Presentation
Severe headaches in a patient known for breast carcinoma on follow-up.
Patient Data
Rounded relatively symmetrical capsulo-lenticular masses isointense to the cortical grey matter on T1, FLAIR and T2 with restricted diffusion on DWI/ADC. Surrounding vasogenic oedema of a low signal on DWI and facilitated diffusion on ADC. No haemorrhagic component on the GE sequence. The postcontrast sequence shows a vivid homogeneous enhancement.
The MR spectroscopy shows an intratumoural choline peak, lipid peak (tumour necrosis) and depleted NAA.
Two other small enhancing nodules are noted in the right temporal and left frontal lobes at the grey-white matter junction..
Trichilemmal cysts are noted.
Case Discussion
The MRI features in a patient known for breast carcinoma are highly suggestive of brain metastases. The symmetrical location in the capsulo-lenticular regions is rarely seen (as in this case).
CNS lymphoma may be considered in the differential diagnosis, however some MRI findings are against this diagnosis:
the location of the frontal and temporal lesions at the grey-white matter junction
the surrounding oedema is usually more prominent in metastases compared to CNS lymphoma
the MR spectroscopy in this case is almost typical of metastases, while in CNS lymphoma, we usually observe a reversed choline/creatinine peak +/- sometimes a lactate peak
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