Neuro_MR_Brain: 37 F, metastatic breast cancer, worsening headaches.

MRI BRAIN WITH AND WITHOUT CONTRAST:

 

CLINICAL HISTORY: 37-year-old woman with widespread metastatic breast cancer including bone and dural metastases, worsening headaches, visual symptoms and papilledema.

 

FINDINGS:

 

Parenchyma, ventricles, and extra axial spaces: There is slight interval increase in prominence of left holohemispheric subdural hygroma effacing the underlying sulci with minimal midline shift, no herniation. Diffuse pachymeningeal thickening and enhancement with multiple areas of plaque-like thickening over the bilateral cerebral convexities, right greater than left, concerning for metastatic involvement. No abnormal leptomeningeal enhancement or intraparenchymal mass. There is enhancement associated with new right cerebellar subacute infarct. Evolution of previously seen infarcts.

There are extensive new microhemorrhages in the bilateral cerebral hemispheres. There are multiple small tortuous vessels within the 

cerebral sulci most notably in the interhemispheric fissure, more notable than prior exam though may be differences in technique. The ventricles are slit-like, and the transverse sinuses and superior sagittal sinus are diminutive. There is abnormal signal in the right transverse-sigmoid sinus junction, hypoenhancing relative to the left with loss of flow void on T2 images, which may represent thrombosis or tumoral invasion. There is

extending inferiorly into diminutive right internal jugular vein, likely representing organizing partial thrombosis.

 

Orbits: There is marked bilateral papilledema most notable on axial FLAIR images (1200 image 21).

 

Visualized paranasal sinuses: Complete opacification of the right frontal sinus, posterior ethmoid air cells, and bilateral sphenoid sinuses, new from prior exam.

 

Mastoid air cells: Clear.

 

Bones: Diffusely abnormal low T1 signal throughout the bone marrow, progressed since January, concerning for diffuse osseous metastatic disease though component could represent treatment related change.

 

Additional comment: None.

  

IMPRESSION:

 

1.  Stigmata of intracranial hypertension, with marked papilledema, slitlike ventricles and small superior sagittal sinus and transverse 

sinuses. Abnormal signal and enhancement in the right transverse/sigmoid sinus junction, could represent slow flow, thrombosis, or tumor, uncertain contribution to intracranial 

hypertension. Superior sagittal sinus is not well seen, enhancement similar to that of dural based tumors, tumor infiltration is 

difficult to exclude. Evaluation with CTA CTV may be useful as clinically indicated.

 

2.  Progression of diffuse pachymeningeal enhancement with multiple areas of plaque-like thickening, right greater than left, concerning for progression of dural metastatic disease. Slight interval increase in left-sided subdural hygroma.

 

3.  Multiple new microhemorrhages bilateral cerebral hemispheres. May be on the basis of intracranial hypertension and/or coagulopathy in the known from thrombocytopenia and DIC.

 

4.  Subacute right cerebellar infarct.

 

5.  Diffuse bone marrow signal abnormality, concerning for metastatic marrow replacement though component may be treatment related.

 

6.  New complete opacification of the right frontal sinus, posterior ethmoid air cells, and sphenoid sinuses, likely congestive.

(Intracranial hypotension)