Presentation
Severe headache, neck stiffness and drowsiness
Patient Data
Lobar intracerebral hematoma involving the right parietal lobe. A small volume of perihaematomal edema is present. Intraventricular hemorrhage in the right lateral ventricle. No subarachnoid hemorrhage.
Mild mass effect with effacement of the right cortical sulci and mild displacement of the right trigone. Right 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. Right globe prosthesis.
There is a vascular structure with an area of focal dilatation immediately inferior to the right parietal hematoma, which traverses close to the right posterior cerebral artery and straight sinus.
Contrast enhancement of the straight and transverse sinuses is more pronounced than the superior sagittal sinus and cortical veins, suggesting early filling/shunting.
Arteriovenous malformation with a small 1 cm nidus. Arterial supply by two small branches of the right posterior cerebral artery. There is venous ectasia for approximately 3cm followed by a 90% venous stenosis. Venous drainage eventually is to the vein of Galen and straight sinus shows tramline appearance consistent with recent straight sinus thrombosis
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.
The patient underwent catheter embolization, however complete embolization was not possible. They, therefore, underwent subsequent stereotactic radiosurgery, which successfully closed the arteriovenous malformation.
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