Man with headache and gait disturbance.
Which choices apply? Please respond to the following with TRUE or FALSE.T or FMultifocal.T or FHemorrhagic.T or FRing enhancement.T or FEdema.
Orginally labeled this as PET scan, (scan bones as well) but not defined soft tissue. This is a CT of the brain.
Ventricles are somewhat mishapen, especially visible in the second image. and Disappear in the lower slices as expected but in normal pattern.
Believed it was multifocal because multi would suggest multiple whereas focal could suggest foci as there appear to be at least two hyper translucent regions.
Definitely Hemorrhagic, blood is clearly visible in this CT scan of the brain.
Does not appear to be ring enhancement.
Edema present, a carcinogenous clot is present in the brain.
Findings: Multiple hemorrhagic lesions throughout the brain. There is edema and sulcal effacement surrounding the larger lesions.Diagnosis: Renal cell carcinoma hemorrhagic brain metastases
Differential diagnosis for high-density lesions on non-contrast head CT:
Neoplasm (primary or metastatic)
Vascular malformations (cavernous angiomas), vasculopathy, vasculitis
Septic emboli with hemorrhage
Cerebral infarction, subacute
Patients with hemorrhagic brain lesion(s) can present with headaches, vomiting, seizure, sensorimotor deficits, and impaired consciousness. Clinical scenario will help narrow differential.
In the setting of trauma, top differential would include:
Cerebral contusion: Peripheral more than deep lesions, anteroinferior frontal and temporal lobes (where brain matter collides with protuberances of the skull in these areas). Intracerebral hemorrhage with surrounding edema. May have other findings of trauma- SAH, etc.
Diffuse axonal injury: Punctate hemorrhages at gray-white junctions, corpus callosum, deep grey matter, midbrain and brainstem.
Nontraumatic differential:
Hypertensive intracranial hemorrhage: Solitary or patchy multiple hemorrhages. Deep more than superficial (basal ganglia, thalami, pons) May see multifocal microbleeds in basal ganglia and cerebellum. Usually older patients
Cerebral amyloid disease: Causes 15-20% of nontraumatic intracranial hemorrhage in older patients. Lobar more often than basal ganglia.
Neoplasm seen in 2-15% of nontraumatic ICH. Hyperdense because hypercellular or hemorrhage.
Metastases: usually see some enhancement. Most common hemorrhagic mets are lung, melanoma, pancreas, thyroid, kidney, melanoma, breast, choriocarcinoma.
Primary neoplasm, m.c. GBM: Necrosis and hemorrhage common. Low density center with hypercellular rim. Can have multifocal GBM. May see disordered hemorrhage evolution.
Cavernous malformations: multiple lesions, NECT often normal unless acute hemorrhage, no mass effect unless hemorrhage
Venous thrombosis: May have dural sinus thrombosis. Patchy cortical/subcortical petechial hemorrhages.
Age <45: vascular malformation, drug abuse, venous thrombosis, vasculitis
Age>45: HTN, cerebral amyloid disease, neoplasm, coagulopathy
Radiologic overview of the diagnosis:
Acute <3days hyperdense (50-80HU) may be mixed density if rapid bleed, coagulopathic, anemic. May start developing surrounding edema.
Subacute 3days-3weeks. Isodense mass.
Chronic >3 weeks. Hypodense mass, hyperdense calcifications seen in 10%
CECT: can see active bleeding or enhancement for neoplasm
Multiple high dense lesions in setting of trauma, think DAI or contusions
Multiple high dense lesions with not trauma, think hypertensive hemorrhage, neoplasm, cerebral amyloid, venous thrombus, vascular malformations
Most common hemorrhagic brain metastases: lung, renal, melanoma, thyroid, pancreas, breast, choriocarcinoma
Most common primary neoplasm to hemorrhage is GBM
Contrast will often show more subtle metastatic lesions
Statdx. Spontaneous intracranial hemorrhage. Accessed 1-11-11.
Osborn et al. 2004. Diagnostic Imaging Brain. Salt Lake City: Amirsys Inc. Pages I48-17.
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