Answer for BIR CoW 28 May 2023
Cavernoma with bleed
Findings
T1/T2 heterointense lesion with perilesional T1 hyperintensity and central T2 hyperintensity in left frontal region with surrounding white matter edema showing central area of intense diffusion restriction with low ADC values and peripheral thick rim of gradient blooming. Impression - Cavernoma with bleed Differentials: Hemorrhagic primary brain tumors (ependymoma and glioblastoma) Hemorrhagic cerebral metastasis(melanoma,RCC,Choriocarcinoma) Calcified lesions like old neurocysticercosis or tuberculoma. Cerebral amyloid angiopathy-usually lobar and tends to spare basal ganglia and pons. Chronic hypertensive encephalopathy-affects basal ganglia ,pons and cerebellar hemispheres.
Discussion
Clinical features may include acute or subacute onset of any of: headache, epileptic seizure, impaired consciousness, or new/worsened focal neurological deficit referable to the anatomic location of the CM. Evidence of acute blood can be easily and accurately identified on CT, which should be performed ideally within 1 week of the onset of a clinical event MRI should ideally be performed within 2 weeks of the onset of a clinical event to demonstrate extracellular methemoglobin which is high signal on T1- and T2-weighted sequences . Gradient recalled echo (GRE) sequences tend to demonstrate increasing signal dropout as hemosiderin emerges and may be particularly helpful for identifying small hemorrhages. Cavernous malformations can be divided into four groups (Zabramski classification) based on their appearance on MRI. Type I lesions appear hyperintense on both T1- and T2-weighted sequences due to their subacute hemorrhage and hemosiderin core. Type II lesions represent the classic "popcorn" lesions often described. These type II lesions have mixed signal intensity on both T1 and T2 sequences due to multiple loculated hemorrhages of various stages enclosed by gliotic margins. For these lesions, the gliotic peripheral rim demonstrates decreased signal intensity on T2 sequences. Type III lesions demonstrate chronic resolved hemorrhage within an isointense core. Type IV lesions are thought to represent small capillary telangiectasias that can only be seen on gradient resonance echo sequences. Conservative management with serial imaging and observation, microsurgical resection, and stereotactic radiosurgery are the 3 main options for the management of cerebral cavernomas.
References:
1. Del Curling O Jr, Kelly DL Jr, Elster AD, Craven TE. An analysis of the natural history of cavernous angiomas. J Neurosurg. 1991;75:702–708.
2. Al-Shahi Salman R, Whiteley WN, Warlow C. Screening using whole-body magnetic resonance imaging scanning: who wants an incidentaloma? J Med Screen. 2007;14:2– 4.
3. Cordonnier C, Al-Shahi Salman R, Bhattacharya JJ, Counsell CE, Papanastassiou V, Ritchie V, Roberts RC, Sellar RJ, Warlow C; SIVMS Collaborators. Differences between intracranial vascular malformation types in the characteristics of their presenting haemorrhages: prospective, population-based study. J Neurol Neurosurg Psychiatry. 2008;79:47–51
Findings
T1/T2 heterointense lesion with perilesional T1 hyperintensity and central T2 hyperintensity in left frontal region with surrounding white matter edema showing central area of intense diffusion restriction with low ADC values and peripheral thick rim of gradient blooming. Impression - Cavernoma with bleed Differentials: Hemorrhagic primary brain tumors (ependymoma and glioblastoma) Hemorrhagic cerebral metastasis(melanoma,RCC,Choriocarcinoma) Calcified lesions like old neurocysticercosis or tuberculoma. Cerebral amyloid angiopathy-usually lobar and tends to spare basal ganglia and pons. Chronic hypertensive encephalopathy-affects basal ganglia ,pons and cerebellar hemispheres.
Discussion
Clinical features may include acute or subacute onset of any of: headache, epileptic seizure, impaired consciousness, or new/worsened focal neurological deficit referable to the anatomic location of the CM. Evidence of acute blood can be easily and accurately identified on CT, which should be performed ideally within 1 week of the onset of a clinical event MRI should ideally be performed within 2 weeks of the onset of a clinical event to demonstrate extracellular methemoglobin which is high signal on T1- and T2-weighted sequences . Gradient recalled echo (GRE) sequences tend to demonstrate increasing signal dropout as hemosiderin emerges and may be particularly helpful for identifying small hemorrhages. Cavernous malformations can be divided into four groups (Zabramski classification) based on their appearance on MRI. Type I lesions appear hyperintense on both T1- and T2-weighted sequences due to their subacute hemorrhage and hemosiderin core. Type II lesions represent the classic "popcorn" lesions often described. These type II lesions have mixed signal intensity on both T1 and T2 sequences due to multiple loculated hemorrhages of various stages enclosed by gliotic margins. For these lesions, the gliotic peripheral rim demonstrates decreased signal intensity on T2 sequences. Type III lesions demonstrate chronic resolved hemorrhage within an isointense core. Type IV lesions are thought to represent small capillary telangiectasias that can only be seen on gradient resonance echo sequences. Conservative management with serial imaging and observation, microsurgical resection, and stereotactic radiosurgery are the 3 main options for the management of cerebral cavernomas.
References:
1. Del Curling O Jr, Kelly DL Jr, Elster AD, Craven TE. An analysis of the natural history of cavernous angiomas. J Neurosurg. 1991;75:702–708.
2. Al-Shahi Salman R, Whiteley WN, Warlow C. Screening using whole-body magnetic resonance imaging scanning: who wants an incidentaloma? J Med Screen. 2007;14:2– 4.
3. Cordonnier C, Al-Shahi Salman R, Bhattacharya JJ, Counsell CE, Papanastassiou V, Ritchie V, Roberts RC, Sellar RJ, Warlow C; SIVMS Collaborators. Differences between intracranial vascular malformation types in the characteristics of their presenting haemorrhages: prospective, population-based study. J Neurol Neurosurg Psychiatry. 2008;79:47–51
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!