Mixed cerebral vascular malformations

Case contribution: Dr Radhiana Hassan


  • A 23 year old male with no known medical illness, presented with complaint of dizziness for 6 days, right eye dropping for 3 days and vomiting for 2 days.
  • Otherwise, no fitting episode, no 1 side body weakness, no blurry of vision or double vision and no history of fall or trauma.
  • CT Brain done noted pontine bleed involving left cerebral peduncle with mass effect and he was admitted for observation.
  • Subsequently he was under clinic follow up.
  • Upon our review in clinic, patient well, no sign and symptom of increase intracranial pressure.
  • GCS E4V5M6, pupils 3/3 reactive. Vital signs are stable
  • CNS: power 5/5 bilaterally with normotonia and normoreflexia
  • Cranial nerve: no opthalmoplegia

MRI findings:

  • A lobulated lesion in the left side of pons posteriorly which shows charateristic ‘popcorn’ appearance (yellow arrows).
  • Variable T1 and T2 hyperintense with T2-hypointense rim is seen.
  • Blooming also noted on Hemo sequence.
  • A central area of restricted diffusion in keeping with late subacute bleed blood product.
  • No enhancement post contrast, however a prominent veins are seen draining to ependymal surface of fourth ventricle (red arrows).
  • Surrounding pons shows normal signal intensity
  • No hydrocephalus. No abnormal leptomeningeal enhancement.

Diagnosis: Mixed vascular malformations (cavernoma and developmental venous anomaly)


  • A mixed vascular malformation is a relatively common congenital cerebral vascular malformation
  • Most frequently composed of a developmental venous anomaly (DVA) and a cavernous malformation
  • As DVA seldom bleed, the risk of a mixed vascular malformation is determined by the other component
  • DVA is also known as cerebral venous angioma = a congenital malformation of veins which drain normal brain. It is characterised by caput medusae sign of veins draining into a single larger containing vein which in turn either drains into a dural sinus or a deep ependymal vein. Usually an incidental finding seen in about 9% on contrast-enhanced MRI brain.
  • Cavernous haemangiomas=cavernous malformation=cavernomas are common cerebral vascular malformations, third most common after DVA and capillary telangiectasia.



Author: radhianahassan