Cerebral haemorrhage and AVM

Case contributed by Prof Peter Mitchell

Presentation

Acute confusion, auditory hallucinations, headache.

Patient Data

Age: 63
Gender: Female
CT

Left anterior temporal intra-parenchymal haemorrhage.  No definite underlying AVM or aneurysm identified.

MRI

MRI

The region of susceptibility artefact involving the left temporal lobe is smaller and consistent with the known focus of previous intraparenchymal haemorrhage. There is much reduced surrounding T2/FLAIR hyperintensity in keeping with near resolved surrounding oedema. Within this region, there is no vascular nidus or serpiginous flow voids to suggest an underlying vascular malformation. No prominent or enlarged arteries are identified within the region. The dedicated MRA of the region is unremarkable demonstrating no aneurysm, stenosis or vascular malformation.

Incidentally however, at the medial aspect of the right precentral gyrus ( parasagittal location ) there is 6mm

vascular nidus of cortical / pial vessels. No definite large draining vein is identified on the preceding MR venogram study nor adjacent thrombosed vein. There is no evidence of gliosis or haemorrhage within this region.

The left midbrain ( left superior colliculus ) focus of high T2 signal is unchanged and consistent with previous haemorrhage. No other regions of signal abnormality is identified. No acute haemorrhage or extra-axial collection.

Conclusion:

There is near complete collapse of the haemorrhagic cavity in the left temporal lobe. No underlying vascular malformation or underlying mass lesion is identified within the

left temporal lobe.There is incidental 6 mm presumed pial arteriovenous malformation involving the medial aspect of the right precentral gyrus.

DSA (angiography)

1. Right pre-central gyrus AVM

2. Left temporal AVM

3. Quadrigeminal plate AVM

Case Discussion

Initial presentation with left ICH - non hypertensive patient on no antiplatelet or anticoagulant medications - should prompt consideration of underlying lesion.  Additional information regarding prior brainstem haemorrhage (another institution) with no cause identified.  Underlying vascular malformation (AVM, cavernoma), less likely tumour.  More anterior than venous sinus thrombosis related haematoma,  but warrants exclusion if no other cause is identified.

Next investigation should be with contrast enhanced MRI/MRA.  This did not explain the temporal lobe haematoma, and there was no evidence of microbleeds or multiple cavernoma syndrome.  The prior bleed in the left posterior midbrain is well shown.  Catheter angiography should be performed as next investigation.  In this case confirming an unruptured AVM in the contralateral hemisphere, but also identifying the AVM responsible for the current bleed, and also the brainstem bleed a decade prior.

Unexplained parenchymal haemorrhage after CT and MRI should always be considered for catheter angiography.  Both carotid and vertebral arteries need to be injected; selective ICA and ECA injections are also required in most cases.

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Case information

rID: 34422
Case created: 19th Feb 2015
Last edited: 17th Dec 2015
Inclusion in quiz mode: Included

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