Subacute infarct

Case contributed by A.Prof Frank Gaillard

Presentation

Uncertain history. No known primary.

Patient Data

Age: 70 years
Gender: Male

CT Brain

Modality: CT

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. 

MRI Brain (4 days later)

Modality: MRI

The left temporal lobe is enlarged with increased T2 signal and areas of intrinsic high T1 signal with susceptibility artefact suggesting haemorrhagic 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 haemorrhage 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 oedematous and contains some neutrophils in the areas of haemorrhage. 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: 

Organising infarct. No tumour 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 tumour. 

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Case Information

rID: 34695
Case created: 5th Mar 2015
Last edited: 2nd Apr 2017
Inclusion in quiz mode: Included

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