Presentation
Chronic headache with background history of major depressive disorder.
Patient Data
Ill-defined serpiginous-like hyperdense mass (bag of worms) at the left frontal region , more towards the vertex. Dilated adjacent cortical veins at the subdural space.
Multiple gyriform-like calcification within the mass and the atrophied left frontal lobe.
No acute intracranial hemorrhage.
No significant mass effect or midline shift.
Large nidus of malformed vessels at the left frontal lobe, with feeding vessels likely arising from the left anterior cerebral artery and left middle cerebral artery and draining veins (enlarged cortical veins) into the superior sagittal sinus.
Bilateral cavernous sinuses are normal in configuration.
Case Discussion
Large left frontal cerebral arteriovenous malformation (AVM).
Differential diagnoses to consider for gyriform-like brain parenchymal calcification are Sturge Weber syndrome, healed cortical infarcts, CNS infection(congenital TORCHs) and post radiotherapy changes. The key for this case is to identify the "bag of worm" vessels, nidus as well as in contrasted study to identify large nidus of malformed vessels.
Catheter angiography is typically performed for proper classification prior to either radiological or surgical intervention.
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