Hemorrhagic intracranial melanoma metastasis

Case contributed by Dr Henry Knipe

Presentation

Sudden onset left leg weakness.

Patient Data

Age: 73
Gender: Male

Posterior right frontal lobe heterogeneous hyperdensity abuts the falx cerebri. Minimal adjacent edema. Linear hyperdensity also noted around the primary hemorrhage and along the left cingulate sulcus

Conclusion:

Right posterior frontal lobar hemorrhage with associated subarachnoid hemorrhage. 

The patient reported a history a metastatic melanoma. This is haemorrhage  was considered highly suspicious for an haemorrhagic metastases.

Hematoma within the posterior right frontal superior gyrus and the paracentral lobule is again demonstrated. There is involvement of the right motor strip. There is a small amount of surrounding edema. Mass-effect results in adjacent sulcal effacement. Nodular areas of contrast enhancement are present on the postcontrast images around the periphery of the lesion. Abnormal diffusion restriction in keeping with hematoma. FLAIR hyperintensity in the left history cingulate gyrus in keeping with the previously demonstrated subarachnoid hemorrhage. There is equivocal wispy but no definite nodular enhancement in this region on post contrast stereotaxis image.

No other enhancing lesions are identified. Deep and periventricular white matter changes in keeping with chronic small vessel ischemia.

Conclusion:

Posterior right frontal hematoma with nodular enhancement is highly suspicious for an underlying lesion, and in clinical context metastatic melanoma should be considered.

Case Discussion

The patient went on to craniotomy. 

MACROSCOPIC DESCRIPTION: Multiple pieces of rubbery dark brown-red tissue 22x22x4mm in aggregate. A1. 

MICROSCOPIC DESCRIPTION: The section shows fragments of blood clot mixed with fragments of a densely hypercellular tumor. Tumor cells have spindle and epithelioid morphology with marked nuclear and cellular pleomorphism. The cytoplasm of several atypical cells contains finely granular black/ brown pigment. Atypical cells are admixed with large numbers of monocyte-macrophages and CD3+ T lymphocytes. Hemosiderin pigment is present within the cytoplasm of many of the monocyte-macrophages. There are scattered mitotic figures. The atypical cells show strong immunostaining for tyrosinase, melan A, HMB-45 and S-100 protein. The features are of metastatic malignant melanoma.

DIAGNOSIS: Metastatic malignant melanoma.

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Case information

rID: 34343
Published: 19th Feb 2015
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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