Developmental Venous Anomalies (DVAs) Mimicking neoplasm on 11C-Methionine PET and DSC Perfusion MRI

Julie H Harreld 1, Mikhail Doubrovin 1, Elizabeth R Butch 1, Angela Edwards 1, Barry Shulkin 1
PMCID: PMC5380515  NIHMSID: NIHMS852167  PMID: 28319499

Abstract

Elevated relative cerebral blood volume (rCBV) on perfusion MRI and increased uptake on 11C-methionine-PET (Met-PET) can be used to diagnose and guide biopsy of brain tumors but are not specific. We report increased uptake on Met-PET associated with 4 developmental venous anomalies (DVAs) in 3 children with brain tumors, which could potentially mimic tumor and misdirect biopsy. Because DVAs are not readily visible on CT, prevention of misdirected biopsy in patients with focally elevated 11C-methionine uptake and rCBV relies on close correlation with contrast-enhanced anatomic MRI to exclude DVA or other non-neoplastic etiology.

Keywords: DVA, methionine, PET, MRI, CBV, pediatric

Uptake of amino acid radiotracers such as 11C-methionine by metabolically active brain or tumor tissue depends first on regional cerebral blood flow (CBF) and then crossing the blood brain barrier (BBB), either by active endothelial transport or passively via BBB disruption, and consequently may be increased in areas of increased cellular proliferation or metabolism, increased CBF or disruption of the BBB, which may occur in tumors but also infectious, inflammatory, ischemic or traumatic brain lesions.(1–4) Similarly, though elevated rCBV is associated with increased capillary volume in tumors, (4, 5) rCBV increases with CBF in normally perfused brain, and is elevated due to compensatory vasodilation in early ischemia/stroke.(6, 7) Developmental venous anomalies, the most common intracranial vascular abnormality and more common in children with brain tumors,(8) consist of abnormally dilated veins converging on a larger draining vein, and have been associated with parenchymal signal abnormalities, elevated rCBV, mean transit time and venous stasis.(9–11) Though the precise mechanism is unknown, our observations in this series suggest that increases in rCBV due to increased regional vascular density or venous congestion associated with DVAs may facilitate active or passive transendothelial transport of radiotracer, followed by preferential uptake of 11C-Met by the more metabolically active cortex in the venous drainage territories, accounting for the disproportionately cortical uptake we observed. Thus, observation of elevated 11C-Met uptake and rCBV, particularly in a somewhat discrepant distribution, should prompt close review of contrast-enhanced MRI to evaluate for a potentially vascular etiology prior to biopsy.

Case 1.

Case 1

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A 16-year-old girl with residual posterior fossa low grade glioma. (a) Met-PET showed increased lesion-to-contralateral-brain ratio (LBR=1.11, black arrowheads) superficial to (b) elevated rCBV (1.78, white arrowheads) in the drainage territory of a right occipital DVA (arrows), which is subtle on(c) FLAIR and visible on (d) post-contrast T1WI, but not visible on (e) CT.

Case 2.

Case 2

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(a) Met-PET to evaluate possible residual right frontal anaplastic astrocytoma in a 16-year-old boy showed increased 11C-methionine uptake (LBR=1.19, black arrowheads) superficial to elevated (b) rCBV (1.44, white arrowheads) surrounding a right temporal DVA (arrow), which was visible on both (c) FLAIR and (d) T1WI with contrast but not (e) CT.

Case 3.

Case 3

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A 9-year-old girl with constitutional mismatch repair deficiency and multifocal low-grade gliomas. (a) 1C-methionine uptake (black arrowheads) and (b) rCBV (white arrowheads) were elevated in the drainage territories of a right cerebellar (arrow, LBR=1.63, rCBV=3.17) DVA, which is visible on (c) FLAIR and (d) T1WI with contrast, but not (e) CT.

Case 4.

Case 4

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Same patient as Case 3. Elevated (a) 11C-methionine uptake (black arrowheads) and (b) rCBV (white arrowheads) in the drainage territory of a left frontal (arrow, LBR=1.17, rCBV=4.2) DVA, but not in adjacent non-enhancing left frontal tumor (*). Again, the DVA is visible on (c) FLAIR and (d) T1WI with contrast, but not (e) CT.

Acknowledgments

The authors wish to thank Scott Snyder, PhD and the St Jude Molecular Imaging Research laboratory staff for supplying 11C-methionine for these studies.

Funding: Supported in part by Grant No. P30 CA021765 from the National Cancer Institute and by the American Lebanese Syrian Associated Charities.

Footnotes

Conflicts of Interest: The authors have no conflicts of interest to disclose.

References

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