Presentation
A 10-year history of headache treated with NSAIDs with no significant relief of pain. No apparent visual, sensory or motor disturbances. First CT scan performed.
Patient Data
On non-enhanced CT scan a subtle ill-defined area of hyperdensity is defined in the left parietal-occipital region, no mass effect is noted, no hemorrhage or calcifications. There is also a subtle linear hyperdensity in the ipsilateral parietal lobe. The rest is unremarkable.
On the contrast-enhanced phase we can appreciate an intense uptake of iodinated contrast in the same region, with multiple tubular images corresponding to a nidus of blood vessels. The lesion is compatible with an AVM. The arterial supply appears to be provided directly by a branch of the middle cerebral artery. Note the engorged principal vein that drains the nest and appears to drain to the internal cerebral veins ar/or the Vein of Galen (3.75 mm slices, thinner slices technically not available) through a tortuous vein.
The nidus measures 35 mm, it is located in an eloquent brain area (parietal-occipital) and has deep and superficial venous drainage. This lesion corresponds to a grade 4 Spetzler Martin classification.
Case Discussion
Cerebral AVMs are graded according to Spetzler Martin classification, which grades the size of the nidus, the location of the lesion in the brain (eloquent vs non-eloquent area) and venous drainage.
The patient had a CT scan for longstanding headache (<10 years), with no apparent neurological deficits at the time of the study. It was the first radiology study ever ordered to the patient. This incidental imaging finding demonstrates the importance of imaging in headache. CT is the modality of choice in emergency settings, however MRI scans can provide us much more detailed information in the majority of cases.
In this case with no apparent neurological deficit and with no bleeding, the question remains the same: should this lesion be treated or not? should we wait until it bleeds or performs treatment because of the headache? (the patient is not asymptomatic, she refers longstanding pain).
Treatment options include endovascular embolization and radiosurgery.
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