Intracerebral hemorrhage secondary to arteriovenous malformation

Case contributed by Mark Rodrigues
Diagnosis certain

Presentation

Punch to head 10 days ago. Persistent headache since with severe lethargy, weakness, nausea, vomiting. Looks unwell and drowsy.

Patient Data

Age: 30 years
Gender: Male

Lobar intracerebral hematoma centered in the right parietal lobe. Its attenuation coupled slightly ill-defined margins are in keeping with a subacute appearance. A small volume of perihaematomal edema is present. No subarachnoid or intraventricular hemorrhage.

Mass effect with leftward mildline shift and partial effacement of the right lateral ventricle. Temporal horn dilatation in keeping with mild obstructive hydrocephalus.

No areas of calcification or obvious abnormal vessels related to the hematoma.

No evidence of small vessel disease. 

CTA performed due to ...

ct

CTA performed due to patient's young age

There are abnormal vessels lying medial to the hematoma. These appear to drain into the vein of Galen, which shows early contrast opacification. The arterial feeders are difficult to identify. The findings are in keeping with an arteriovenous malformation.

A catheter angiogram was performed which confirmed a small right tmeporal lobe arteriovenous malformation with a small nidus in the posteromedial right temporal lobe.
The feeding artery looks to be the right anterior choroidal which may be distorted by the hematoma. It is very tortuous and small and forms a 360 degree loop. The draining vein is deep, into the straight sinus.

Case Discussion

The imaging shows a spontaneous intracerebral hemorrhage secondary to an arteriovenous malformation. 

  • Macrovascular lesions, such as arteriovenous malformations, underlie 10-15% of spontaneous intracerebral hemorrhage.
  • Early identification of such abnormalities is important to allow appropriate treatment.
  • Young age is a risk factor for an underlying macrovascular lesion 1,2, and should lead to vascular imaging.

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