A 45-year-old man is brought to the emergency department due to new-onset seizure. His family witnessed an episode of blank staring followed by a generalized tonic-clonic convulsion with tongue biting and urinary incontinence. The patient has a past medical history of seasonal asthma and takes no prescription medications. He does not use alcohol or illicit drugs. Vital signs and neurologic examination are normal. Noncontrast head CT and brain MRI are consistent with a diagnosis of cavernous hemangioma. This patient is at greatest risk of developing which of the following complications?

Question

A 45-year-old man is brought to the emergency department due to new-onset seizure.  His family witnessed an episode of blank staring followed by a generalized tonic-clonic convulsion with tongue biting and urinary incontinence.  The patient has a past medical history of seasonal asthma and takes no prescription medications.  He does not use alcohol or illicit drugs.  Vital signs and neurologic examination are normal.  Noncontrast head CT and brain MRI are consistent with a diagnosis of cavernous hemangioma.  This patient is at greatest risk of developing which of the following complications?

Quizplus · Accepted Answer

Cavernous hemangiomas are vascular malformations (sporadic or familial) that most commonly occur within the brain parenchyma above the cerebellar tentorium. They consist of clusters of dilated, thin-walled capillaries with little or no intervening nervous tissue. Patients with cavernous hemangiomas often have seizures and may develop progressive neurologic deficits due to mass effect with interruption of the cerebral microcirculation. These lesions also have a tendency to bleed, which can contribute to neurologic symptoms (eg, due to subcortical/cortical tissue irritation) and appear as an irregular hyperdense/bright mass on head CT. (Choice A) Epidural hematomas usually result from rupture of the middle meningeal artery in the setting of head trauma (eg, skull fracture at the pterion). (Choice C) Cavernous hemangiomas increase the risk of hemorrhagic as opposed to ischemic stroke. Ischemic stroke typically occurs in older individuals with cardiovascular risk factors (eg, diabetes mellitus, hypertension, hyperlipidemia, smoking history) due to vessel occlusion caused by thrombosis or cardioembolism. (Choice D) Migraine headache is a primary headache disorder commonly seen in young women. Although migraine headaches can have a secondary cause, they have not been linked specifically to cavernous hemangiomas. (Choice E) Subarachnoid hemorrhage is usually caused by ruptured saccular aneurysms and is an infrequent consequence of bleeding vascular malformations. (Choice F) Subdural hematoma results from rupture of the bridging veins in the subdural space (between the dura and arachnoid membranes) and is most commonly caused by head trauma. Vascular malformations do not typically result in subdural hematomas. Educational objective: Cavernous hemangiomas are vascular malformations that occur most commonly within the brain parenchyma; they carry an increased risk of intracerebral hemorrhage and seizure. __________ References: CNS cavernous haemangioma: "popcorn" in the brain and spinal cord. (http://www.ncbi.nlm.nih.gov/pubmed/22137800) Management of cerebral cavernous malformations: from diagnosis to treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25629087)

A 45-Year-Old Man Is Brought to the Emergency Department Due