A focal Vermian bleed on MRI

 

MRI BRAIN WITH CONTRAST REPORT

This MRI study of brain reveals an ~ 12x13mm well defined round to ovoid nodular lesion in cerebellar vermis at the roof of fourth ventricle. Lesion is bright on T1 with high signal on T2 suggestive of blood degradation product with low signal on GRE. No marked peri lesional odema. No significant mass effect or mid line shift.

Imaging wise diagnosis suggested was Tumor nodule with bleed, however possibility of underlying vascular malformation can not be ruled out on imaging.

Operated with posterior fossa craniotomy. E/o complete excision of lesion on post operative scans. No major extra / intra axial bleed.

REPORT OF HISTO PATHOLOGICAL EXAMINATION

Specimen         : Excisional biopsy – SOL in base of skull (cerebellar vermis). 
Gross Appearance    : The specimen consists of few irregular soft pieces of dull greyish white tissue; together measuring 0.3X0.3X0.2 cm. The entire tissue is submitted for processing.    

Microscopy        : Section and additional made serial deeper section shows fragmented bits of reactive cerebellar tissue with the central portion showing ectatic vascular channel with undulating wall, devoid of smooth muscle and elastic lamellae. Also seen are couple of fragments with microhaemorrhage and scattered haemosiderophages along with prominent perivascular lymphocytic cuffing. There is no evidence of malignancy. 

Final Diagnosis  : Bleed secondary to Cavernous Angioma (Cavernoma).

Cavernoma with Bleed

Non contrast CT study of brain shows right frontal Cavernoma with punctate calcifications. An adjacent Gliosis noted. 
MRI study of brain shows right frontal Cavernoma appears to be complicated with bleed which has resolved and is evident by Gliosis with low signal intensity hemosiderin staining on GRE. It is not uncommon for a Cavernoma patient to be asymptomatic, massive bleed in a Cavernoma is known but a rare complication. 


Cavernoma (Cavernous Malformation)
A benign vascular hamartoma, composed of closely packed immature blood vessels with intra lesional micro hemorrhages, without any neuronal tissue.
Best diagnostic clue is "Pop corn ball" like appearance with hemosiderin rim on T2w images.
Occur anywhere in brain. Rare in Spinal cord.
Vary in size from few mms to cms. Average size is between 1 to 5cm.
Usually single solitary, may be multiple, discrete lesions.
MRI is more sensitive and specific for detection of lesion.
Hyper dense on non contrast CT. Punctate Calcifications seen in ~ 50% cases. No to faint enhancement on post contrast.
On MRI lobulated appearance due to multiple locules which show variable signals, depending up on the blood degradation products. T1 bright locules attributed to Meth Hb - a sub acute stage blood degradation product. Low signal intensity hemosiderin rim on T2 images. Low signal intensity blooming on  T2*GRE images. No to faint enhancement on post contrast T1 images.
No to mild peri lesional odema.
No mass effect.

Clinical presentation:
Seizures 50%
Neuro deficit 25%
Asymptomatic 20%, detected as an incidnetal finding.
No intervention is a rule. But need follow up imaging as it may show progression or regression in size. Rarely show massive bleed.
Can affect any age group.
No gender preponderance.
Familial association in Hispanic Americans - Multiple Cavernoma Syndrome, carries higher risk for bleed and re bleed.

Similar cases:
cavernoma
cavernous-malformation
venous angioma with bleed

Multiple Brain and a Spinal Cavernous Malformation in same patient

A 40 yo male presented with sudden onset paraplegia. 

MRI Spine done first revealed an intra medullary focal lesion with T1 bright meth Hb staining and low signal intensity hemosiderin staining on GRE. 

Brain screening done in same setting revealed multiple similar intra cranial lesions. 

MRI brain and spine images of same patient.

Description of findings:
MRI Brain shows multiple intra axial focal lesions with typical pop corn ball appearance on T2w images with low signal intensity hemosiderin rim. Few T1 bright locules of meth Hb - a sub acute stage blood degradation product. Lesion show low signal intensity blooming on T2*GRE. No mass effect.
MRI Spine shows a similar intra medullary focal lesion at the level of C7, marked adjacent cord odema.

Diagnosis: Multiple Brain and a Spinal Cavernous Malformation.

Cavernoma (Cavernous Malformation)

A benign vascular hamartoma, composed of closely packed immature blood vessels with intra lesional micro hemorrhages, without any neuronal tissue.
Best diagnostic clue is "Pop corn ball" like appearance with hemosiderin rim on T2w images.
Occur anywhere in brain. Rare in Spinal cord.
Vary in size from few mms to cms. Average size is between 1 to 5cm.
Usually single solitary, may be multiple, discrete lesions.
MRI is more sensitive and specific for detection of lesion.
Hyper dense on non contrast CT. Calcification seen in ~ 50% cases. No to faint enhancement on post contrast.
On MRI lobulated appearance due to multiple locules which show variable signals, depending up on the blood degradation products. T1 bright locules attributed to Meth Hb - a sub acute stage blood degradation product. Low signal intensity hemosiderin rim on T2 images. Low signal intensity blooming on  T2*GRE images. No to faint enhancement on post contrast T1 images.
No to mild peri lesional odema.
No mass effect.

Clinical presentation:
Seizures 50%
Neuro deficit 25%
Asymptomatic 20%, detected as an incidnetal finding.
No intervention is a rule. But need follow up imaging as it may show progression or regression in size. Rarely show massive bleed.
Can affect any age group.
No gender preponderance.
Familial association in Hispanic Americans - Multiple Cavernoma Syndrome, carries higher risk for bleed and re bleed.

Similar cases: 

Cavernoma

cavernoma-with-bleed

Intraventricular-cavernoma

venous angioma with bleed

Cavernoma (Cavernous Malformation)

Imaging findings of Cavernoma (Cavernous Malformation) are very typical on MR as in this case.

A focal lesion in right cingulate gyrus faintly hyper dense on Non contrast CT.
On MRI typical "popcorn ball" appearance with low signal intensity hemosiderin rim on T2w images.
T1 bright locules of Meth Hb on T1w images.
Low signal intensity blooming on T2*GRE due to paramagnetic effect of blood degradation product.
Faint enhancement on post contrast T1.
Mild perilesional edema on FLAIR.
No mass effect.

Cavernoma (Cavernous Malformation)


A benign vascular hamartoma, composed of closely packed immature blood vessels with intra lesional micro hemorrhages, without any neuronal tissue.
Best diagnostic clue is "Pop corn ball" like appearance with hemosiderin rim on T2w images.
Occur anywhere in brain. Rare in Spinal cord.
Vary in size from few mms to cms. Average size is between 1 to 5cm.
Usually single solitary, may be multiple, discrete lesions.
MRI is more sensitive and specific for detection of lesion.
Hyper dense on non contrast CT. Calcification seen in ~ 50% cases. No to faint enhancement on post contrast.
On MRI lobulated appearance due to multiple locules which show variable signals, depending up on the blood degradation products. T1 bright locules attributed to Meth Hb - a sub acute stage blood degradation product. Low signal intensity hemosiderin rim on T2 images. Low signal intensity blooming on  T2*GRE images. No to faint enhancement on post contrast T1 images.
No to mild peri lesional odema.
No mass effect.

Clinical presentation:
Seizures 50%
Neuro deficit 25%
Asymptomatic 20%, detected as an incidnetal finding.
No intervention is a rule. But need follow up imaging as it may show progression or regression in size. Rarely show massive bleed.
Can affect any age group.
No gender preponderance.
Familial association in Hispanic Americans - Multiple Cavernoma Syndrome, carries higher risk for bleed and re bleed.

DD:
AVM; may see 'pop corn ball'  appearance, but characterised by incomplete hemosiderin rim, flow voids on T2w images, areas of bleed instead of multiple locules of variable signals.

Similar Case :
Cavernoma
Cavernoma-with-venous-angioma
Cavernoma with bleed