Answer for BIR CoW 20 Nov 2022
THROMBOSED CAVERNOMA
Findings
Relatively well defined T1 /T2 heterointense lesion with surrounding perilesional edema of size measuring 4.2×3.5×3.3 cm in the left parietal lobe showing few areas of diffusion restriction with low ADC values .The lesion shows significant blooming on gradient sequence with few prominent superficial veins noted along the left parietal lobe .The above lesion seen indenting the atrium of left lateral ventricle .On contrast administration the lesion shows heterogenous enhancement in substracted images Impression Relatively well defined heterogeneously enhancing T1 /T2 heterointense lesion with surrounding perilesional edema in the left parietal lobe showing significant blooming on gradient sequence with few areas of diffusion restriction - Thrombosed cavernoma
Discussion
Cerebral cavernous venous malformations, also known as cavernous hemangiomas or cavernomas, are common cerebral vascular malformations, is the third most common cerebral vascular malformation after developmental venous anomaly and capillary telangiectasia. According to newer nomenclature (ISSVA classification of vascular anomalies) these lesions are now officially termed slow flow venous malformations.Most patients present symptomatically at 40-60 years of age. Most patients have single lesions. Multiple lesions may be familial.Cavernous malformations, along with capillary telangiectasias are commonly seen following cerebral radiotherapy. The majority of lesions remain asymptomatic throughout life and are found incidentally. Presentation due to hemorrhage may cause a headache, seizure or focal neurological deficit. The risk of hemorrhage is 1% per patient-year for familial cases.Histologically cavernous malformations are composed of a "mulberry-like" cluster of hyalinized dilated thin-walled capillaries, with surrounding hemosiderin. These vessels are thrombosed to varying degrees. Unlike AVM,there is no normal brain between the interstices of these lesions. Imaging findings Cerebral cavernous malformations tend to be supratentorial (~80% cases) but can be found anywhere including the brainstem. Brain MRI with SWI or GRE is recommended for the investigation and follow-up of cerebral cavernous malformations. For investigation of new symptoms suspicious for cerebral hemorrhage, CT can be used within 1 week of onset and MRI after 1 week. Unless large, these lesions are difficult to see on CT. They do not enhance. If large they appear as a region of hyperdensity resembling blood products and speckles of calcification. If there has been a recent bleed then the lesion is more conspicuous and may be surrounded by a mantle of edema. MRI is the modality of choice, demonstrating a characteristic “popcorn” or "berry" appearance with a rim of signal loss due to hemosiderin. T1 shows varied signal depending on the age of the blood products, small fluid-fluid levels may be evident .T2 shows hypointense rim with varied signal internally depending on the age of blood products.If a recent bleed has occurred, surrounding edema may be present.GRE T2*/SWI shows prominent blooming and T1 C+ (Gd) shows generally no enhancement, although possible .Cavernous malformations are angiographically occult and do not demonstrate arteriovenous shunting. DSA is useful to differentiate a cerebral cavernous malformation from an arteriovenous malformation . Cavernous malformations can be grouped into four types based on MRI appearances using the Zabramski classification Type I: subacute hemorrhage T1: hyperintense T2: hypo or hyperintense Type II: most common type - classic "popcorn" lesion T1: mixed signal intensity centrally T2: mixed signal intensity centrally T2*: low signal rim with blooming Type III: chronic hemorrhage T1: hypointense to isointense centrally T2: hypointense centrally T2*: low signal rim with blooming Type IV: multiple punctate microhemorrhages T1: difficult to identify T2: difficult to identify T2*: "black dots" with blooming difficult to distinguish from small capillary telangiectasias Treatment and prognosis Many cavernous malformations are asymptomatic and can be treated conservatively. Symptoms can relate to mass effect, epileptic activity or repeated hemorrhage. Symptomatic lesions should, when possible, be resected and complete resection is curative
Findings
Relatively well defined T1 /T2 heterointense lesion with surrounding perilesional edema of size measuring 4.2×3.5×3.3 cm in the left parietal lobe showing few areas of diffusion restriction with low ADC values .The lesion shows significant blooming on gradient sequence with few prominent superficial veins noted along the left parietal lobe .The above lesion seen indenting the atrium of left lateral ventricle .On contrast administration the lesion shows heterogenous enhancement in substracted images Impression Relatively well defined heterogeneously enhancing T1 /T2 heterointense lesion with surrounding perilesional edema in the left parietal lobe showing significant blooming on gradient sequence with few areas of diffusion restriction - Thrombosed cavernoma
Discussion
Cerebral cavernous venous malformations, also known as cavernous hemangiomas or cavernomas, are common cerebral vascular malformations, is the third most common cerebral vascular malformation after developmental venous anomaly and capillary telangiectasia. According to newer nomenclature (ISSVA classification of vascular anomalies) these lesions are now officially termed slow flow venous malformations.Most patients present symptomatically at 40-60 years of age. Most patients have single lesions. Multiple lesions may be familial.Cavernous malformations, along with capillary telangiectasias are commonly seen following cerebral radiotherapy. The majority of lesions remain asymptomatic throughout life and are found incidentally. Presentation due to hemorrhage may cause a headache, seizure or focal neurological deficit. The risk of hemorrhage is 1% per patient-year for familial cases.Histologically cavernous malformations are composed of a "mulberry-like" cluster of hyalinized dilated thin-walled capillaries, with surrounding hemosiderin. These vessels are thrombosed to varying degrees. Unlike AVM,there is no normal brain between the interstices of these lesions. Imaging findings Cerebral cavernous malformations tend to be supratentorial (~80% cases) but can be found anywhere including the brainstem. Brain MRI with SWI or GRE is recommended for the investigation and follow-up of cerebral cavernous malformations. For investigation of new symptoms suspicious for cerebral hemorrhage, CT can be used within 1 week of onset and MRI after 1 week. Unless large, these lesions are difficult to see on CT. They do not enhance. If large they appear as a region of hyperdensity resembling blood products and speckles of calcification. If there has been a recent bleed then the lesion is more conspicuous and may be surrounded by a mantle of edema. MRI is the modality of choice, demonstrating a characteristic “popcorn” or "berry" appearance with a rim of signal loss due to hemosiderin. T1 shows varied signal depending on the age of the blood products, small fluid-fluid levels may be evident .T2 shows hypointense rim with varied signal internally depending on the age of blood products.If a recent bleed has occurred, surrounding edema may be present.GRE T2*/SWI shows prominent blooming and T1 C+ (Gd) shows generally no enhancement, although possible .Cavernous malformations are angiographically occult and do not demonstrate arteriovenous shunting. DSA is useful to differentiate a cerebral cavernous malformation from an arteriovenous malformation . Cavernous malformations can be grouped into four types based on MRI appearances using the Zabramski classification Type I: subacute hemorrhage T1: hyperintense T2: hypo or hyperintense Type II: most common type - classic "popcorn" lesion T1: mixed signal intensity centrally T2: mixed signal intensity centrally T2*: low signal rim with blooming Type III: chronic hemorrhage T1: hypointense to isointense centrally T2: hypointense centrally T2*: low signal rim with blooming Type IV: multiple punctate microhemorrhages T1: difficult to identify T2: difficult to identify T2*: "black dots" with blooming difficult to distinguish from small capillary telangiectasias Treatment and prognosis Many cavernous malformations are asymptomatic and can be treated conservatively. Symptoms can relate to mass effect, epileptic activity or repeated hemorrhage. Symptomatic lesions should, when possible, be resected and complete resection is curative
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!