Cerebral mass lesions: unknown cause

Case contributed by Dr Mohammad A. ElBeialy

Presentation

75 year old female patient with headache, disturbed level of consciousness and difficulty in waking with gait disturbance. CT shows mass lesion.

Patient Data

Age: 75 years
Gender: Female
Modality: MRI

Multiple right cerebral hemisphere heterogeneously enhancing and necrotic irregular mass lesions are seen as follows: 

  • A right anterior frontal para-falcine mass lesion is seen measuring 4.5 X 3.4 X 3.1 cm. The lesion is heterogeneously hypointense T1 and hyperintense T2 / FLAIR signal with heterogeneous predominantly marginal post-contrast enhancement. The lesion shows restricted diffusion with of its enhancing peripheral portion. 
  • Other similar lesions are seen at the right hypothalamus and the floor of the 3rd ventricle as well as the right thalamic regions, measuring about 2.5 X 2.5 X 1.5 and 1.5 X 1.5 X 1 cm, the lesions are seen surrounded by vasogenic brain oedema with compression of the 3rd ventricle and moderate supratentorial hydrocephalus as well as transpendymal periventricular CSF permeation . Mild contra-lateral left midline shift about 5 mm is noted. 
  • Other smaller subcentimetric enhancing lesions are seen at the right high frontal region.
  • MR spectroscopy of the lesion shows significant depression or almost nullification of the neuronal markers; N-acetyl aspartate (NAA) and creatine (Cr) with slight elevation of the choline. Single voxel MR spectroscopy show significant elevation of the lipid / lactate.
  • Bilateral cerebral demyelinating foci of high T2 / FLAIR signal are seen within the corona radiata and centrum semiovale.

Case Discussion

Multiple right sided cerebral lesions with moderate supratentorial hydrocephalus have a differential of glioblastoma or cerebral metastases. 

The spectroscopy suggests metastatic disease, whereas the morphology and location (including thalamus and subependymal surface) favour glioblastoma. 

Unfortunately histology is unavailable and a it is not know whether the patient had known metastatic disease. 

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Case Information

rID: 23552
Case created: 23rd Jun 2013
Last edited: 26th Feb 2016
Inclusion in quiz mode: Excluded

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