Presentation
Headache of one month duration and progressive right side body weakness of two weeks.
Patient Data
There are multiple, well-defined, T1 hypointense lesions of various sizes involving the bilateral fronto-parietal regions, left frontal lobe, bilateral temporal lobes, left thalamus, right basal ganglia, and cerebral cortex. Most of the larger frontal and parietal corticomedullary junction and cerebellar lesions have internal intermediate and high signal T1 components. There are also multiple T1 hypointense bilateral cerebellar hemisphere lesions with small internal high signal components.
Most of the lesions have high and intermediate signals on T2, representing the cystic and solid components of the lesions, respectively. The T1 hyperintense component of the lesions becomes T2 hypointense, likely representing the haemorrhagic component. There is also cystic component signal suppression and disproportional perilesional vasogenic oedema on FLAIR images. In contrast, the small cortical lesions show no oedema on either T2 or FLAIR images.
The solid components of the larger lesions exhibit peripheral diffusion restriction, whereas the cystic parts show facilitated diffusion on DWI/ADC mappings.
On post-contrast study, the lesions display both nodular ring and homogeneous solid component enhancement, with progressive increase on delayed images.
Case Discussion
Before the MRI, the patient underwent a non-contrast brain CT scan which showed multiple hypodense lesions with areas of high attenuation and significant vasogenic oedema.
On MRI, multiple T1 hypointense and T2 hyperintense lesions with FLAIR signal suppression and significant vasogenic oedema were observed, representing cystic lesions at the white matter and grey matter junctions. Most lesions have a T1 hyperintense, T2 hypointense component and multiple intermediate signal nodules. Some of the lesions have peripheral diffusion restriction, while others have facilitated diffusion. Post-contrast nodular ring and solid enhancement were more prominent on delayed images.
Most cortical lesions are discrete, whereas others are interconnected with vasogenic oedema on T2/FLAIR images. Based on these findings, multifocal/multicentre GBM and metastasis were considered as two competitive differentials.
With further work-up, a contrast-enhanced chest CT scan showed that the patient has lung cancer, leading to a diagnosis of multiple cystic and haemorrhagic brain metastases.
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