Presentation
Confusion and headache.
Patient Data
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Three nodular heterogeneous masses identified in the right parietal, left frontal and left temporal lobes associated with mass effect characterized by vasogenic edema and displacement of adjacent structures. These lesions shows spontaneous hyperdensity and heterogenous contrast enhancement, the central areas are hypodense probably due necrosis.
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Three nodular masses are again demonstrated with no signals of continuity between them, showing heterogeneous hemorrhagic component and contrast enhancement.
The radiologic features favor the diagnosis of a metastatic disease. When considering the hemorrhagic component and the demographic data (Australian man) most probable primary tumors are melanoma and pulmonary carcinoma. GBM is less likely due the distribution as three apparently isolated lesions.
Further investigation was proposed with CT Chest and CT Abdomen and pelvis.
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Three solid nodular enhanced lesions were identified: in the left hemithorax an anterior juxtapleural nodule; a left sub diaphragmatic nodule and a right subcutaneous nodule in the lower portion of middle axillary line.
Case Discussion
This case illustrates large brain hemorrhagic metastatic nodules that raise the possibilities for a malignant melanoma or a lung carcinoma (considering the most common hemorrhagic metastasis for this specific demographic data). Further body investigation with CT scan confirmed other metastasis foci, including one in the subcutaneous which theoretically established melanoma as the primary tumor.
The diagnostic was pathologically proven as a scalp malignant melanoma.
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