A 31-year-old gentleman presented with sudden onset headache and seizures requiring intubation. CT brain demonstrated a thrombosed developmental venous anomaly (DVA) and occipital infarction; intravenous heparin was commenced. Shortly afterwards a fixed dilated right pupil was noted. Repeat neuroimaging showed extensive intracerebral haemorrhage with mass effect, neccesitating decompressive craniectomy. CT venogram showed thrombus within the collecting vein of a large right parietal DVA, with patent dural venous sinuses (Abstract 008 figure 1 below). The patient did well with neurorehabilitation and on discharge had mild left-sided hemiparesis and left inferior quadrantinopia. DVAs are abnormal clusters of small vessels draining into a collecting vein creating a ‘caput medusae’ appearance on neuroimaging. This replaces normal brain venous architecture; removal can cause catastrophic venous infarction. DVAs are the commonest cerebral vascular malformation (incidence 2.6%). DVAs are usually incidental and benign, although as around 40% are associated with cavernous malformations a search for other vascular abnormalities (or a wider neurocutaneous disorder) is essential. DVA thrombosis is rare; case reports suggest that this should be managed as per venous sinus thrombosis. If surgical decompression is undertaken, the collecting vein must be preserved to avoid compromising venous drainage. The prognosis is usually good with complete recovery or mild neurological deficit.
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