Neuro_MR_Brain: 74 F, history of multiple ICH.

MRI BRAIN WITH AND WITHOUT CONTRAST:

 

CLINICAL HISTORY: 74 years of age, Female, presenting with left extremity weakness surgically found to have right frontal intraparenchymal hematoma. Evaluate for AVM or underlying tumor.

 

FINDINGS:

 

Parenchyma: Interval increase in size of large, acute right frontal intraparenchymal hematoma now measuring 5.9 x 4.5 x 4.5 cm which demonstrates fluid-fluid level and associated surrounding edema, previously measuring 6.0 x 2.3 x 2.3 cm. There is effacement of the adjacent sulci, brain parenchyma and frontal horn of the right 

lateral ventricle. Linear focus of enhancement within the anterior portion of the hematoma, at the previously seen position of 

enhancing vessel from prior CTA, is less conspicuous than prior but remains present. There is scattered subarachnoid hemorrhage in the frontal lobes bilaterally and in the right central sulcus.

 

There is expected perfusion deficit in the region of the hematoma. No evidence of acute infarction, mass or abnormal enhancement. No abnormal tangle of vessels or increased signal on the ASL images.

 

 

Nonspecific, scattered periventricular and subcortical T2/FLAIR hyperintensities compatible with chronic small vessel ischemic disease.

 

Ventricles and extra-axial spaces: No ventriculomegaly. There is no 

intraventricular hemorrhage. There is 3 mm leftward subfalcine herniation.

 

Orbits: Bilateral lens replacements.

 

Visualized paranasal sinuses: Clear.

 

Mastoid air cells: Clear.

 

Bones: Normal.

 

INTRACRANIAL ANGIOGRAM:

 

Anterior circulation: No flow-limiting stenosis or aneurysm.

 

Posterior circulation: No flow-limiting stenosis or aneurysm.

 

Dural venous sinuses: Patent.

 

Additional comment: Decreased conspicuity of previously identified dilated vessel coursing through the anterior aspect of the intraparenchymal hematoma, which may be secondary to hematoma enlargement.

 

Additional comment: None.

  

IMPRESSION:

 

1.  Interval increase in size of large, acute right frontal intraparenchymal hematoma with fluid-fluid level and associated local mass effect and mild leftward subfalcine herniation. 

 

2.  Diagnostic considerations for the cause of this intraparenchymal hemorrhage remain broad and include the following. The previously seen tubular hyperdense structure may represent a vascular structure, which may suggest an occult dural arteriovenous fistula or arteriovenous malformation, although there is no evidence of these 

pathologies on this MRI. The presence of bilateral sulcal hemosiderin staining is consistent with cerebral amyloid angiopathy, which should be strongly considered in a patient of this age with a lobar intraparenchymal hemorrhage. Lastly, an underlying tumor may also cause this type of hemorrhage, and a follow up MRI with contrast after the hematoma resolves should be performed to evaluate for this possibility.

 

3.  No flow-limiting stenosis, aneurysm or occlusion in the intracranial circulation.

 

RECOMMENDATIONS:

 

1.  Digital subtraction angiogram to evaluate for an occult dAVF or AVM.

 

2.  Follow up MRI with contrast after the hematoma resolves to evaluate for an underlying tumor.