Presentation
Gradually increasing severe left sided headache with sudden onset vomiting, drowsiness and altered sensorium.
Patient Data
A layered pattern of acute hemorrhage is seen within the left central capsuloganglionic region appearing hyperdense on CT. Resultant mass-effect is seen in the form of effacement of body of ipsilateral lateral ventricle with dilatation of the frontal, temporal and occipital horns of the left lateral ventricle. There is also mild dilatation of the right lateral ventricle, likely due to obstruction at the level of the foramen of Monro. The third ventricle is effaced. The fourth ventricle appears normal. There is midline shift to the right. Left uncal herniation is seen causing mild rotation of the midbrain.
Heterogenous signal intensity on T1 and T2 weighted images and blooming on SWI. There is no obvious post-contrast enhancement seen. T2/FLAIR hyperintense perilesional edema is seen extending superiorly to adjacent corona radiata and inferiorly to the retrolentiform and sublentiform regions. Resultant mass-effect is seen in the form of effacement of body of ipsilateral lateral ventricle with dilatation of the frontal, temporal and occipital horns of the left lateral ventricle. There is also mild dilatation of the right lateral ventricle, likely due to obstruction at the level of foramen of Monro. The third ventricle is effaced. The fourth ventricle appears normal. There is midline shift to the right. Left uncal herniation is seen causing mild rotation of the midbrain.
A thin linear hyperdense vessel is seen along the anterosuperior aspect of the lesion, which shows blooming on SWI. However, it shows enhancement on post-contrast images and therefore likely represents venous congestion.
The lesion was angiographically occult. There was no enlarged arterial feeder, nidus or early draining vein seen.
Imaging features are suggestive of a giant cavernoma with acute intralesional hemorrhage.
Patient underwent gross total excision of the lesion. Post-operative CT reveals near complete excision of the lesion with associated post-operative changes and reduction in mass effect.
Case Discussion
Histology
Histopathology confirmed the imaging diagnosis of a giant cavernoma.
Discussion
- giant cavernomas are rare. In the setting of acute intralesional hemorrhage, atypical imaging features like vasogenic edema, mass effect, loss of peripheral hemosiderin rim, fluid-fluid levels or perilesional hemorrhage may be seen 1. Angiography is warranted in such cases. Follow up imaging is recommended if the lesion is not surgically treated 1,2.
- MRI is the investigation of choice. DTI and fMRI are useful in surgical planning and intra-operative neuronavigation when the lesion is seated close to the eloquent areas 3.
- associated developmental venous anomaly (DVA) should be looked for in all cases of cavernoma, as they are often seen together and the presence of a DVA increases the chances of intralesional hemorrhage 4.
Corr. Author of the case : Dr. Ullas V Acharya.