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Cavum Velum Interpositum (CVI) 849ee468-35c4-46e3-9297-96196109cdb8
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a25c450b-3d34-4f64-bba3-cc0834813df6 Miral D. Jhaveri, MD, MBA
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5cff4116-3654-4b3a-bb75-5ebe0b8c9850 Anne G. Osborn, MD, FACR
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Brain
Diagnosis
Anatomy-Based Diagnoses
Ventricles and Cisterns
Normal Variants
Cavum Velum Interpositum (CVI)

title: "Cavum Velum Interpositum (CVI)" docid: "849ee468-35c4-46e3-9297-96196109cdb8" authors:

  • key: "a25c450b-3d34-4f64-bba3-cc0834813df6" value: "Miral D. Jhaveri, MD, MBA"
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  • name: "Cavum Velum Interpositum (CVI)" slug: "cavum-velum-interpositum-cvi" treeNodeId: null category: "Brain" documentVersionId: "75312185-3ddd-4300-a4fb-d824b606effc" imageCount: 12 lastUpdated: "05/08/20" pageDescription: "Cavum Velum Interpositum (CVI)" pageKeywords: "Brain, Diagnosis, Anatomy-Based Diagnoses, Ventricles and Cisterns, Normal Variants, Cavum Velum Interpositum (CVI)" pageTitle: "Cavum Velum Interpositum (CVI) | STATdx" enhancedTitle: "Cavum Velum Interpositum (CVI)" type: "DX" references: true breadcrumbs:
  • "Brain"
  • "Diagnosis"
  • "Anatomy-Based Diagnoses"
  • "Ventricles and Cisterns"
  • "Normal Variants"
  • "Cavum Velum Interpositum (CVI)"

KEY FACTS

  • Terminology

    • Cavum velum interpositum (CVI), cyst of velum interpositum (VI)

  • Imaging

    • Triangular CSF space - Between lateral ventricles, over thalami - Apex points toward foramen of Monro - Elevates, splays fornices - Flattens, displaces internal cerebral veins inferiorly
    • Size varies from slit-like linear to triangular to round/ovoid CSF collection
    • Isodense/isointense with CSF - Suppresses completely on FLAIR - Does not restrict on DWI - Does not enhance
    • US shows hypoechoic midline interhemispheric cyst

  • Top Differential Diagnoses

    • Normal cistern of velum interpositum
    • Cavum septi pellucidi, cavum vergae
    • Arachnoid cyst
    • Epidermoid cyst

  • Clinical Issues

    • Can be found at any age - Common in infants, rare in adults
    • Symptoms - Usually asymptomatic, found incidentally - Headache (relationship to cyst unclear) - Large CVI can obstruct normal CSF flow; treated by endoscopic fenestration

  • Diagnostic Checklist

    • CSF-like "cyst" could be epidermoid
    • Include FLAIR and DWI to distinguish between CVI, epidermoid cyst

TERMINOLOGY

  • Abbreviations

    • Cavum velum interpositum (CVI), cyst of velum interpositum (VI)

  • Definitions

    • Cystic dilation of VI

IMAGING

  • General Features

    • Best diagnostic clue

      - Triangular-shaped CSF space
        - Between lateral ventricles, over thalami
        - Apex points toward but does not extend anteriorly beyond foramen of Monro
        - Base contiguous with quadrigeminal cistern

    • Location

      - Midline between lateral ventricles, below fornices
- Continuous with choroid plexus subependymally

    • Size

      - Varies (few mm to several cm)

  • CT Findings

    • NECT

      - Triangle of CSF between lateral ventricles

    • CECT

      - Does not enhance

  • MR Findings

    • T1WI

      - Sagittal: Varies from slit-like linear to round/ovoid
        - Elevates fornices
        - Flattens, displaces internal cerebral veins inferiorly
- Axial: Triangle of CSF between lateral ventricles

    • T2WI

      - Isointense with CSF

    • FLAIR

      - Suppresses completely

    • DWI

      - Does not restrict

  • Ultrasonographic Findings

    • Color Doppler

      - Hypoechoic midline interhemispheric cyst

  • Imaging Recommendations

    • Best imaging tool

      - MR ± contrast

    • Protocol advice

      - FLAIR/DWI (distinguish between CVI and epidermoid)

DIFFERENTIAL DIAGNOSIS

  • Normal Cistern of Velum Interpositum

    • Usually small (slit-like or oval)
    • Does not elevate fornices or depress internal cerebral veins

  • Cavum Septi Pellucidi, Vergae

    • CSP + CV elongated, finger-like CSF space

  • Arachnoid Cyst

    • Lined with arachnoid (may be indistinguishable)

  • Epidermoid Cyst

    • Lobulated, insinuating mass
    • Does not suppress with FLAIR; DWI shows restriction

PATHOLOGY

  • General Features

    • Etiology

      - Pia infolds along transverse fissure, forms CSF cistern (VI)
- Cystic dilatation of VI may occur (precise etiology unknown)

    • Associated abnormalities

      - Usually none (large CVIs may cause hydrocephalus)

  • Gross Pathologic & Surgical Features

    • Normal cistern of VI is small to inapparent at autopsy
    • Pial-lined CSF-filled space

  • Microscopic Features

    • Occasionally cysts of midline CSF spaces contain glial cells, scattered neurons

CLINICAL ISSUES

  • Presentation

    • Most common signs/symptoms

      - Usually asymptomatic, found incidentally
- Headache (relationship to cyst unclear)

  • Demographics

    • Age

      - Can be found at any age
        - Common in infants, rare in adults

    • Gender

      - M = F

  • Treatment

    • Usually none

DIAGNOSTIC CHECKLIST

  • Consider

    • CSF-like "cyst" could be epidermoid
    • Use DWI, FLAIR to differentiate from other cysts

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References

Selected References

  1. Krejčí T et al: Symptomatic cysts of the cavum septi pellucidi, cavum vergae and cavum veli interpositi: A retrospective duocentric study of 10 patients. Clin Neurol Neurosurg. 185:105494, 2019
  2. Akinola RA et al: Caval variations in neurologically diseased patients. Acta Radiol Short Rep. 3(5):2047981614530288, 2014
  3. Tong CK et al: Endoscopic fenestration of cavum velum interpositum cysts: a case study of two symptomatic patients. Childs Nerv Syst. 28(8):1261-4, 2012
  4. Tubbs RS et al: Cavum velum interpositum, cavum septum pellucidum, and cavum vergae: a review. Childs Nerv Syst. 27(11):1927-30, 2011
  5. Tubbs RS et al: The velum interpositum revisited and redefined. Surg Radiol Anat. 30(2):131-5, 2008
  6. Osborn AG et al: Intracranial cysts: radiologic-pathologic correlation and imaging approach. Radiology. 239(3):650-64, 2006
  7. Eisenberg VH et al: Prenatal diagnosis of cavum velum interpositum cysts: significance and outcome. Prenat Diagn. 23(10):779-83, 2003
  8. Vergani P et al: Ultrasonographic differential diagnosis of fetal intracranial interhemispheric cysts. Am J Obstet Gynecol. 180(2 Pt 1):423-8, 1999
  9. Chen CY et al: Sonographic characteristics of the cavum velum interpositum. AJNR Am J Neuroradiol. 19(9):1631-5, 1998

Images

Selected Images

Sagittal graphic with axial insert shows a cavum velum interpositum (CVI). Note the elevation and splaying of the fornices . Also noted is the inferior displacement of the internal cerebral veins and 3rd ventricle . Sagittal graphic with axial insert shows a cavum velum interpositum (CVI). Note the elevation and splaying of the fornices . Also noted is the inferior displacement of the internal cerebral veins and 3rd ventricle .

Sagittal graphic with axial insert shows a cavum velum interpositum (CVI). Note the elevation and splaying of the fornices . Also noted is the inferior displacement of the internal cerebral veins and 3rd ventricle . Sagittal graphic with axial insert shows a cavum velum interpositum (CVI). Note the elevation and splaying of the fornices . Also noted is the inferior displacement of the internal cerebral veins and 3rd ventricle .

Sagittal T1 MR shows a classic CVI as a CSF-like enlargement that elevates the fornix and flattens and displaces the internal cerebral vein inferiorly. These are usually asymptomatic; however, large ones can cause CSF obstruction and can be treated by fenestration. Sagittal T1 MR shows a classic CVI as a CSF-like enlargement that elevates the fornix and flattens and displaces the internal cerebral vein inferiorly. These are usually asymptomatic; however, large ones can cause CSF obstruction and can be treated by fenestration.

Axial T2 MR in a 37-year-old man with headaches shows a triangular-shaped CSF collection between the lateral ventricles, spreading the fornices laterally . Axial T2 MR in a 37-year-old man with headaches shows a triangular-shaped CSF collection between the lateral ventricles, spreading the fornices laterally .

Axial FLAIR MR in the same patient shows complete suppression of the CSF signal within the cyst similar to the lateral ventricles. Findings are consistent with a classic cavum velum interpositum. FLAIR and DWI distinguish between cavum velum interpositum and an epidermoid cyst. Axial FLAIR MR in the same patient shows complete suppression of the CSF signal within the cyst similar to the lateral ventricles. Findings are consistent with a classic cavum velum interpositum. FLAIR and DWI distinguish between cavum velum interpositum and an epidermoid cyst.

Additional Images

Axial T2 MR shows a cavum septi pellucidi (CSP) along with a very small cavum velum interpositum . Note that these 2 unrelated lesions do not communicate with each other. It is common to see a CSP with a cavum vergae; it is rare to see a CSP and a CVI in the same patient. Axial T2 MR shows a cavum septi pellucidi (CSP) along with a very small cavum velum interpositum . Note that these 2 unrelated lesions do not communicate with each other. It is common to see a CSP with a cavum vergae; it is rare to see a CSP and a CVI in the same patient.

Coronal T1 C+ MR shows classic cavum velum interpositum that spreads the fornices apart. Coronal T1 C+ MR shows classic cavum velum interpositum that spreads the fornices apart.

Axial T2 MR shows a small, triangular-shaped CSF space. Note the cavum velum interpositum interposed between the fornices and lateral ventricles. The CVI ends at the foramen of Monro. Axial T2 MR shows a small, triangular-shaped CSF space. Note the cavum velum interpositum interposed between the fornices and lateral ventricles. The CVI ends at the foramen of Monro.

Axial T1 MR shows a very large cavum velum interpositum. Note the splaying of fornices and anterior displacement of the septum pellucidum . Mild enlargement of the lateral ventricles is seen. Axial T1 MR shows a very large cavum velum interpositum. Note the splaying of fornices and anterior displacement of the septum pellucidum . Mild enlargement of the lateral ventricles is seen.

Sagittal T1 MR in the same patient shows anterior/superior displacement of the fornix and inferior displacement of the 3rd ventricle . The corpus callosum is elevated and thinned. Sagittal T1 MR in the same patient shows anterior/superior displacement of the fornix and inferior displacement of the 3rd ventricle . The corpus callosum is elevated and thinned.

Sagittal T1 MR in a 40-year-old woman with headaches shows CSF-like enlargement of the velum interpositum that elevates the fornix and flattens and displaces the internal cerebral vein inferiorly . This large CVI is probably unrelated to the patient's symptoms. Sagittal T1 MR in a 40-year-old woman with headaches shows CSF-like enlargement of the velum interpositum that elevates the fornix and flattens and displaces the internal cerebral vein inferiorly . This large CVI is probably unrelated to the patient's symptoms.

Axial T2 MR in a 46-year-old woman with headaches shows a classic CVI with a triangular-shaped CSF collection , spreading the fornices laterally . The posterior location between the lateral ventricles is typical. Axial T2 MR in a 46-year-old woman with headaches shows a classic CVI with a triangular-shaped CSF collection , spreading the fornices laterally . The posterior location between the lateral ventricles is typical.

Sagittal T1 MR shows a variant CVI that elevates the fornix , flattens the internal cerebral vein , and extends into the quadrigeminal and suprasellar cisterns . This case probably represents an arachnoid cyst of the cavum velum interpositum. Sagittal T1 MR shows a variant CVI that elevates the fornix , flattens the internal cerebral vein , and extends into the quadrigeminal and suprasellar cisterns . This case probably represents an arachnoid cyst of the cavum velum interpositum.

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