Pontine hemorrhage with hypertensive microangiopathy and persistent trigeminal artery
Presentation
Acute onset of slurred speech and left sided body weakness.
Patient Data
Acute hematoma centered at the pons. No significant effacement onto the forth ventricle. No hydrocephalus.
MRI brain performed on six week after the initial plain CT brain to look for any possibility of vascular malfomation.
Evidence of pontine hematoma which demonstrates hyperintensity on both T1W and T2W with hemosiderin rim in keeping with subacute hematoma. No significant mass effect onto the adjacent forth ventricle.
Multiple small susceptibility foci scattered predominantly centered at bilateral basal ganglia, brainstem and bilateral cerebellar hemispheres which are consistent with chronic hypertensive encephalopathy. A few subcentimeter susceptibility foci noted at right temporal lobe which are in keeping with cerebral microhemorrhages.
Confluent hyperintensities on both T2W and FLAIR sequences at bilateral deep white matter at both centrum semiovale and corona radiata, as well as periventricular hyperintensity on T2W/FLAIR are consistent with chronic small vessel ischemia.
Prominent perivascular spaces at both lentiform nuclei. Chronic lacunar infarcts noted at right thalamus and bilateral corona radiata.
No restricted diffusion on DWI / ADC to suggest acute infarction.
MRA TOF:
Anterior circulation:
Bilateral ICAs, ACAs, MCAs and ACOM demonstrates normal flow signal intensities.
Posterior circulation:
An artery is seen arising from the junction between petrous and cavernous segments of right internal carotid artery and supplying the mid basilar artery consistent with persistent primitive trigeminal artery. It has characteristic "tau sign" on sagittal view (refer to annotated image below).
Right fetal posterior communicating artery with absence of P1 segment of right posterior cerebral artery. Normal left PCA and left PCOM artery.
Dominant left vertebral artery. Normal AICA, PICA and superior cerebellar arteries.
No flow-limiting stenosis, aneurysmal dilatation or arteriovenous malformation.
Annotated image showed the labeled anatomy of the posterior circulation and the appearance of "Tau sign"
Case Discussion
Subacute pontine hematoma with background of hypertensive microangiopathy, small vessel disease and chronic multifocal lacunar infarcts. Patient has history of poorly controlled hypertension. The distribution of cerebral microhemorrhages and the pontine hemorrhage are typical attributed by hypertension.
Incidental findings of persistent carotid-vertebrobasilar anastomoses- persistent trigeminal artery -Saltzman classification type II : fetal origin of ipsilateral posterior communicating artery.
Unable to process the form. Check for errors and try again.