PMC9238210_01
A 48-year-old female showing a large ICH with thrombosis within a developmental venous anomaly.. A. Axial non-contrast brain CT scan obtained on admission. Note the extensive ICH (black arrows) in the left occipitotemporal lobe. A segmental low-attenuation area (empty arrows) mimics left posterior cerebral artery infarction. The multifocal linear hyperdense areas (right image, arrowheads) were confirmed as thrombosed collector veins on MR angiography (MRI; black arrowheads in D).. B-D. Axial T2-weighted images (B), T2 fast-field echo image (C), and post-contrast images (D) on admission. Marked swelling and ICHs (black arrows) are seen in the left occipital lobe, correlating with the CT findings. Note the signal-void vascular structures of the medullary veins, intermediate collector veins, and a single confluent collector vein (empty arrowheads in B, D) traversing the swollen left occipital lobe and multifocal thrombosis (black arrowheads) in the collector veins as filling defects, causing occlusion and partial obstruction. The findings also show left lingual gyrus herniation (white arrows), leading to the collapse of the vein of Galen (asterisks in D).. E. Axial post-contrast MR images obtained 3 weeks after hospitalization demonstrates complete loss of venous thrombosis, reappearance of the collector veins (black arrowhead, in comparison with the left image of D), and increased size of the DVA outlet, while still showing residual stenosis at the outlet of the confluent collector vein (empty arrowhead, in comparison with the right image of D). Note the sequential improvement of the ICH (black arrow, in comparison with C) and lingual gyrus herniation, resulting in recovery of the vein of Galen (asterisk).. F. Digital subtraction angiography scans in the anteroposterior (left image) and lateral (right image) views obtained 2 weeks after the craniotomy show delayed appearance of a couple of intermediate collecting veins (black arrowheads) and a fusiform confluent collector vein (black arrows) with a remnant filling defect. The intrinsic stenosis of the confluent collector vein outlet and superimposed collapse (empty arrows, corresponding MR image not shown here) by lingual gyrus herniation are visible. This DVA seems to drain venous flow to the vein of Galen. Note that the caudal end of the contrast bolus is passing the sigmoid sinus normally, suggesting a delayed venous phase.. DVA = developmental venous anomaly, ICH = intracerebral hemorrhage
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CT revealed an approximately 6-cm ICH at an unusual site adjacent to diffuse low attenuation portions in the left occipital lobe, mimicking a left posterior cerebellar artery territory infarction (Fig. 1A). Subsequent MRI revealed different stages of hematomas in the left occipital lobe with perilesional edema, which corresponded with the CT's low attenuation change (Fig. 1B-D). DVA and partial filling defect (Fig. 1F). DVA was unveiled to have a peculiar architecture with several intermediate collector veins and a single confluent collector vein, as observed on MRI. A week later, MRI showed complete disappearance of the DVA thrombus, reappearance of the intermediate collector veins, and restoration of the outlet size of the confluent collector vein, which seemed to have an underlying segmental narrowing in the distal portion (Fig. 1E).