Case Report Australasian Radiology (2005) 49, 144–150 Case Report Pyogenic abscess complicating a resolving cerebral haematoma secondary to a cavernous haemangioma: Computed tomography and magnetic resonance imaging findings AD Borsaru and P Naidoo Department of Diagnostic Imaging, Monash Medical Centre, Melbourne, Victoria, Australia SUMMARY A case is discussed of a brain abscess complicating an intracerebral haemorrhage occurring in a cavernous haemangioma. A young child presented with focal seizures as a result of a large intracerebral haemorrhage, occurring in a cavernous haemangioma. The only clue to the underlying vascular malformation was the presence of an associated developmental venous anomaly. The case was complicated by the development of a brain abscess at the site of the intracranial haematoma. The CT and MRI findings are discussed. Key words: brain abscess; cavernous haemangioma; computed tomography; developmental venous anomaly; magnetic resonance. INTRODUCTION trauma, surgery, or occur in prolonged septic states such as Intracerebral cavernous haemangiomas are defined as well- bacterial endocarditis or osteomyelitis. 2 circumscribed vascular malformations consisting of clusters Metastatic brain abscesses associated with transient of endothelial-lined sinusoidal spaces without any normal inter- bacteraemia have only rarely been described, but they can vening brain tissue. Histologically, there is a great overlap with occur and should be considered in the differential diagnosis of other vascular malformations, especially capillary telangiecta- possible complications of intracerebral haemorrhage. This is sia, both representing two extreme forms of cerebral capillary a case of a pyogenic abscess complicating an intracerebral 1 malformations. An association with developmental venous haematoma secondary to a cavernous haemangioma. anomalies (DVA), especially venous angiomas, has been described.1–6 CASE REPORT Haemorrhage is a common complication of cavernous An 18-month-old girl, previously well, presented with a pro- haemangioma. In 21% of cases, haemorrhage is the first longed left focal seizure. Examination revealed an irritable presentation of a cavernous haemangioma. It is also now rec- child with mild left-sided weakness, increased tonus, and ognized that intracerebral haemorrhages in patients with DVA hyperreflexia, and an upgoing plantar reflex on the left. A are most often secondary to the coexisting cavernous haeman- contrast-enhanced CT was performed. The CT showed a 2-cm gioma. The risk of haemorrhage in a cavernous haemangioma hyperdense nonenhancing lesion in the right frontal lobe with is estimated at 13% per patient per year, or about 0.5–2% per mild surrounding oedema, felt to be consistent with an acute lesion per year. A rare complication of vascular malformations intracerebral haemorrhage (Fig. 1a). Prominent contrast- is intracerebral abscess. These are generally associated with enhancing vessels were identified close to the haematoma and AD Borsaru MB BS; P Naidoo FRANZCR. Correspondence: Dr P Naidoo, Department of Diagnostic Imaging, Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168, Australia. Email: p.naidoo@southernhealth.org.au Submitted 1 November 2002; accepted 5 March 2003. ABSCESS IN A CAVERNOUS HAEMANGIOMA HAEMORRHAGE 145 Fig. 1. (a) Axial non-contrast CT scan shows a 2-cm hyperdensity in the right frontal lobe with mild surrounding vasogenic oedema. (b–d) Postcontrast CT scans at the same level and below show enhancing vessels draining to a single large vein anteriorly. the diagnosis of a small arteriovenous malformation was to be that of a haemorrhage secondary to a cavernous entertained (Fig. 1b–d). A MRI performed 2 days later con- haemangioma. firmed the presence of a subacute haematoma in the right The patient was treated conservatively, started on anti- frontal lobe, with an enhancing structure nearby, typical of convulsant medication and discharged home a few days later. a DVA (Fig. 2). Given this finding, the diagnosis was revised She remained generally well for the next few weeks with the 146 AD BORSARU AND P NAIDOO Fig. 2. (a) Axial fast spin echo (FSE) T1-weighted image and (b) axial fluid attenuated inversion recovery image show an early subacute right frontal lobe haematoma with marginal vasogenic oedema. (c) Axial FSE T2-weighted image at a slightly lower level shows a prominent flow void directed to a large draining cortical vein. (d) Axial gadolinium-enhanced FSE T1-weighted image at the level of the lesion shows an enhancing leash of vessels draining to a large vein situated inferior to the haematoma. ABSCESS IN A CAVERNOUS HAEMANGIOMA HAEMORRHAGE 147 Fig. 2. (e) Axial and (f–h) coronal gadolinium-enhanced FSE T1-weighted images at the level of the lesion show an enhancing leash of vessels draining to a large vein situated inferior to the haematoma. 148 AD BORSARU AND P NAIDOO Fig. 3. (a,b) Pre-contrast-enhanced and (c,d) post-contrast-enhanced CT show the presence of a large multiloculated rim-enhancing lesion consistent with a large cerebral haematoma. Residual subacute haemorrhage in one of the cavities, marked surrounding oedema and evidence of impending subfalcine and transtentorial herniation are also present. exception of short episode of gastroenteritis that was compli- origin, which was associated with increased irritability, poor cated by a Staphylococcus aureus bacteraemia. appetite and drowsiness but no evidence of focal neurological Over the next few months, the patient presented three times signs. Septic screens performed at each presentation were to the emergency department with a febrile illness of unknown negative and no clear pathology was detected until her fourth ABSCESS IN A CAVERNOUS HAEMANGIOMA HAEMORRHAGE 149 presentation where she developed a sudden and severe neuro- lesions with minimal (if any) surrounding oedema or mass logical deterioration consisting of prolonged generalized tonic effect. Calcification can also be present. Contrast enhancement clonic seizures. is variable.9 The emergency contrast-enhanced CT done at this stage The MRI appearance is somewhat more characteristic. showed a 7 × 7 × 8 cm multiloculated rim-enhancing lesion in A definite diagnosis can be made if a strongly contrast- the right frontal lobe, with evidence of subacute haemorrhage enhancing, well-defined, popcorn-like lesion can be identified. and marked surrounding vasogenic oedema (Fig. 3). There The lesion has usually a heterogeneous core of mixed signal as was significant mass effect associated with this lesion, with a result of haemorrhagic residue in different stages of evolution subfalcine herniation, contralateral ventricular enlargement and and a hypointense peripheral rim of haemosiderin. The low- impending transtentorial herniation. An emergency frontal signal rim of haemosiderin is typical for the cavernous haeman- craniotomy and excision of the mass lesion was performed. gioma and is responsive for the bloom phenomenon present The pathology result confirmed the presence of a multilocu- on gradient echo T2-weighted imaging. Magnetic resonance lated cerebral abscess containing large quantities of S. aureus. angiography is invariably negative, but very occasionally a The presence of groups of ectatic blood vessels confirmed the blush can be present in the late capillary phase on catheter presence of a pre-existent cavernous haemangioma. angiography.10 The child was treated with high-dose antibiotics for 6 weeks The presence of acute haemorrhage may often obscure and made a complete recovery. All focal neurological signs the typical features of the cavernous haemangioma. 9 Persistent had completely resolved by the time of her 4-week outpatient abnormalities on further subsequent scans after resolution of review. the haemorrhage or the presence of an associated DVA may be the only clues to the presence of an underlying cavernous DISCUSSION haemangioma. Although haemorrhage alone is a common Cavernous haemangiomas are the second most common complication of vascular malformations, cerebral abscess com- intracerebral vascular malformation after arteriovenous mal- plicating a non-traumatic haematoma is rare. Abscesses are 1 formations. They have a suggested incidence of between 0.02 commonly the result of direct seeding (traumatic or iatrogenic), and 0.13% in large autopsy series, but would appear to be even or local extension from an adjacent infective site. Haematoge- more frequent according to newer studies (up to 0.4% reported nous spread is rare and usually associated with prolonged in more recent MRI series7,8). episodes of subacute infections such as endocarditis or osteo- They are classically described as well-defined, multilocu- myelitis, but a few cases associated with short episodes of lated, berry-like lesions containing blood in various stages of bacteraemia have been described. The most commonly found evolution. Histologically, they are clusters of endothelial-lined pathogens are streptococci and staphylococci. A 1993 study sinusoidal spaces without any intervening brain tissue. The suggested that in the case of staphylococcal bacteraemia, majority are supratentorial, usually situated at the grey–white metastatic foci occur in up to 27% of cases. 11 It is thought that matter junction, or in the basal ganglia. Infratentorial lesions haematomas may represent areas of impaired immunity and are occur in 20% of cases. Multiple lesions occur in 20–50% of therefore favourable sites of infection during bacteraemia. 12,13 cases.2 Unfortunately, cerebral abscesses can be very difficult to They commonly present between 20 and 40 years of diagnose clinically. As in previous cases described in the litera- age with seizures, headaches, progressive neurological deficit ture, the clinical presentation in our case was non-specific and or haemorrhage. Occult, recurrent haemorrhages are common virtually no neurological signs pointing towards an intracerebral and characteristic for cavernous haemangiomas. Large, source of infection manifested until very late in the course of the clinically significant haemorrhage is less common, with an esti- illness. Neurological deterioration was late, severe and very mated risk of 0.5–2.0% per lesion per annum. 2 An association sudden. The definitive diagnosis was made postoperatively by with DVAs is now well recognized and possibly implicated as a histopathology.14–17 risk factor for haemorrhage.1–6 Reciprocally, it is now well recognized that haemorrhagic complications in patients with DVAs CONCLUSION are usually secondary to the coexistent cavernous haemangi- Recurrent small intracerebral haemorrhages are well-recog- oma. In our case, it was the presence of a typical DVA that nized complications of cavernous haemangiomas, but when suggested the presence of a cavernous haemangioma as a large haemorrhages occur they can often obscure the presence cause for the initial cerebral haemorrhage. of an underlying cavernous haemangioma. The presented case Computed tomography is generally considered a good is an example of haemorrhage complicating and obscuring a modality for diagnosing cavernous haemangiomas, although cavernous haemangioma, where the initial clue to the under- the features can be sometimes non-specific. 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