J Clin Neurol.  2010 Dec;6(4):221-223. 10.3988/jcn.2010.6.4.221.

Medullary Hemorrhage after Ischemic Wallenberg's Syndrome in a Patient with Cavernous Angioma

• Yang HD
• Lee KH

• KMID: 1462812
• DOI: http://doi.org/10.3988/jcn.2010.6.4.221

Abstract

BACKGROUND
The main complication of cerebral cavernous angioma is hemorrhage. Ischemic stroke as a complication of cerebral cavernous angioma has rarely been described, and hemorrhage after ischemic Wallenberg's syndrome has not been reported before.
CASE REPORT
A 45-year-old woman presented with perioral numbness, hoarseness, dysphagia, and worsening of her previous sensory symptoms. The patient had been taking aspirin for 3 years after suffering from ischemic Wallenberg's syndrome with left paresthesia as a residual symptom. Brain computed tomography revealed an acute medullary hematoma in the previously infarcted area. Follow-up magnetic resonance imaging revealed a cavernous angioma in the right medulla.
CONCLUSIONS
We presume that cerebral cavernous angioma was responsible for both the ischemia and the hemorrhage, and we also cautiously speculate that the aspirin contributed to the development of hemorrhage in the previously infarcted area.

Keyword

cavernous angioma; hemorrhage; ischemia; medulla oblongata

MeSH Terms

Aspirin
Brain
Caves
Deglutition Disorders
Female
Follow-Up Studies
Hemangioma, Cavernous
Hematoma
Hemorrhage
Hoarseness
Humans
Hypesthesia
Ischemia
Lateral Medullary Syndrome
Magnetic Resonance Imaging
Medulla Oblongata
Middle Aged
Paresthesia
Stress, Psychological
Stroke
Aspirin

Figure

• 

  Fig. 1 Brain images of the patient. A-C: Transverse sections of T2-weighted, fluid-attenuated inversion recovery, and T1-weighted MR images taken when the patient had Wallenberg's syndrome 3 years ago show an acute ischemic infarction of the dorsal medulla. D: Brain CT shows hemorrhage in the previously infarcted area. E-H: Follow up MRI including T2-weighted, T1-weighted, after gadolinium enhancement, and a gradient-echo T2-weighted images show target appearance lesion with central high signal and surrounding low signal of hemosiderin deposition which is more conspicuous on gradient-echo image, one of the patterns of cavernous angioma.

Reference

1. Kwon HM, Park JM, Lee JY, Yoon BW. Primary medullary hemorrhage with hypertension. J Clin Neurol. 2005. 1:177–179.

2. Mastaglia FL, Edis B, Kakulas BA. Medullary haemorrhage: a report of two cases. J Neurol Neurosurg Psychiatry. 1969. 32:221–225.

3. Ryang YM, Oertel MF, Thron A, Gilsbach J, Rohde V. Rare intramedullary hemorrhage of a brainstem hemangioblastoma. Zentralbl Neurochir. 2007. 68:29–33.

4. Kempe LG. Surgical removal of an intramedullary haematoma simulating Wallenberg's syndrome. J Neurol Neurosurg Psychiatry. 1964. 27:78–80.

5. Cohen HC, Tucker WS, Humphreys RP, Perrin RJ. Angiographically cryptic histologically verified cerebrovascular malformations. Neurosurgery. 1982. 10:704–714.

6. Chaudhuri A, Shah PU. Spontaneous medullary haemorrhage due to occult vascular malformations. J Assoc Physicians India. 1996. 44:424–426.

7. Jung HH, Baumgartner RW, Hess K. Symptomatic secondary hemorrhagic transformation of ischemic Wallenberg's syndrome. J Neurol. 2000. 247:463–464.

8. Kattapong VJ, Hart BL, Davis LE. Familial cerebral cavernous angiomas: clinical and radiologic studies. Neurology. 1995. 45:492–497.

9. Lee SH, Bae HJ, Kwon SJ, Kim H, Kim YH, Yoon BW, et al. Cerebral microbleeds are regionally associated with intracerebral hemorrhage. Neurology. 2004. 62:72–76.

10. Tanaka A, Ueno Y, Nakayama Y, Takano K, Takebayashi S. Small chronic hemorrhages and ischemic lesions in association with spontaneous intracerebral hematomas. Stroke. 1999. 30:1637–1642.

11. Cardona-Portela P, Escrig-Avellaneda A, Rubio-Borrego F. [Wallenberg's syndrome as the presenting symptom of a cavernous angioma]. Rev Neurol. 2004. 39:837–840.

12. Cantu C, Murillo-Bonilla L, Arauz A, Higuera J, Padilla J, Barinagarrementeria F. Predictive factors for intracerebral hemorrhage in patients with cavernous angiomas. Neurol Res. 2005. 27:314–318.

13. Mayo NE, Levy AR, Goldberg MS. Aspirin and hemorrhagic stroke. Stroke. 1991. 22:1213–1214.

14. Nighoghossian N, Hermier M, Adeleine P, Blanc-Lasserre K, Derex L, Honnorat J, et al. Old microbleeds are a potential risk factor for cerebral bleeding after ischemic stroke: a gradient-echo T2^*-weighted brain MRI study. Stroke. 2002. 33:735–742.

15. Wong KS, Mok V, Lam WW, Kay R, Tang A, Chan YL, et al. Aspirin-associated intracerebral hemorrhage: clinical and radiologic features. Neurology. 2000. 54:2298–2301.