Evolution of Clinical Picture After Hemorrhage of Cavernous Malformation

A 6-year-old girl presented with her first focal seizure involving her right arm with head turning to the right and eyes deviated to right.  The seizure secondarily generalizes.  A CT scan was done after the onset.

Unenhanced CT scan of cavernous malformation: Image obtained at presentation shows a hemorrhagic lesion (red arrow) at the pole of the right frontal lobe.

 

She was treated conservatively and put on an anticonvulsant. An MRI was obtained 3 months later.

Unenhanced T1-weighted axial MRI: The lesion in the right frontal pole is hyperintense, consistent with subacute hematoma. It is irregular in shape and extends beyond a hypodense dark rim, suggesting an overt hematoma.
 
Contrast-enhanced T1-weighted axial MRI: There is mild contrast enhancement.
 

T2-weighted axial MRI: The dark rim can be seen more clearly. It represents hemosiderin from the hematoma. Focal edema is present.
 
GRE axial MRI of multiple cavernous malformations: The lesion is dark and amplified, representing the blooming artifact of hemosiderin on GRE MRI sequence.
 

Sagittal MRA of same patient: No abnormal vascularity is seen in the frontal area.
 
Axial MRA of same patient: There is no evidence of an AVM.
 

 

The patient had another seizure 11 months after the first attack.

Axial CT scan: The image shows an acute hemorrhage in the right frontal pole.
 

 

A follow-up MRI was obtained 1 year after the first seizure attack and 1 month after the second attack.

T1-weighted axial MRI: The lesion in the right frontal pole has become hypointense and smaller than it appeared on the previous MRI because the hematoma has resolved.
 
Gadolinium-enhanced T1-weighted axial MRI: There is mild contrast enhancement. This may represent the cavernous malformation.
 

T2-weighted axial MRI: The lesion is dark due to the hemosiderin. The focal edema has disappeared.
 
GRE axial MRI of multiple cavernous malformations: The blooming artifact of hemosiderin persists.

 

The patient underwent surgery for excision of the lesion 3 months later (15 months after the initial presentation)

Operative photograph of cavernous malformation: A hemosiderin-stained lesion abutting the surface is shown.

 

The pathology confirmed cavernous malformation.