Presentation
Sudden loss of consciousness. No hypertension. No seizures. No fever. No trauma.
Patient Data
There is presence of T2/FLAIR hyperintense, T1 hypointense lesion in right thalamus - suggestive of hyperacute bleed. It is showing blooming on SWI and diffusion restriction on DWI. There is intraventricular extension (all ventricles). Mass effect is seen in the form of mild midline shift and compression of third ventricle. Bilateral lateral ventricles are prominent.
MRA- Bilateral intracranial ICA are severely attenuated (L>R). Multiple vessels of the circle of Willis are severely attenuated (Right PCA, Left A1 ACA, Left M1 MCA) with abnormal collateral vessels with focal areas of aneurysmal dilatation.
Confluent & discrete T2/FLAIR hyperintensities are seen in periventricular area and centrum semiovale - suggestive of ischemic changes in white matter.
NCCT was done on day 2, to look for any interval change.
Bleed is seen in right thalamus with intraventricular extension. Mass effect is seen in the form of mild midline shift & compression of third ventricle. No significant interval change is seen.
Case Discussion
Hemorrhage on MRI can have different appearances on MRI based on the time since bleed. Having a good knowledge of aging blood on MRI helps us to make an accurate diagnosis. NCCT is of great help.
Moyamoya syndrome - has characteristic imaging appearance with the involvement of intracranial vessels, especially the Circle of Willis.
When no cause could be identified - it is termed as Moyamoya disease (idiopathic).
In children, it usually presents as ischemic strokes and cystic encephalomalacic changes on imaging, whereas in adults, presentation is usually intracranial hemorrhage from the abnormal vessels.