Figure 1
axial brain CT without contrast showing spontaneous hyperdense nodular lesion on the left frontal lobe, associated with calcifications. There was also mild corticosubcortical hypodensity nearby
Cavernous venous malformation associated with postictal changes: Imaging assessment on an illustrative case
SectionNeuroradiology
Case TypeClinical Cases
Authors
Caio Tasso Oliveira Rego1, Pedro Neves Paiva de Castro1, Héber Samuel Colares Costa1, Roberto, Queiroz dos Santos1, Carlos Henrique Basoni1, Dequitier Carvalho Machado1, Janio Nogueira2
Connected authors
45 years, male
Clinical History
A 45-year-old male with no relevant previous clinical history presented with a tonic-clonic seizure episode, initially refractory to drug treatment. After stabilisation with benzodiazepines, the medical team indicated an imaging assessment. The cerebrospinal fluid (CSF) was negative for infection or other diseases.
Imaging Findings
The initial CT demonstrated a left frontal nodular lesion with spontaneous hyperdensity and calcifications. In addition, there was a subcortical white matter hypodensity near the lesion (Fig. 1 to 4).
The subsequent MRI showed the nodular lesion with a classical popcorn-like appearance of the cavernous venous malformation, as also post ictal findings in the nearby middle and inferior left frontal gyrus (Fig. 5 to fig 12). The post-surgery MRI showed haematic material inside the surgical cavity and a partial resolution of the postictal findings, especially the cortical thickening (Fig. 13 to Fig 16).
Discussion
Cerebral cavernous venous malformations are the third most common cerebral vascular malformation composed of hyalinized dilated thin-walled low-flow capillaries, sometimes with surrounding hemosiderin [1,2].
When symptomatic, these malformations usually manifest in patients around 40 to 60 years with intraparenchymal bleeding or subarachnoid and extra-axial haemorrhage [1,2]. In addition, however, there is an association between cavernous venous malformation and epilepsy [3,4].
At first, CT detected a frontal nodular lesion with calcifications and other hyperintensity areas that could represent haematic material. Succeeding MRI could support the diagnosis, demonstrating a type II Zabramski classification cerebral cavernous malformation with postictal MRI changes in nearby cerebral parenchyma [2,5,6,7].
The cavernous malformation appeared as a classic popcorn-like-lesion, showing T1-hypointensity with hyperintense foci (subacute haematic material) within, T2-hypersignal centrally with surrounding low signal rim, and SWI blooming [2]. In addition, the lesion presented low perfusion on the CBV map, corresponding to the low-flow characteristic of these venous malformations, helping to distinguish from hypervascular lesions.
The middle and inferior left frontal gyrus showed classic postictal changes: swelling and an abnormal corticosubcortical sign, especially with T2 and FLAIR hyperintensity, diffusion restriction of the grey matter, and vasogenic oedema in white matter [5,6,7]. These changes are related to excessive metabolic demands on tissues due to sustained seizure activity, resulting in hypoxia and, if severe enough, cell death [3,4,5].
After the imaging diagnosis, surgery is the treatment of choice in symptomatic cases [4,5]. Afterwards, the patient responded clinically well to the surgery, presenting no seizures. A 72-hour control MRI detected subacute haematic residue inside the surgical cavity, indicating a post-surgery expected finding. In addition, MRI showed a partial reduction of the swelling and hypersignal in FLAIR and T2 of the left frontal middle and inferior gyrus, corroborating the improvement of the postictal changes.
When there are postictal changes in a patient with seizures and a cortical cavernous venous malformation, the neuroradiologist can determine the causal relationship, and the precise imaging diagnosis and surgical treatment established.
Differential Diagnosis List
Status epilepticus MRI changes secondary to a cavernous venous malformation
Gliomas
Non-atheromatous vasculopathy
Cerebral amyloid angiopathy
Haemorrhagic cerebral metastases
Final Diagnosis
Status epilepticus MRI changes secondary to a cavernous venous malformation
References
[1] Brunereau L et al. 2000. Familial form of intracranial cavernous angioma: MR imaging findings in 51 families. French Society of Neurosurgery. Radiology. Jan;214(1):209-16. (PMID: 10644126)
[2] Zabramski J, M et al. 1994. The natural history of familial cavernous malformations: results of an ongoing study. J Neurosurg. Mar;80(3):422-32. (PMID: 8113854)
[3] Lee Y et al. 2017. Clinical outcome following medical treatment of cavernous malformation related epilepsy. Seizure. Feb;45:64-69. (PMID: 27936450)
[4] Colpan M,E et al. 2010. De novo formation of cerebral cavernous malformation in a patient with intractable epilepsy: case report and review. J Neuroimaging. Jul;20(3):302-6. (PMID: 19226336)
[5] Wang F et al. 2018. Microsurgical treatment of temporal cavernous malformation presenting with epilepsy. Mar 6;98(9):658-661. Chinese. (PMID: 29534399)
[6] Kim J, A et al. 2001. Transient MR signal changes in patients with generalized tonicoclonic seizure or status epilepticus: periictal diffusion-weighted imaging. AJNR Am J Neuroradiol. Jun-Jul;22(6):1149-60. (PMID: 11415912)
[7] Sirven J, I et al. 2003. MRI changes in status epilepticus. Neurology. Jun 10;60(11):1866. (PMID: 12796558)
Case information
| URL: | https://www.eurorad.org/case/17639 |
| DOI: | 10.35100/eurorad/case.17639 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
post-contrast axial brain CT (vascular window) shows no significant contrast enhancement
Figure 3
post-contrast axial brain CT (cerebral window) shows no significant enhancement in the lesion or the nearby parenchyma
Figure 4
post-contrast coronal brain CT (cerebral window) shows the same findings as figure 3
Figure 5
axial FLAIR showing the classic popcorn-like cavernous venous malformation on the left frontal lobe, as also swelling and hypersignal of the cortex, associated with vasogenic oedema of the subcortical white matter, indicating postictal findings
Figure 6
axial T2 showing the classic popcorn-like cavernous venous malformation on the left frontal lobe, as also swelling and hypersignal of the cortex, associated with vasogenic oedema of the subcortical white matter, indicating postictal findings
Figure 7
coronal T2 showing the classic popcorn-like cavernous venous malformation on the left frontal lobe, as also swelling and hypersignal of the cortex, associated with vasogenic oedema of the subcortical white matter, indicating postictal findings
Figure 8
axial non-contrast T1 showing the hyposignal of the cavernous venous malformation on the left frontal lobe, with some hypersignal-foci (subacute haemorrhage), as also swelling of the nearby cortex
Figure 9
axial post-contrast T1 showing irregular enhancement of the cavernous venous malformation
Figure 10
CBV perfusion map demonstrating low perfusion of the cavernous venous malformation corroborating the low-flow characteristics of these lesions and helping to distinguish from high grade/anaplastic tumours
Figure 11
axial DWI sequence demonstrating restricted diffusion confined to the cortex. These characteristics can be found in postictal states and represent the excessive metabolic demands on tissues due to sustained seizure activity
Figure 12
ADC sequence showing restricted diffusion of cortex nearby the cavernous malformation, complementing the findings of figure 11
Figure 13
post-surgery axial FLAIR shows liquid/hematic residue inside the surgical cavity and partial reduction of the swelling and hypersignal of the nearby cortex, indicating improvement of the postictal state
Figure 14
post-surgery axial T2 showing the same signs demonstrated in FLAIR (figure 13)
Figure 15
post-surgery axial SWI showing intense blooming inside surgical cavity due to the haematic residue
Figure 16
post-surgery axial T1 without gadolinium showing early subacute haematic residue inside the surgical cavity
axial brain CT without contrast showing spontaneous hyperdense nodular lesion on the left frontal lobe, associated with calcifications. There was also mild corticosubcortical hypodensity nearby
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-contrast axial brain CT (vascular window) shows no significant contrast enhancement
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-contrast axial brain CT (cerebral window) shows no significant enhancement in the lesion or the nearby parenchyma
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-contrast coronal brain CT (cerebral window) shows the same findings as figure 3
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
axial FLAIR showing the classic popcorn-like cavernous venous malformation on the left frontal lobe, as also swelling and hypersignal of the cortex, associated with vasogenic oedema of the subcortical white matter, indicating postictal findings
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
axial T2 showing the classic popcorn-like cavernous venous malformation on the left frontal lobe, as also swelling and hypersignal of the cortex, associated with vasogenic oedema of the subcortical white matter, indicating postictal findings
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
coronal T2 showing the classic popcorn-like cavernous venous malformation on the left frontal lobe, as also swelling and hypersignal of the cortex, associated with vasogenic oedema of the subcortical white matter, indicating postictal findings
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
axial non-contrast T1 showing the hyposignal of the cavernous venous malformation on the left frontal lobe, with some hypersignal-foci (subacute haemorrhage), as also swelling of the nearby cortex
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
axial post-contrast T1 showing irregular enhancement of the cavernous venous malformation
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
CBV perfusion map demonstrating low perfusion of the cavernous venous malformation corroborating the low-flow characteristics of these lesions and helping to distinguish from high grade/anaplastic tumours
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
axial DWI sequence demonstrating restricted diffusion confined to the cortex. These characteristics can be found in postictal states and represent the excessive metabolic demands on tissues due to sustained seizure activity
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
ADC sequence showing restricted diffusion of cortex nearby the cavernous malformation, complementing the findings of figure 11
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-surgery axial FLAIR shows liquid/hematic residue inside the surgical cavity and partial reduction of the swelling and hypersignal of the nearby cortex, indicating improvement of the postictal state
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-surgery axial T2 showing the same signs demonstrated in FLAIR (figure 13)
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-surgery axial SWI showing intense blooming inside surgical cavity due to the haematic residue
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
post-surgery axial T1 without gadolinium showing early subacute haematic residue inside the surgical cavity
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
© Department of Radiology, Americas Medical City, Americas Serviços Médicos, Brazil, 2022
