Presentation
G2P0, 36/40, presented with sudden onset headache with associated nausea and right-sided facial sensory changes.
Patient Data
This scan demonstrates intra-axial mass lesion within the right side of the midbrain and pons measuring 2.8 x 2.0 x 2.5 cm. It also shows internal fluid-fluid levels at the superior margin with associated susceptibility artefact. This is most consistent with hemorrhage into a cavernoma, although there is no complete hemosiderin rim.
Surrounding the lesion FLAIR/T2 hyperintense signal change involving the right and left sides of the pons and right side of the midbrain extending into the right superior and middle cerebellar peduncles and cerebral peduncle.
The mass is associated with expansion of the pons and mass effect on the fourth ventricle which is distorted but not obliterated.
No hydrocephalus or cerebellar tonsillar herniation is demonstrated.
Summary: Right midbrain/pontine hemorrhagic lesion most likely represents a cavernoma. A follow-up MRI (in the postpartum setting) is suggested to ensure expected evolution.
Right-sided pontine cavernous malformation is demonstrated, with previously demonstrated edema having abated. No current edema to suggest recent hemorrhage.
Case Discussion
This patient presented 36 weeks' pregnant with sudden onset headache and ataxia. Fortunately she went on to have a successful cesarian section at 38 weeks after a period of observation. Most neurological symptoms fully resolved. Due to the location of the lesion it was thought to be too high risk for operative intervention. Further pregnancies would likely be periods of high risk for recurrent bleeds.
At 20-month follow up imaging demonstrates that acute hemorrhagic changes including edema have resolved, supportive of the diagnosis of cavernoma.
Cavernous malformations of the brainstem are uncommon, but the natural history appears to be worse than those in other locations 1. Retrospective annual hemorrhage rates appear to be around 5% 1 with increased rates of hemorrhage thought to occur during pregnancy 2,3.
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