Cerebral Cavernous Malformation Associated With Left Middle Cerebral Artery (MCA) Aneurysm and Bilateral Internal Carotid Artery (ICA) Dissections

Abstract

Cerebral cavernous malformations (CCMs) are the second most common type of cerebral vascular lesions. They are often associated with other vascular lesions, typically developmental venous anomalies. CCMs are not known to be associated with cerebral aneurysms and there is a paucity of literature on this occurrence. We report the case of a patient who presented with a focal seizure from a symptomatic CCM with acute hemorrhage and was incidentally found to have a cerebral aneurysm and bilateral internal carotid artery (ICA) dissections secondary to fibromuscular dysplasia. The presence of a cerebral aneurysm has clinical implications as these patients will need closer monitoring.

Keywords: bilateral ica dissections; cerebral cavernous malformations; focal seizure without impairment of awareness; magnetic resonance imaging; middle cerebral artery aneurysm.

Figure 1. Initial CT imaging

(A) Axial CT brain without contrast demonstrating left frontoparietal intraparenchymal hemorrhage; (B) Axial CT angiogram of the head and neck with contrast demonstrating dissecting pseudoaneurysm of the right internal carotid artery. Arrows are used where appropriate to indicate pathology.

Figure 2. MRI of the brain obtained on 3 Tesla scanner

(A) Axial T1 showing subacute hemorrhage in the left frontotemporal lobe; (B) Axial T2 showing heterogenous “popcorn” lesion with perifocal hemorrhage in the left frontotemporal lobe; (C) Axial susceptible weighted imaging showing blooming artifact in the left frontotemporal lobe. This is consistent with early subacute hemorrhage. Arrows are used where appropriate to indicate pathology.

Figure 3. Diagnostic cerebral angiography

(A) Anterior-posterior view of fusiform aneurysm of the parietal branch of the left middle cerebral artery; (B) Lateral view of fusiform aneurysm of the parietal branch of the left middle cerebral artery. Aneurysm measures approximately 5.4 mm x 2.8 mm; (C) Irregular appearance of the left internal carotid artery can be seen indicative of fibromuscular dysplasia. There is a dissection of the distal cervical segment of the left internal carotid artery with an intimal flap; (D) Dissection of the distal cervical segment of the right internal carotid artery with an intimal flap. Arrows are used where appropriate to indicate pathology.