A Radiologic Grading System for Assessing the Radiographic Outcome of Treatment in Lymphatic and Lymphatic-Venous Malformations of the Head and Neck

BDL grade 2 response. A 7-year-old girl with a left cheek mass was found to have a de Serres stage II mixed macro-/microcystic LM of the head. A, Preprocedural T2 fat-suppressed axial MR imaging at the level of the maxillary alveolar process shows involvement of the left buccal and parotid spaces (white arrow). B, Seven  months later, following 2 sclerotherapy treatments, T2 fat-suppressed axial MR imaging at the same level shows BDL grade 2 near-complete resolution of the LM with trace residuals (white arrow).

BDL grade 3B response. A 6-year-old boy with dysphagia was found to have a de Serres stage II mixed macro-/microsystic LM of the head. A, Preprocedural T2-weighted axial MR imaging at the level of the submandibular glands shows involvement of the left submandibular, sublingual, and parapharyngeal mucosal (not shown) spaces (white arrow). B, Thirty-seven months later, following 1 sclerotherapy treatment, T2-weighted axial MR imaging at the same level shows BDL grade 3B partial regression, with <50% estimated volume of residual malformation (white arrow) and intermediate signal granulation tissue formation within the treatment bed (white arrowhead). C, At the follow-up time point, note precontrast axial T1-weighted MR imaging isointensity of the suspected granuloma with muscle (white arrowhead). D, Postcontrast axial T1 at the same level demonstrates enhancement of the suspected granuloma (white arrowhead), confirming 3B grading.

BDL grade 4 response. An 18-year-old woman with an extensive bilateral de Serres stage IV mixed macro-/microcystic LVM of the supra- and infrahyoid neck presents for sclerotherapy after receiving multiple treatments at an outside institution. A, Preprocedural T2-weighted axial MR imaging at the level of the alveolar process of the maxilla shows widespread LVM bilaterally (white arrow). B, Preprocedural T1 fat-saturated postcontrast axial MR imaging at the same level demonstrates enhancement of venous structures within the LVM (white arrow). C, Thirty-five  months later, following 1 sclerotherapy treatment targeting the left buccal region, repeat T2-weighted axial MR imaging at the same level shows BDL grade 4 partial regression (white arrow) with >50% estimated volume of residual malformation.

BDL grade 5 response. A 2-month-old boy with tongue swelling was found to have a de Serres stage II mixed macro-/microcystic sublingual LM. A, Preprocedural T2 fat-suppressed axial MR imaging at the level of the mandibular symphysis shows involvement of the right and middle aspects of the sublingual space (white arrows). B, Five years later, following 1 sclerotherapy treatment, T2 fat-suppressed axial MR imaging at the same level shows BDL grade 5 recurrence of the LM without a gross interval change from baseline (white arrows).

BDL grade 6 response. An 8-year-old boy with right facial prominence was found to have a de Serres stage II mixed macro-/microcystic LM. A, Preprocedural T2 fat-suppressed axial MR imaging at the level of the oropharynx shows trans-spatial involvement of the right neck extending from the right parotid and masticator spaces to the pharyngeal mucosal space (white arrow), sparing the retropharyngeal space. B, One  year later, following 2 sclerotherapy treatments, T2 fat-suppressed axial MR imaging at the same level shows BDL grade 6 regression within the treatment bed and extension into the retropharyngeal space, which was previously uninvolved (white arrow).