Presentation
Collapse, headache, right sided weakness
Patient Data
Lobar intracerebral haematoma involving the left parietal lobe. Small volume localised subarachnoid haemorrhage. No intraventricular haemorrhage.
There is mass effect on the left lateral ventricle and mild rightward midline shift. No hydrocephalus.
Partially calcified lesion immediately superior to the haematoma and possible enlarged vessels are in keeping with a vascular malformation.
No evidence of small vessel disease.
Postero-superiorly to the left parietal intracerebral haematoma is an arteriovenous malformation with a 3.5 cm nidus, fed by enlarged branches of the left anterior, middle and posterior cerebral arteries. The intracerebral haemorrhage has likely arisen from a 7 mm aneurysm on the feeding left posterior cerebral artery. Venous drainage appears predominantly superficial.
No CTA spot sign.
Multiple aneurysms also arise from: left ICA terminus - 4mm; left MCA trifurcation - 7mm; Sylvian portion of an engorged left MCA - 3mm; and more distally off the same vessel as it runs over the cortex - 1.5mm.
Case Discussion
- Macrovascular lesions, such as arteriovenous malformations, underlie 10-15% of spontaneous intracerebral haemorrhage.
- Early identification of such abnormalities is important to allow appropriate treatment.
- Specific features on non contrast CT of an underlying macrovascular lesion include enlarged vessels or calcifications along margins of ICH 1. However, these non contrast CT findings are not sensitive and their absence does not exclude a macrovascular lesion.
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