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CASE 4: Explanation of Imaging Findings
MRI of the brain without and with contrast
A brain MR examination was performed without and with contrast. Select images are depicted above.
Questions
1. What are the above sequences?
2. Where is the abnormality located?
3. Describe the abnormalities using appropriate terminology.
4. What is your imaging differential diagnosis for the imaging findings?
Multiple Ring Enhancing Masses
- Neoplasm: Metastatic disease, lymphoma and primary brain tumor are on the differential. Given the multiplicity of the masses and the patient’s history of smoking, metastatic disease is favored. Metastatic disease often occurs at the gray-white junction. Common primary tumors that metastasize to the brain include lung cancer, breast cancer, melanoma, renal cell cancer and colon cancer. Primary brain tumors are often solitary masses, so in this patient, a primary brain tumor this is considered less likely.
- Infection: Abscesses can also present as a ring enhancing mass and should be considered. However the lack of fever, elevated WBC or other signs of infection- this is considered less likely.
- Demyelinating Disease: Acute demyelination in the setting of multiple sclerosis can present as ring enhancing lesions. The unilateral distribution and location at the gray-white junction is atypical for MS. MS often occurs within the periventricular white matter.
5. Based on this information, how would you work up this patient if he did not have a known cancer diagnosis?
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