• A 72-year-old female is brought to the ER by her husband who informs you that she has been becoming progressively more weak on the right side over the past 2 weeks. He reports that over the past week, significant communication problems have also developed.
    • Past medical history: Breast cancer (18 years ago)
    • Past surgical history: Mastectomy
    • Meds: none
    • Examination:
      • Pupils are equal, round and reactive
      • Fundoscopy: no papilledema
      • Motor exam reveals 1/5 weakness in Right upper and lower extremities and full strength on left side
      • Flattening of the nasolabial fold (R side), mild facial asymmetry
      • profound dysphasia - word finding and expressive ability is poor

    Figure 1. CTscan

    Figure 2.

    1. Based on the clinical presentation and imaging, the most likely diagnosis is:

    2. Each of these options may be appropriate in the initial evaluation and management of this patient, EXCEPT:

    3. All initial evaluation steps return without findings. You decide that a biopsy is required. How would you proceed?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:

    • Don't use negative stems (EXCEPT) or have mixed category distractors
    • Interesting case
    • The imaging provided is limited. Given the homogeneous enhancement of the lesion this could be either a meningioma or a dural based metastasis. Either way, surgical resection and not a biopsy would be my recommendation, especially given the significant hemiparesis in this patient.
    • Rather than going in for biopsy, I will aim at total excision of the lesion.
    • Wanted to know of chemotherapy regime taken, cycles.
    • In view of the location, uniform enhancement lymphoma would need to be in the d/d; but gbm / mets / other mass lesion are all on the list. Steroids would give rise to negative yield if started prior to biopsy so if pt is stable would do it immediately after the biopsy and then plan definitive treatments.
    • Very challenging case as far as diagnostic, treatment stratyegy obligatory
    • I make the total remove tumor in open surgery.
    • differential is wide for this history and these few pictures.
    • This is for me a problema of a cerebral abscess in progretion, so with the biopsy I will be preparate to evacuate an abscess. Many times the image of a tumor like glioblastoma is very similar in a TAC, but with de NMR, the image is like a change in the acuous site,T2.
    • The periventricular location, enhancement pattern with contrast, hyperdensity of the lesion in plain CT scan, proportionate perilesional edema make me think of PCNSL as the first differential. Metastasis could be the second possibility considering the past history of breast cancer and her age. Since I think of PCNSL I will avoid dexamethasone. However I will not do LP though its not going to produce coning since there is no ICT. If frameless stereotaxy is available I will prefer that over the frame based STB.
    • would also say dexamethasone is contra-indicated until a biopsy is obtained, as this could be lymphoma
    • What was the final diagnosis?
    • Lesion looks like a lymphoa ( Periventricular, robust enhancement, elderly lady), hence I would withhold steroids( not much of perilesional edema or significant mass effect) and confirm the diagnosis by stereitactic biopsy
    • a lady previously diagnosed case of ca breast is most likly suffering from hemorrhagic brain mets,needs workup for mets,craniotomy excision and evacution of hemorhagic mets plus tissue for histopath and post op chemo or radiotherapy accordingly
    • I am neurosurgeon with indian army.
    • Need an ADC Map to go with the DWI, so see if the DWI is showing true restricted diffusion vs shine-thru.

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