Headache Medicine 2020, 11(4):95-97 ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2020.27

Headache Medicine

Case Report

Frontal brain cavernoma in a 14-year-old boy: differential diagnosis

of secondary headache

Eduardo de Almeida Guimarães Nogueira , Marcos Vinicius de Queiroz, Philipe Rachas Saccab,

Marcelo Motta Zanatelli

Portuguese Society of Benecence of Santos, Clinical Medicine, Santos, São Paulo, Brazil

Abstract

Cavernoma consists of a rare type of vascular anomaly that can present with different neurolo-

gical manifestations. This article reports a case of cavernoma in a 14-year-old boy, whose rst

symptom was headache

Eduardo de Almeida Guimarães

Nogueira

eduagn@hotmail.com

Edited by

Mario Fernando Prieto Peres

Keywords:

Headache

Cerebral Hemorrhage

Frontal Lobe

Received: September 20, 2020

Accepted: November 30, 2020

ASAA

Nogueira EAG, Queiroz MV, Saccab PR, Zanatelli M

Frontal brain cavernoma in a 14-year-old boy: differential diagnosis of secondary headache

Introduction

avernoma is a rare type of vascular anomaly¹ char-

acterized by constituting a space lacking in the brain

parenchyma, lled mainly by dilated sinusoidal veins.² It

affects mostly males in the third decade of life and is divided

into sporadic or familial.³ The aim of this article is to report a

case of cavernoma in a young patient and draw attention to

this pathological entity as a cause of secondary headache.

Material and Methods

The data contained in this report were obtained through in-

terview with the patient and his family members, and review

of the medical record.

Case Report

A 14-year-old male patient was brought to the emergency

room on the morning of Nov. 11th, 2020, with a complaint

of frontal shooting headache, fever (38°C), and an episode

of vomiting preceded by nausea the night before.

The patient was previously healthy, was not taking any med-

ication continuously, and had never undergone any surgical

procedures. The mother reported that during intrauterine life,

the patient developed only one umbilical artery, and that he

was followed by a neurosurgeon during the rst four years

of life, due to an above average brain girth. As he never

manifested any neurological symptoms, he was discharged.

She also informed that her son had suffered two head traumas

throughout his life, both in the frontal region of the skull, the

last one three years prior to the report. Both accidents did

not cause major repercussions.

Figure 1. Entry CT scan showing right frontal cavernoma.

The physician on duty requested a complete blood count and

urine test, both within normal limits. Besides the laboratory

tests, the patient had a chest X-ray and a CT scan of the

skull without contrast. The X-ray showed no changes, but

the CT scan showed a rounded, heterogeneous lesion with

well-dened contours in the right frontal lobe, compressing

the ventricle and deviating the midline.

The patient was evaluated by the neurosurgery team, which

suggested the possibility of a vascular malformation and

advised that a magnetic resonance imaging of the brain be

performed. The patient was sent to the intensive care unit

(ICU) with a prescription for intravenous corticosteroids and

prophylactic intravenous phenytoin.

He was admitted to the ICU asymptomatic, with a completely

normal neurological examination without any focal decits,

speech, or ocular changes.

Magnetic resonance imaging (MRI) of the brain was per-

formed and revealed a recent hemorrhagic lesion with slight

contrast enhancement with mild deviation of midline structures

and compression of the frontal horns of the lateral ventricles,

more accentuated on the right, measuring 2.6 x 3.5 x 2.7 cm,

conrming the hypothesis of cerebral cavernoma.

The patient underwent surgery with no major intercurrences

and was released 72 hours later after a control CT scan was

performed.

Discussion

Cryptic hemangiomas or cerebral hamartomas, also called

cavernomas are lesions easily visualized on CT scans due

to their hyperdense nodular formation. The most common

symptoms reported are epileptic seizures, headache, and

dizziness.

Vaquero et al.³ reported 16 cases of brain cavernomas, with

50% presenting with seizures, 37.5% manifesting focal symp-

toms and 12.5% intracerebral hemorrhages. The frontal lobe

was the second site with the highest incidence of hamartoma

(25%), second only to the parietal lobe (31%). The exam of

choice for the diagnosis of cavernoma is magnetic resonance

imaging of the brain. Since most of the time the anomaly is not

connected to adjacent arteries, angiography is unnecessary.

In 1994, Zabramski et al.

created a classication that groups

cavernomas into groups I through IV according to their ap-

pearance on MRI.

The most encountered type is II, also called

"popcorn" lesion due to the heterogeneous appearance, since

in many cases, the nodulation is surrounded by a hyperintense

halo due to the presence of hemorrhage.¹

ASAA

Nogueira EAG, Queiroz MV, Saccab PR, Zanatelli M

Frontal brain cavernoma in a 14-year-old boy: differential diagnosis of secondary headache

The case we report presented with sudden headache of

strong intensity, originating from an intracerebral hemorrhage

that through a mass effect raised the intracranial pressure and

shifted the midline.

Studies show that up to 18% of patients who go to the emer-

gency room with headache complaints have a secondary

cause for their pain.

SNNOOP 10 (Systemic, Neoplasm, Neurologic, Onset,

Older, Pattern) is a mnemonic tool for physicians to remember

the warning signs for further investigation when encountering

a headache in the emergency.

The patient had a sudden onset headache (Onset) and the

rst crisis of his life (Pattern), so investigation with the imaging

exam that found the lesion was necessary.

The third revision of the International Classication of Head-

ache Disorders (ICHD-3) classies headache due to non-trau-

matic intracranial hemorrhage as item 6.2, in the secondary

headache session.

There are eight sessions devoted to secondary headaches,

with the one attributed to cranial or cervical vascular disorder

being the second session.

Author’s contributions: EAGN- methodology, writing, preparation

of the original; MNVQ- data collect; PRS- investigation, supervi-

sion; MZ- methodology, writing, review and editing, supervision

Financing source: No

Conflict of interests: No

Eduardo de Almeida Guimarães Nogueira

https://orcid.org/0000-0002-6035-560X

Marcelo Motta Zanatelli

https://orcid.org/0000-0001-7146-082X

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Figure 2. Magnetic resonance imaging of the brain showing Zabramski cavernoma 1.

Figure 3. Coronal MRI section of the brain Cavernoma Zabramski 1