J Korean Neurosurg Soc.  2012 Jan;51(1):37-39. 10.3340/jkns.2012.51.1.37.

Massive Intracerebral Hemorrhage Caused by a Cavernous Malformation

• Kim YS
• Lee JI
• Choi CH
• Ko JK

• KMID: 2190466
• DOI: http://doi.org/10.3340/jkns.2012.51.1.37

Abstract

We present a rare case of massive intracerebral hemorrhage resulting from a small, superficially-located supratentorial cavernous malformation, or cavernoma. These lesions rarely lead to massive, life-threatening intracerebral hemorrhages. A 17-year-old female presented with a 3-week history of declining mental status. Brain computed tomography and magnetic resonance imaging revealed a sizable intracranial hemorrhage, within the right occipital region, associated with a small nodule at the hematoma's posterior margin. An emergency operation removed the entire hematoma and nodule. Histological examination of the nodule was compatible with a diagnosis of cavernous malformation. The patient's post-operative course was uneventful.

Keyword

Cavernous malformation; Intracerebral hemorrhage

MeSH Terms

Adolescent
Brain
Caves
Cerebral Hemorrhage
Emergencies
Female
Hematoma
Humans
Intracranial Hemorrhages
Magnetic Resonance Imaging

Figure

• 

  Fig. 1 Pre-treatment computerized tomography and magnetic resonance images. Axial computerized tomography (A) shows a large, hemorrhagic lesion, with a hyperdense acutely hemorrhagic nodule, within the right occipital lobe, causing a midline shift and right lateral ventricle compression. Axial (B) and coronal (C) T1-weighted magnetic resonance images after gadolinium injection demonstrate that the lesion comprises an acutely hemorrhagic nodule (arrows), isointense with deoxyhemoglobin, and a larger subacute hematoma (asterisks), which is hyperintense due to methemoglobin. An axial T2-weighted image (D) reveals the classic "popcorn ball" configuration of a cavernous malformation (arrow) at the hematoma's posterior margin.

• 

  Fig. 2 Low power photomicrograph shows a lesion consisting of randomly distributed telangiectatic and congested vascular channels in a stroma, with little intervening neural tissue. The vessels are separated by fibrotic tissue containing hemosiderin deposition (H&E stain, ×100).

• 

  Fig. 3 Follow-up computerized tomography performed nine days after surgery, showing no space-occupying lesion and no pathological densities.

Reference

1. Acciarri N, Galassi E, Giulioni M, Pozzati E, Grasso V, Palandri G, et al. Cavernous malformations of the central nervous system in the pediatric age group. Pediatr Neurosurg. 2009; 45:81–104. PMID: 19307743.

2. Aiba T, Tanaka R, Koike T, Kameyama S, Takeda N, Komata T. Natural history of intracranial cavernous malformations. J Neurosurg. 1995; 83:56–59. PMID: 7782850.

3. Avci E, Oztürk A, Baba F, Karabağ H, Cakir A. Huge cavernoma with massive intracerebral hemorrhage in a child. Turk Neurosurg. 2007; 17:23–26. PMID: 17918674.

4. Chicani CF, Miller NR, Tamargo RJ. Giant cavernous malformation of the occipital lobe. J Neuroophthalmol. 2003; 23:151–153. PMID: 12782930.

5. Clatterbuck RE, Eberhart CG, Crain BJ, Rigamonti D. Ultrastructural and immunocytochemical evidence that an incompetent blood-brain barrier is related to the pathophysiology of cavernous malformations. J Neurol Neurosurg Psychiatry. 2001; 71:188–192. PMID: 11459890.

6. Consales A, Piatelli G, Ravegnani M, Pavanello M, Striano P, Zoli ML, et al. Treatment and outcome of children with cerebral cavernomas : a survey on 32 patients. Neurol Sci. 2010; 31:117–123. PMID: 19834644.

7. Corapçioğlu F, Akansel G, Gönüllü E, Yildiz K, Etuş V. Fatal giant pediatric intracranial cavernous angioma. Turk J Pediatr. 2006; 48:89–92. PMID: 16562795.

8. D'Angelo VA, De Bonis C, Amoroso R, Cali A, D'Agruma L, Guarnieri V, et al. Supratentorial cerebral cavernous malformations : clinical, surgical, and genetic involvement. Neurosurg Focus. 2006; 21:e9. PMID: 16859262.

9. 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. PMID: 1919691.

10. Kim DS, Park YG, Choi JU, Chung SS, Lee KC. An analysis of the natural history of cavernous malformations. Surg Neurol. 1997; 48:9–17. discussion 17-18. PMID: 9199678.

11. Kivelev J, Niemelä M, Kivisaari R, Dashti R, Laakso A, Hernesniemi J. Long-term outcome of patients with multiple cerebral cavernous malformations. Neurosurgery. 2009; 65:450–455. discussion 455. PMID: 19687688.

12. Kondziolka D, Lunsford LD, Kestle JR. The natural history of cerebral cavernous malformations. J Neurosurg. 1995; 83:820–824. PMID: 7472549.

13. Kupersmith MJ, Kalish H, Epstein F, Yu G, Berenstein A, Woo H, et al. Natural history of brainstem cavernous malformations. Neurosurgery. 2001; 48:47–53. discussion 53-54. PMID: 11152360.

14. Porter RW, Detwiler PW, Spetzler RF, Lawton MT, Baskin JJ, Derksen PT, et al. Cavernous malformations of the brainstem : experience with 100 patients. J Neurosurg. 1999; 90:50–58. PMID: 10413155.

15. Washington CW, McCoy KE, Zipfel GJ. Update on the natural history of cavernous malformations and factors predicting aggressive clinical presentation. Neurosurg Focus. 2010; 29:E7. PMID: 20809765.

16. Zabramski JM, Henn JS, Coons S. Pathology of cerebral vascular malformations. Neurosurg Clin N Am. 1999; 10:395–410. PMID: 10419567.

17. Zimmerman RS, Spetzler RF, Lee KS, Zabramski JM, Harqraves RW. Cavernous malformations of the brain stem. J Neurosurg. 1991; 75:32–39. PMID: 2045915.