Presentation
Bilateral upper and lower limb tingling and numbness.
Patient Data
Bilateral cerebral, cerebellar, and pontine multiple scattered small space-occupying lesions. The largest lesion is seen on the left occipital lobe. The lesions appear isointense on T1 WI and high signal on T2 WI with ring enhancement with some of them show blooming effect on SWI, except for the large left occipital lesion which shows heterogeneous signal and enhancement and is seen surrounded by vasogenic edema signal. MRS criteria are impressive of neoplastic process demonstrating high Choline peak and Cho/cr ratio, low NAA peak, and elevated lipid lactate peak.
MRI and MRS criteria were suggestive of a neoplastic (most likely metastatic) process.
PET-CT study demonstrated a left upper lobar FDG avid neoplastic soft tissue mass lesion, likely representing primary bronchogenic cancer.
Multiple FDG avid metastatic lesions are seen at the following:
- Mediastinal and right supraclavicular lymph nodes, the mediastinal lymph nodes are seen on the superior mediastinal, paratracheal, prevascular, aorto-pulmonary, subcarinal, and left hilar nodes.
- Metastatic left pulmonary nodules.
- Bilateral adrenal nodules.
- Multiple metastatic osseous lesions were seen at the right acromion, vertebrae,sternum, left iliac bone, and left femur.
Case Discussion
The multiplicity of the cerebral, cerebellar, and pontine space-occupying lesions as well as their morphological appearance especially their small size, ring enhancement, and facilitated diffusion were radiologically characteristic of cerebral metastasis. Also, MRS was helpful to further characterize the lesions as neoplastic and exclude the inflammatory or granulomatous process.
PET-CT in such cases might be helpful to confirm metastatic lesions and identify primary neoplasms, as in this case the bronchogenic cancer was the primary tumor.
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