Presentation
Acute onset headache and left hemianopia.
Patient Data
Intraparenchymal hematoma in the right superior temporal and parietal lobe. This demonstrates surrounding hypoattenuation most in keeping with vasogenic edema and is associated with mass effect characterized by minor leftward midline shift.
There are multiple prominent serpiginous vessels at the lateral margin of the hematoma traversing the cortical/pial surface. These include prominent branches from the right middle cerebral and right posterior cerebral arteries, which feed into the lesion. The branch from the posterior cerebral artery passes in close relation to the right transverse and sigmoid sinuses which enhance normally. No definite draining vein or intranidal aneurysm identified.
Right temporoparietal hematoma demonstrates mildly hyperintense T1, heterogeneous T2 and hypointense EPI signal consistent with blood product. Abnormal DWI signal within the lesion is due to blood product. No other diffusion restriction. There is surrounding FLAIR hyperintensity in keeping with vasogenic edema. Mass effect characterized by partial effacement of the right lateral ventricle and 2 mm leftward midline shift is stable. High FLAIR signal in right temporal sulci represents subarachnoid blood.
Tortuous flow voids and enhancing serpiginous vessels are again evident at the lateral aspect of the hematoma along the cortical/pial surface, consistent with a 12 x 21 mm nidus.
On the post contrast FSPGR, the nidus is supplied from the right middle cerebral artery and also from a PCA branch. There is a prominent cortical vein traversing from the posterior margin of the lesion into the posterior aspect of the superior sagittal sinus, and there may be smaller veins draining to the closely adjacent dural sinus (junction transverse and sigmoid). No deep venous drainage or intranidal aneurysm detected.
Temporal branches from the PCA and MCA supply this parenchymal temporal lobe AVM with dominant venous filling passing superficially to the SSS. A smaller component joins the Transverse sinus. Nidus less than 3cm, no deep venous drainage, eloquent brain = Spetzler & Martin grade 2 Arteriovenous malformation.
Case Discussion
A young patient presenting with intraparenchymal hematoma, with no history of hypertension, drug use or trauma should be suspected of harboring an underlying lesion. Typically AVM, cavernoma, aneurysm and venous sinus thrombosis would be considered. The site and absence of SAH make an aneurysm unlikely, and there was no evidence of underlying lesion separate from the hematoma to suggest a cavernoma. The prominent vessels prompts the diagnosis of AVM - which was confirmed on MRI, MRA and subsequent DSA. An important differential diagnosis for this site if of transverse sinus thrombosis with Labbe territory venous hemorrhage - excluded in this case by the obvious AVM.
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