Neuro_MR_Brain: 52 M, lung lesions, brain lesions on CT.


CLINICAL HISTORY: 52-year-old smoker, without other past medical history, presenting with two day history of right-sided weakness and tremor in the face and arm, several month history of severe low back pain, transferred from an outside hospital after a head CT demonstrated multiple lesions concerning for metastatic disease.



Parenchyma: Multiple well-demarcated, T2 hyperintense lesions within the supratentorial parenchyma predominantly at the gray-white interface, involving the bilateral frontal lobes, left caudate head and lentiform nucleus, and right posterior centrum semiovale. The lesions demonstrate marked rim enhancement, central regions of necrosis with diffusion restriction, and minimal peripheral GRE susceptibility artifact suggesting mild hemorrhage. T2/FLAIR signal hyperintensity surrounding these lesions is consistent with surrounding edema. The largest, lobulated lesion in the left caudate head and lentiform nucleus, involves an approximate 1.6 x 2.9 cm region and extends to the ependymal surface of the anterior horn of the left lateral ventricle (series 23, images 84-90). This lesion demonstrates GRE susceptibility artifact at the medial margin at the ependymal surface. Additional lesions include a 1.4 x 1.3 cm left frontal lobe lesion (series 23, image 116), a 0.8 x 0.9 cm right frontal lobe lesion immediately lateral to the genu of the corpus callosum (series 23, image 99), and a 5 mm lesion in the right posterior centrum semiovale (series 23, image 113).

An additional ovoid well-demarcated 1 x 1 cm lesion involving the hypothalamus and superior aspect of the infundibulum (series 23, image 62) demonstrates different signal characteristics as compared with the above described lesions. This lesion is hyperdense on prior CT in distinction to the hypodense lesions, and demonstrates T2 hypointensity, moderate GRE signal loss suggesting more hemorrhage or intrinsic calcification, and heterogeneous enhancement without central necrosis or marked diffusion restriction. This lesion causes mass effect with anterior displacement of the optic chiasm.

Ventricles and extra-axial spaces: The above-described left lentiform nucleus and caudate head lesion effaces, and possibly invades the anterior horn of the left lateral ventricle. The ventricles and extra-axial spaces are otherwise normal.

Orbits: Normal.

Visualized paranasal sinuses: Clear.

Mastoid air cells: Clear.

Bones: Heterogeneous marrow signal within the clivus concerning for possible disease involvement without focal lesion.

Additional comment: Multiple fiducial markers noted at the scalp.


Counting from C2, there are five lumbar type vertebral bodies. The last well-formed disc is labeled as L5-S1.

Alignment: Normal.

Vertebrae: Extensive abnormal enhancement within the cervical, thoracic, and lumbar spine consistent with osseous metastatic involvement. No evidence of pathologic fractures are identified.

Within the cervical spine, there is abnormal enhancement of the majority of the C2 vertebral body with heterogeneous enhancement within multiple posterior elements including the C2, C4, and C6 levels concerning for metastatic involvement. There is no obvious epidural extension within the cervical spine.

Within the thoracic spine, abnormal enhancement involves multiple vertebral bodies, posterior elements, neural foramen and the paraspinal soft tissues. Findings are centered at the T4 level, with extensive abnormal enhancement within the T4 vertebral body and posterior elements, with abnormal enhancement involving the left T3-4 neural foramina and extending into the left paraspinal soft tissues. The lesion extends posteriorly to involve the epidural space eccentric to the left lateral aspect (series 25, image 34) with effacement of the ventral surface of the thecal sac. Involvement extends superiorly to include the left T2-3 neural foramina with extensive enhancement around the left lateral process of the T2 vertebral body. Heterogeneous enhancement appears within multiple additional vertebral bodies including T5, T7, T8, T9, and T12. At the T12 level, extensive enhancement circumferentially surrounds the vertebral body with epidural extension effacing the anterior aspect of the thecal sac bilaterally (series 27, image 19).

Within the lumbar spine, abnormal enhancement involves multiple vertebral bodies and posterior elements, most marked at the L2 and L3 vertebral bodies. The majority of the L2 and L3 vertebral bodies are involved with abnormal enhancement extending within the right L2-3 neural foramen, the right L3 transverse process, and the adjacent right psoas muscle (series 27, image 37). There is diffuse involvement of the sacrum and bilateral iliac wings, incompletely evaluated on this study with example lesions in the posterior aspect of the right ilium (series 27, image 54) and the right lateral aspect of S1 (series 27, image 51).

Cord and conus: Normal contour and signal characteristics

Extra-vertebral soft tissues: See above.

Visualized chest, abdomen, and pelvis: A large mediastinal lesion and multiple sites of metastatic disease in the anterior and lateral ribs are seen to better advantage on same day thoracic CT.


1. Multiple cystic/ necrotic, rim-enhancing supratentorial lesions with surrounding edema, predominantly at the gray-white interface , with marked diffusion restriction and minimal associated hemorrhage. The largest lesion, measuring approximately 1.6 x 2.9 cm, lies at the left caudate head and left lentiform nucleus with possible extension into the anterior horn left lateral ventricle. These lesions cause mild local mass effect without evidence of hydrocephalus or herniation. These lesions are most consistent with cerebral abscesses.

2. Ovoid lesion at the hypothalamus and superior aspect of the infundibulum causing mass effect on the optic chiasm demonstrates markedly different signal characteristics than the above-described supratentorial lesions with findings suggesting calcification or more marked hemorrhage and heterogeneous rather than rim enhancement. Given the overwhelming evidence of diffuse metastatic disease, this lesion is favored to represent abnormal characteristics of a metastatic lesion of similar etiology.

3. Extensive abnormal signal and enhancement within the cervical, thoracic, and lumbar spine, consistent with metastatic osseous involvement. No evidence of compression fractures. Metastatic lesions extend into the neural foramen and prevertebral soft tissues at multiple levels as described. Extension into the epidural space is seen at T4 and T12 with effacement of the anterior aspect of the thecal sac. No deformation or abnormal signal within the spinal cord.

(Cerebral abscesses and metastatic disease)

Accession: CL27388466