Presentation
Acute headache and gaze palsy. History of SLE.
Patient Data
Hemorrhagic quadrigeminal plate lesion with associated intraventricular hemorrhage. The lesion most likely represents a cavernous venous malformation (cavernoma), although the low T2 rim typically seen is not as conspicuous as is often the case. In the setting of connective tissue disease (SLE) the possibility of this representing a hemorrhage related to cerebral vasculitis should be entertained, although in the absence of other lesions and a normal MRA, this is less likely. Another occult underlying hemorrhagic lesion (e.g. small AVM, hemorrhagic metastasis or primary tumor) are also considerations, although less likely. Careful follow-up, including eventually a contrast enhanced study are required. CT / CTA / angiography are unlikely to significantly contribute in this setting.
Repeat MRI 6 months later demonstrates resolution of edema and intraventricular hemorrhage. A small hemosiderin lined lesion remains in the midbrain suggestive of a small cavernoma.
Case Discussion
Follow-up of these lesions is important to ensure that no sinister underlying cause is present. In this instance it almost certainly represents a tiny cavernous malformation (cavernoma).
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