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Widespread cerebral cavernous haemangiomata found after 24 years of intermittent symptoms
  1. M R TURNER
  1. Academic Neurosciences Centre
  2. Institute of Psychiatry
  3. De Crespigny Park
  4. London, SE5 8AF, UK
  5. Hurstwood Park Neurological Centre
  6. Haywards Heath
  7. West Sussex, RH16 4EX, UK
  1. Dr M R Turner m.turner{at}iop.kcl.ac.uk
  1. W N MACLEOD
  1. Academic Neurosciences Centre
  2. Institute of Psychiatry
  3. De Crespigny Park
  4. London, SE5 8AF, UK
  5. Hurstwood Park Neurological Centre
  6. Haywards Heath
  7. West Sussex, RH16 4EX, UK
  1. Dr M R Turner m.turner{at}iop.kcl.ac.uk

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The diagnosis of many types of cerebral pathology has been greatly facilitated by the development of MRI. We report on a 65 year old man who presented to his local casualty department with diplopia, right sided sensory disturbance, and unsteadiness. Questioning disclosed a 24 year history of intermittent diplopia of both eyes for up to 2 months at a time but always resolving completely. The patient had attributed these symptoms to a minor head injury at the age of 41. One year before this presentation he developed a left facial nerve palsy associated with recurrent diplopia. Although the facial weakness resolved spontaneously within several weeks, his diplopia persisted. He had been fitted with corrective prisms after opthalmological review. No cerebral imaging was performed.

At this presentation the patient showed profound oscillopsia and was unable to stand without support. Further examination disclosed bilateral abducens nerve palsy with vertical nystagmus. Pinprick sensation was reduced in the ophthalmic branch of the right trigeminal nerve, and there was a left lower motor neuron-type facial nerve weakness. Evidence of right sensorineural deafness was also present. There was mild right hemiplegia and hemisensory disturbance in addition. Limb reflexes were brisk on the right with a right sided extensor plantar response.

Brain CT (figure A) showed small foci of increased attenuation throughout both hemispheres and the cerebellum which showed mild enhancement with intravenous contrast. He was initially investigated for evidence of an extracerebral primary neoplasm—none was found. T1 weighted MRI (figure B) was equally unhelpful in disclosing the true extent of his pathology, which can be clearly seen on the T2 weighted images (figure C). The numerous haemorrhagic lesions of varying ages, as suggested by the presence of lesions with darker ring patterns representing haemosiderin deposits, formed a striking Swiss cheese-like appearance.

This appearance is characteristic of cerebral cavernous haemangiomata, whose natural history of intermittent haemorrhage is well described. Seizure is the most common presenting symptom, and most lesions are solitary, multiple cavernomas tending to be more common in familial clusterings (our patient did not report any such family history).

This also serves as an example of the variable sensitivity of MRI to certain pathology depending on the image acquisition parameters.

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