Technique: Multiplanar multisequence imaging including pre- and post-contrast T1, T2, FLAIR, DWI/ADC and MRA in accordance with the AVM protocol. Stereotaxis has also been performed.
Comparison: Previous MRI and CT.
Findings: Right parietal mass measuring 10 x 13 x 12 mm has increased in size from 6 x 5 x 5 mm and has a broad dural attachment, most likely extra-axial in location. This lesion is hypointense on T1, intermediate on T2 and demonstrates vivid predominantly homogeneous contrast enhancement. Abutting the inferior margin of this mass in the right post-central gyrus is a new parenchymal region of signal abnormality measuring 20 x 26 mm. This demonstrates heterogeneous predominantly hypointense T2 and hypointense T1 signal associated with marked susceptibility artefact. The signal characteristics are those of subacute blood (intracellular methaemoglobin). There is surrounding vasogenic oedema and local mass effect in keeping with recent haemorrhage.
Multiple further lesions with susceptibility artefact in the left superior frontal gyrus, left cingulate gyrus, left occipital lobe and right occipital lobe at the junction of the parieto-occipital sulcus have all reduced in size and conspicuity. Previously demonstrated vasogenic oedema surrounding the left occipital lesion has resolved and this lesion is now predominantly hypointense on T1 and T2 sequences consistent with expected haemorrhage evolution. Lesion in the right medial thalamus is stable. These lesions do not demonstrate contrast enhancement and are consistent with cavernomas.
Assessment of DWI is hampered by the presence of blood product. Allowing for this, there is no true restricted diffusion evident. MRA is unremarkable. No developmental venous anomaly.
Conclusion: Recent haemorrhage in the right postcentral gyrus associated with vasogenic oedema and local mass effect. This is favoured to be secondary to an underlying cavernoma, and follow-up is recommended to ensure expected evolution. Adjacent to this haemorrhage, enhancing likely extra-axial mass has increased in size. The most likely diagnosis for this lesion is a meningioma, and given its fairly rapid growth the possibility of an atypical meningioma should be considered. Although the haemorrhage and mass are anatomically in close proximity, they are not felt to be part of a single unifying diagnosis. Multiple other lesions consistent with cavernomas have decreased in size. In the absence of a history of radiotherapy, these raise the possibility of autosomal dominant multiple cavernoma syndrome.