Recurrent thalamic haemorrhage attributed to a cerebellar arteriovenous malformation.

摘要

A 55-year-old man presented with acute-onset right-sided hemiparesis. Cranial CT on admission revealed an intracranial haemorrhage in the left thalamus and parts of the internal capsule (Figure 1 A). The patient had no history of arterial hypertension, bleeding diathesis or tobacco or alcohol abuse, and did not receive any anti-platelet agent or anticoagulant. Four weeks later cranial magnetic resonance imaging (MRI) and MR angiography (0.5T, gadolinium-enhanced Tl-SE, T2-TSE, FLAIR, 3D-dynamic contrast-enhanced angiography) showed normal blood resorption, with no signs of a vascular disorder or neoplasm. The patient was discharged to a rehabilitation centre. Six months later he was re-admitted after the acute onset of headache followed by left-sided hemiparesis and dysarthria. The CT scan showed an intracranial haemorrhage in the right thalamus, with ventricular rupture (Figure IB). Following six months of rehabilitation, a second MRI scan (1.5T, gadolinium-enhanced Tl-SE, T2-TSE, T2-FFE, FLAIR) failed again to demonstrate a cause for the bilateral thalamic lesions. Digital subtraction angiography (DSA), however, revealed a small arteriovenous malformation (AVM) located superficially in the lower third of the superior vermis (Figures 2A and B). Arterial blood supply was derived from vermian branches of the left posterior inferior cerebellar artery. The venous phase showed AVM drainage to the transverse sinus via the superior vermian veins to the basal vein of Rosenthal, draining to the vein of Galen and the straight sinus (Figure 2C and D). Two years following radiosurgery, DSA confirmed complete occlusion of the AVM and normal venous drainage pattern. On long-term follow-up more than six years after treatment, the patient's neurological examination revealed a mild spastic tetraparesis and moderate neuropsychological deficits. There were no recurrent episodes of bleeding reported.