Presentation
Found unresponsive at home. Complained of headache earlier in the evening. Aphasic and left sided neuro signs ?bleed.
Patient Data
Small lobar intracerebral hematoma involving the right occipital lobe. A small volume of perihaematomal edema. Localized subarachnoid hemorrhage in the overlying cortical sulci extending to the right Sylvian fissure and right ambient cistern. Probable small right cerebellar tentorial acute subdural hemorrhage. Small volume intraventricular hemorrhage.
Mild localized mass effect. Lateral and third ventricle hydrocephalus.
Lobulated curvilinear increased attenuation with areas of calcification adjacent to the hematoma are in keeping with an arteriovenous malformation.
Posterior predominant periventricular and subcortical white matter low attenuation in keeping with small vessel disease.
Right occipital arteriovenous malformation. Arterial supply from the enlarged right posterior cerebral artery and smaller feeding vessels from the right middle cerebral artery branches. The right occipital artery is also enlarged. Large serpentine drainage predominantly into the distal superior sagittal sinus and distal right transverse sinus, with early contrast enhancement of these structures. Possible further communication with the distal straight sinus.
1) The right occipital AVM measures less than 3 cm in each orthogonal dimension. It is approximately 19 x 20 x 24 mm in the AP x trans x CC dimensions.
2) The AVM is supplied by the right P1/fetal origin R PCA.
3) Venous drainage is superficial to the right transverse sinus and separately to the superior sagittal sinus.
4) There may be a 5 mm nidal aneurysm centrally within the nidus - this is difficult to distinguish from the nidus itself.
Case Discussion
The imaging shows a small spontaneous intracerebral hemorrhage secondary to an arteriovenous malformation.
- Macrovascular lesions, such as arteriovenous malformations, underlie 10-15% of spontaneous intracerebral hemorrhage.
- Early identification of such abnormalities is important to allow appropriate treatment.
- Specific features on non-contrast CT of an underlying macrovascular lesion include enlarged vessels and calcifications within or along margins of an intracerebral hemorrhage 1. However, these non-contrast CT findings are not sensitive and their absence does not exclude a macrovascular lesion.
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