Dural-based Cavernous Malformation at the Temporal Convexity Presenting with Hemorrhage in a Pregnant Woman: Case Report

Abstract

Intracranial cavernous malformations (CMs) are benign vascular malformations that arise mostly within the brain parenchyma, but occasionally from the dura mater. Here, we report an extremely rare case of a 29-year-old pregnant woman presenting with hemorrhage in a dural-based CM at the temporal convexity. She presented with headache at 38 weeks of pregnancy. Imaging showed a hemorrhagic mass lesion in the left temporal lobe. Consciousness was clear, with no apparent neurological symptoms or headache. Her baby was delivered by emergency Caesarean section. Magnetic resonance (MR) imaging revealed an enhanced lesion around the hematoma and flow void appearances. Cerebral angiography confirmed the left middle meningeal artery feeding the lesion with apparent contrast medium pooling. Surgical removal of the lesion as a single block was performed. Histological examinations were consistent with CM. The lesion was located outside the brain and attached to the dura mater of the convexity, so the final diagnosis was dural-based CM. The patient was discharged home with her baby without any neurological deficits, and no recurrence has been seen for 2 years. Dural-based CM at the temporal convexity was detected, presenting as headache induced by hemorrhage during pregnancy. The relationship between bleeding of the lesion and pregnancy remains unclear, but female hormones and vascular growth factors during pregnancy can induce morphological changes and angiogenesis in CMs.

Extra-Axial Cavernous Angioma: A Case Report and Review of the Literature

“…These changes have been associated with female hormones (such as estrogen and progesterone) and vascular growth factors (such as vascular endothelial growth factor), which are released during pregnancy [ 26 , 27 ]. For example, in 2021, Ishii et al reported a case of dural-based CM at the temporal convexity in a pregnant patient that presented with hemorrhage [ 28 ]. On the other hand, there have also been reports of dural-based CMs without hemorrhage in pregnancy.…”

“…In addition, focal neurological deficits such as sensorimotor deficits, dysphasia, and cranial nerve impairments/palsies are observed in 35–50% of the patients when the motor cortex, speech region, basal ganglia, or brainstem are involved [ 1 , 9 , 17 , 35 ]. Dural-based CMs that are located outside of the middle fossa are rarely associated with intracranial hemorrhage [ 28 ]. However, there have been reports of subdural hematoma in dural-based CMs located at the dural convexity [ 36 , 37 ].…”

“…The treatment of choice for symptomatic dural-based cavernoma is surgery. Adjuvant therapy would be unnecessary following total surgical removal [ 1 , 28 ]. Uzunoglu et al recommended considering surgery for extra-axial lesions, especially when the radiological findings are suggestive of a meningioma.…”

“…Therefore, histopathological confirmation of dural hemangioma would be possible [ 1 ]. However, the site of these lesions and MRI results are important in the decision-making process of surgery [ 1 , 28 ]. For example, surgical resection of the CAs involving the cavernous sinus is usually difficult and may be associated with intraoperative blood loss.…”