How can hemorrhage on a cavernous hemangioma be confirmed?

Confirmation of Hemorrhage on Cavernous Hemangioma

MRI is the imaging study of choice for confirming hemorrhage on cavernous hemangioma, with specific sequences showing evidence of recent blood products and comparison to prior imaging being essential for accurate diagnosis. 1

Diagnostic Approach

MRI - Gold Standard

• T1 and T2-weighted sequences: Show various stages of hemorrhage
• Gradient Echo (GRE) or Susceptibility Weighted Imaging (SWI): Most sensitive for detecting hemorrhage
  • Shows "blooming effect" due to hemosiderin deposits
  • May reveal additional cavernomas not visible on standard spin-echo imaging 1
• FLAIR sequences: Should be performed within 2 weeks of clinical event to demonstrate extracellular methemoglobin (high signal on T1 and T2-weighted sequences) 1

CT Imaging

• Should be performed ideally within 1 week of symptom onset
• Shows high density consistent with acute hemorrhage
• To confirm hemorrhage, the high density should be:
  • New compared to previous CT imaging
  • Have Hounsfield units consistent with acute blood
  • Resolve on follow-up CT performed at least 2 weeks later 1

Criteria for Confirming Hemorrhage

A confirmed hemorrhage from a cavernous hemangioma requires BOTH:

1. Clinical symptoms: Acute or subacute onset of:

   • Headache
   • Epileptic seizure
   • Impaired consciousness
   • New/worsened focal neurological deficit referable to the anatomic location of the cavernous malformation 1

2. Radiological evidence: One of the following:

   • MRI signal changes indicative of recent hemorrhage that are new compared to previous MRIs
   • Signal changes that resolve on follow-up MRI performed 2 months later
   • CT showing new high density with Hounsfield units consistent with blood
   • Surgical, pathological, or CSF evidence of recent hemorrhage 1

Important Distinctions

• Not considered hemorrhage:

  • Mere presence of hemosiderin halo
  • Increase in cavernoma diameter without other evidence of recent hemorrhage 1
  • Stable appearance of a cavernoma on repeated imaging

• Follow-up imaging: Essential for confirming hemorrhage, as recent hemorrhage may completely or partially obscure the cavernoma itself on initial MRI 1

Special Considerations

• In children, cavernomas account for 17% of hemorrhagic strokes, with 62% presenting with hemorrhage 1
• Trauma may be a risk factor for acute hemorrhage in patients with cavernous malformations, particularly those with associated developmental venous anomalies (DVAs) 2
• Cavernomas are typically angiographically occult (not visible on conventional angiography) 1

Pitfalls to Avoid

• Relying solely on the presence of a hemosiderin ring without evidence of recent hemorrhage
• Misinterpreting an increase in cavernoma diameter as evidence of hemorrhage without appropriate signal changes
• Delayed imaging that may miss the acute phase of hemorrhage
• Failing to compare with prior imaging when available

By following these guidelines, clinicians can accurately confirm hemorrhage from cavernous hemangiomas and make appropriate management decisions based on reliable diagnostic information.