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Hemorrhagic cerebral metastasis

Case contributed by Dr Bruno Di Muzio



Patient Data

Age: 53
Gender: Male

CT shows a large right parietotemporal intraparenchymal hemorrhage with surrounding vasogenic edema extending medially into the posterior limb of the internal capsule, external capsule and thalamus. The mass effect promotes a 6.5 mm midline shift and right cerebral hemisphere sulcal effacement. No herniation. 

There is large mass of heterogenous T1 and T2 signal in the right temporoparietal junction with involvement of the inferior aspect of the right frontal lobe. The lesion demonstrate peripheral and focal medial central as well as posterior area of enhancement indicative of hemorrhage within the intra-axial tumor. There is susceptibility within most of the lesion.

There is surrounding FLAIR and T2 hyperintensity are in keeping with vasogenic edema. There is sulcal effacement and the left right midline shift of 9 mm. There is a small area of the FLAIR hyperintensity with associated enhancement very close to the pre-chiasmatic right optic nerve and probably along the most posterior aspect of the planum sphenoidale on the right side and probably the right side of the diaphragma sellae.

The patient underwent surgery in which a hemorrhagic lesion was identified and partially resected (residual tumor left). 


MICROSCOPIC DESCRIPTION: fin sections show fragments of an extensively necrotic tumor. Viable areas are composed of markedly pleomorphic cells with small overlapping hyperchromatic nuclei and minimal cytoplasm. These are arranged in diffuse sheets and thick cuffs around viable blood vessels. Frequent mitotic figures are identified. There is extensive tumor necrosis. Immunohistochemistry shows strong nuclear staining in tumor cells for TTF-1 and strong cytoplasmic staining for CD56, synaptophysin and neuron specific enolase (NSE). There is also patchy moderate cytoplasmic staining for pancytokeratin AE1/AE3. No staining for Napsin A or cytokeratin CK7 is seen in tumor cells. The features are of metastatic small cell carcinoma arising from lung. DIAGNOSIS: Brain lesions: Metastatic small cell carcinoma arising from lung

Case Discussion

CT scan demonstrated a hemorrhagic right temporoparietal lesion that was confirmed to correspond to a intra-axial tumor on MRI sequences. The appearances, along with the history, are in keeping with cerebral metastasis

There is second focal enhancement very close to the pre-chiasmatic right optic nerve and probably along the planum sphenoidale. This could either represent a small meningioma versus a dural based metastasis.It was opted not to approach this lesion on surgery. 

Hemorrhagic intracranial metastases are considered to represent between 3-14% of all cerebral metastases.

The patient was submitted to a surgery partial resection of the main lesion. Pathology study reveals a metastatic small cell carcinoma arising from lung. Further radiotherapy treatment is being considered.  

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