Cerebral arteriovenous malformation

Case contributed by Hoe Han Guan
Diagnosis almost certain

Presentation

Sudden onset of left sided body weakness.

Patient Data

Age: 55 years
Gender: Female
This study is a stack
Axial
non-contrast
This study is a stack
Coronal
non-contrast
This study is a stack
Sagittal
non-contrast
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Info

Acute intraparenchymal hematoma with epicenter at the right insula.
Abnormal gyriform-like/worm-like slightly hyperdense structures lateral to the aforementioned hematoma and within the right Sylvian fissure.
Asymmetrical dilatation of M1 and M2 segments of right middle cerebral artery as well as enlarged cortical veins at right subdural/subarachnoid spaces.
Abnormal calcification noted within the enlarged vessels at the right fronto-temporal region.

No significant midline shift or hydrocephalus.

Proceeded with MRI brain after 2 months of initial presentation.

This study is a stack
Axial
T2
This study is a stack
Axial
T1
This study is a stack
Axial
FLAIR
This study is a stack
Axial
Gradient Echo
This study is a stack
Axial
DWI
This study is a stack
Axial
ADC
This study is a stack
Axial
MRA
This study is a stack
Axial
MRV
This study is a stack
Axial
T1 C+
This study is a stack
3D MRA
MIP
This study is a stack
3D MRA
MIP
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Serpiginous flow-voids at the right fronto-temporal region which represents the nidus of arteriovenous malformation.
Arterial supply is arising from the right middle cerebral artery, which the MCA itself is larger in caliber compared to left counterpart.
Multiple sites of draining veins, include dilated right vein of Trolard, right cortical veins draining into the superior sagittal sinus, another draining vein is via enlarged right basal vein of Rosenthal into the great vein of Galen.
No arterial aneurysm.

Annotated image
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Annotated images showed some of the review areas for acute lobar hematoma in order to identify the possible diagnosis of arteriovenous malformation.

Case Discussion

Right fronto-temporal cerebral arteriovenous malformation. This case showed that the location of the acute intraparenchymal hematoma which is very near to the right basal ganglia/lentiform nucleus to be wrongly attributed to the TYPICAL location of hypertensive bleed. However, there are many imaging features to suggest the possibility of the cerebral AVM in plain CT brain.

  • Abnormal vessel calcification adjacent to the acute hematoma
  • Dilated and tortuous cortical veins
  • Abnormal worm-like structure (not like normal cortex) adjacent to the acute hematoma.

Reporting radiologist should always look for the possible etiology for acute lobar hematoma.

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