Presentation
A 18-year-old girl presented with headache and left-sided weakness. No history of seizure, trauma, or loss of consciousness.
Patient Data
There is a cortical-based non-enhancing nodule measuring 2.9x2.0x1.5 cm in the right parietal region appearing isointense on T1 and mixed-signal on T2 weighted image with hypointense areas within (flow voids/calcification). The nodule is located eccentrically surrounded by a large well-defined area (hyperintense on T1W and mixed hyper-/hypointense on T2W) with hypointense rim on SWI s/o subacute hemorrhage. There is significant perilesional edema with mass effect as evidence by the effacement of the ipsilateral cortical sulci and lateral ventricle.
MACROSCOPIC DESCRIPTION:
Multiple, grayish-white to grayish-brown, soft friable tissue fragment altogether measures 3.0x2.5 cms with hematoma of different stages with localized capsule and vascular nodule. (not shown)
MICROSCOPIC DESCRIPTION:
Section studies show glial tissue fragments with multiple thin walled blood vessels lacking muscular coat along with the areas of necrosis, fibrosis, hemorrhage (different stage of evolution), calcifications and inflammatory infiltrate. There are multiple hemosiderin-laden macrophages.
DIAGNOSIS: Benign vascular lesion (Cavernoma)
Case Discussion
Sometimes the Aunt Minnies of pathology is arduous to unveil when they change in appearance after complication.
Being meticulous about the content of the lesion is invaluable to narrow the diagnosis, as in this case of cavernoma which could be misinterpreted as cortical-based cystic mass with non-enhancing nodule.
Cavernoma is an intracranial vascular malformation with repeated intralesional hemorrhages into thin walled angiogenically immature blood filled locules called caverns. These are well marginated lesion that do not contain normal brain parenchymas and is surrounded by hemosiderin rim. They occur anywhere in the CNS and appear as non-enhancing discrete reticular or ‘popcorn ball’ lesions with mixed-signal core surrounded by complete hemosiderin rim on T2WI that boom on T2*.
Differential diagnosis:
Ganglioglioma: cortical-based cyst with non-enhancing mural nodule but no gross hemorrhage or frank necrosis.
Pilocytic astrocytoma: supratentorial and hemorrhage uncommon, cystic with strong enhancing mural nodule and calcification, among children in the posterior fossa (60%).
Pleomorphic xanthoastrocytoma: supratentorial well-delineated peripheral cortically based mass in children and young adults with cyst and enhancing nodule and calcification (40%). Despite its fat content, they appear hypointense on T1. Hemorrhage is rare.
Oligodendroglioma: rare in children (1-5%), slow-growing peripheral cortically based non-enhancing nodule with calcification and cystic degeneration. Gross hemorrhage and peritumoral edema are less common if present and indicate malignant degeneration.
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