Cavernoma, DVA and right ICA aneurysm

Case contributed by Prof Peter Mitchell

Presentation

Altered sensation left upper limb.

Patient Data

Age: 45
Gender: Female
Modality: CT

CT Brain

Non-contrast helical acquisition with multiplanar reformats

Contrast studies were not performed because of previous thyroid disorder and planned contrast enhanced MRI and MRA will follow.

There is a hyperdense lesion measuring 15 x 13 x 16 mm (AP x LR x SI) in the right middle cerebellar peduncle with surrounding hypoattenuation extending into the right cerebellar hemisphere and pons. A tubular, serpiginous hyperdense structure coursing through the right cerebellopontine angle cistern and along the inferior margin of the lesion is in keeping with a prominent vessel, probably petrosal vein. A small speck of calcification is situated immediately posteroinferior to the haemorrhage. There is associated mass effect, with expansion of the right middle cerebellar peduncle and partial effacement of the fourth ventricle. No hydrocephalus.

Note hyperdense mass adjacent to right anterior clinoid process.

No further intracranial haemorrhage detected. No evidence of acute ischaemia. No calvarial abnormality. The imaged paranasal sinuses and mastoid air cells are clear.

Conclusion:

Right middle cerebellar peduncle haemorrhage is favoured to represent haemorrhage due to an underlying AVM/AVF or cavernous malformation. Less likely differential diagnoses include haemorrhagic metastasis or hypertensive haemorrhage. Suspect Right ICA aneurysm adjacent to anterior clinoid.  MRI/MRA is recommended for further evaluation.

 

Modality: MRI

There is a 15mm medial right middle cerebellar peduncle mass lesion with moderate surrounding FLAIR abnormality indicating vasogenic edema; and significant T2* shortening on the GRE and EPI images, consistent with hemorrhage, concordant with the CT findings.

This lesion is associated with a relatively large developmental venous anomaly, with compartmental "caput medusa" within the right cerebellar hemisphere and superiorly into the pons; exiting from the right cerebellopontine angle and draining into the right superior/inferior petrosal and cavernous sinus confluence.

On the background of hypoplastic left A1 and P1, MRA demonstrating a large right sided paraclinoid aneurysm, pointing anterolaterally, measuring approximately 9 x 8 x 7mm in perpendicular dimensions. The aneurysm neck is likely situated over the carotico-ophthalmic segment, with the aneurysm configuration appearing bilobed. The less likely possibility is two aneurysms very closely located.

No convincing further abnormalities identified.

Conclusion:

The findings are most consistent with a haemorrhage into right cerebellar/cerebellar peduncle cavernoma, associated with a relatively large DVA. 

Note also made of an incidental right caroticophthalmic aneurysm.

Modality: DSA (angiography)

1. Large bi-lobed right ICA transitional but at least partially intradural aneurysm, laterally pointing. Broad necked, measuring up to 9mm. Fusiform involvement of the parent vessel. Immediately distal to the opthalmic artery.

2. Large right cerebellar developmental venous anomaly (DVA) draining into the basilar plexus.

3. No evidence of posterior fossa aneurysm.

Conclusion:

The findings are entirely in keeping with a right cerebellar cavernoma.

Incidental right ICA aneurysm, which could be amenable to flow diverting stent, however this would require dual anti-platelets. .

Modality: DSA (angiography)

4*20 mm Pipeline Embolization Device (PED) deployed across the aneurysm neck.

PlayAdd to Share

Case Information

rID: 33890
Case created: 28th Jan 2015
Last edited: 17th Dec 2015
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.