PMC3551500_01
Axial CT image without intravenous contrast shows a nodular, high attenuation, intraaxial hematoma in the left thalamus and left cerebral peduncle with localized mass effect
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F1
A computed tomography (CT) examination of his head revealed a left thalamic/midbrain "overt" hemorrhage with hydrocephalus [Figure 1].
(a) Axial T2-weighted MR image shows the lesion to have a slightly irregular rim of low signal surrounding a central zone with mixed high and low signal. A small poorly defined zone of high signal consistent with edema is seen in the adjacent brain tissue, (b) Coronal gradient echo MR image at the same time as a shows a low signal at the site of the hematoma, (c) Axial T2-weighted image 2 months later shows evolutional changes of the intraaxial hematoma with low signal hemosiderin anterior to a high signal cystic-appearing zone. There is decreased mass effect associated with the lesion
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F2
CM [Figures 2a and b]. Conventional cerebral angiography revealed no abnormal findings. Unfortunately, despite improvement on MRI [Figure 2c], he has persistent right-sided hyperthesias, dysesthesias, and allodynia consistent with thalamic pain syndrome, also known as Dejerine - Roussy syndrome.
(a) Axial CT image without intravenous contrast at the same time as Figure 2c shows a small zone of low attenuation consistent with resolved hematoma and remaining cystic-appearing zone, (b) Axial CT image without intravenous contrast one year after the initial hemorrhage shows a small zone with slightly high attenuation consistent with localized rehemorrhage located anterior to the cystic-appearing zone
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F3
Given his symptoms and CT showing a new slight hyperdensity in the area of his prior bleed the authors suspected he had another small bleed or "ooze" from his suspected cavernoma [Figure 3a and b].