Presentation
Uncertain history. No known primary.
Patient Data
Low-density change in the temporal lobe, appearing to be mostly confined to the white matter, although the grey matter of the anterior and mesial temporal lobe is also lost. No convincing abnormal contrast enhancement.
The left temporal lobe is enlarged with increased T2 signal and areas of intrinsic high T1 signal with susceptibility artefact suggesting hemorrhagic foci. Heterogeneous patchy diffusion restriction. Minor contrast-enhancement, mostly cortical in location.
MR spectroscopy demonstrates increased lactate and decreased NAA and choline/creatine peaks. MR perfusion demonstrates mixed areas of increased and decreased perfusion.
Left temporal horn is effaced. No hydrocephalus. Left-to-right-midline shift of 4.5 mm. Mild left uncal herniation.
The patient went on to have a biopsy due to mass effect and concern for an underlying mass.
Histology
MICROSCOPIC DESCRIPTION:
The sections include cerebral cortex and white matter. There are areas of hemorrhage and necrosis in the cortex, associated with sheets of foamy macrophages. Scattered necrotic neurons are present. They have shrunken nuclei with loss of nuclear staining. There is perivascular inflammation. The infiltrate comprises mixed small mature lymphocytes, plasma cells and larger reactive lymphocytes. The neuropil is focally edematous and contains some neutrophils in the areas of hemorrhage. No granulomas are seen. No viral inclusions are identified. There is no evidence of malignancy. The lymphoid cells show no nuclear atypia. There is normal distribution of B and T-lymphocytes. Some amyloid plaques are seen in the cortex. The blood vessels show no amyloid.
FINAL DIAGNOSIS:
Organizing infarct. No tumor identified.
Case Discussion
Subacute cerebral infarction is an important differential to always consider and depending on the timing, the appearances can be quite bizarre and mimic tumor.
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