A 21-year-old man, previously fit and well, experienced facial injuries in an alleged assault one evening, having consumed about eight units of alcohol previously. About 45 min later the patient had a tonic-clonic seizure at a bus stop, witnessed by his girlfriend. The patient then walked home. The following day the patient had a headache and noticed weakness of his right leg. That evening the patient attended the A&E department.
The initial neurological examination was unremarkable and his Glasgow coma scale score was 15/15. The patient was referred to the maxillofacial service for management of facial injuries.
Facial fractures were excluded and no maxillofacial surgical intervention was required. However, the examining surgeon noted spastic weakness of the right leg, with hyper-reflexia and a positive Babinski sign. There were no sensory abnormalities. The remainder of the neurological examination was normal.
An uncontrasted CT brain () revealed a solitary lesion in the left presylvian region. A subsequent brain MRI () showed the lesion to be a cavernous haemangioma (cavernoma) measuring approximately 10 mm in diameter, with evidence of previous haemorrhage. There was no restricted diffusion on diffusion weighted imaging, suggesting that the haemorrhage was confined. No treatment was required.
Uncontrasted CT brain scan. There is a solitary, well defined hyperintense 0.6 cm lesion to the left of the midline at the vertex, in the leg area of the primary motor cortex.
Figure 2 MRI brain. Left panel, T2-weighted image. The ‘popcorn’ lesion (arrow) measures 10 mm. The heterogeneity is caused by the dark rim of haemosiderin, suggesting previous haemorrhage, but there is no restricted diffusion on diffusion-weighted (more ...)