• HPI: The patient a 56-year-old, left handed male, who presented with increasing left hemibody numbness over 48 hours, and left arm, greater than leg weakness over 24 hours. 

    PMH: Cholecystectomy, 2010. Melenoma, resected from nose with negative margins in 1998. 

    Social History: Works as a machinist. Has a 30 pack year smoking history. Drinks about 5 beers per week. 

    Family History: Unremarkable. 

    Exam: Cranial nerves II-XII nonfocal. 4-/5 muscle strength in the proximal left arm, 2/5 in hand grip and intrinsic muscles. 4-/5 strength in all muscle groups in the left leg. Sensation decreased to light touch diffusely over the left hemibody. Wheezes and crackles in all lung fields. 

    Figure 1. Multiple axial post contrast T1-weighted MRI images demonstrating four 1 – 2.5 cm ring-enhancing lesions in the right temporal, frontal, and parietal lobes with associated edema.

    Figure 2. Axial T2-weighted MRI redemonstrating multiple masses in the right hemisphere with substantial associated edema.

    1. What would be your next step in managing this patient?

    2. Given that your next step is surgical resection/biopsy of the lesion(s), how would you proceed?

    3. Given the patientÂ’s history and the imaging appearance of this lesion, what do you think is the most likely pathology?

    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:

    • In Puerto Rico
    • 1. metastatic melanoma is very high on differentials. A chest CT scan is necessary to screen for chest metastases but in my setting we will start with a chest X-ray. Biopsy of the hyper-intense right maxillary sinus mass or a chest lesion if found on imaging should preceed consideration for brain lesion biopsy.
    • first question: First, a CXR would ask; if there is anything suspicious, ask for a CT scan of chest, abdomen and pelvis, if I find nothing in the chest radiograph would ask a PET-CT directly
    • this a tuberculoma i resect the right temporal lesion and proceed with medical therapy
    • It seems that its a multiple mets case. i will search for a primary, in case the general study is negative a sterotaxic biopsy will be my next step, along with steroids, whole brain rdtx will be indicated,open surgery probably will not be performed.
    • diagnosis melanoma mets
    • Parasitics. HIV ?
    • 1. PET exam 2. gamma knife
    • I think it is multiple secondaries. Second option is metastatic abscess.Primary site is Lungs. I prepare open biopsy and further managements accordingly.Mean while I put him on Dexamethasone,PPI/H-2 blocker and antoconvulsant.
    • Tuberculoma?
    • I think it is probably melanoma metastazing to the brain.
    • Could be multiple granulomas also; the posterior frontal lesion on the right shows more of a 'disc'enhancement and there is also T2 'shortening'in both the T2W images- tuberculomas?
    • I think is a metastatic lesion.Promary lesion was melanoma/lungs.It could be a metastatic abscess also. I prefare open biopsy and managements accordingly. Meanwhile i put him on dexamethasone,PPI/H-2 blocker and anticonvulsant.
    • great chase..
    • The above lesions are suggestive of Neurocysticercosis. I would put the patient on Tab. Albendazole 400mg b.i.d. x 2 weeks plus Tab. Phenytoin sodium 100mg t.i.d and do a CCT scan at the end of 2 weeks. If he shows signs of increased ICP, dexamethasone i.v. can be used as a short course. The possibility of Tuberculosis should be considered in this case in India.
    • i think this is a melanome multiple metatastase case, is the classic MRI image. I practice in Central America El Salvador, but it is not in the practice choice list above??
    • 1st diagonstic should be with other doctors so the computer does not give you a negitive?
    • 56 LHCM with progressive neurological deficits for 48hrs and multifocal lesions suggest to be septic/infectious in nature until proven otherwise. Information not given that would conclude diagnosis would be vitals, wbc, esr and crp. Even if above are within normal limits, timeline of symptoms still suggest septic emboli. Multifocal glioma and/or metz are not from differential given imaging findings and patient's social history. Open biopsy would be adequate for diagnosis.
    • Although the clinical history may be suggestve of multiple metastases, the MRI appearance {especially T2) is highly suggestive of the diagnosis of multiple intracranial tuberculomas. This can be confirmed with serelogical tests for TB, ZN stain and culture of the biopsied specimen for acid fast bacilli
    • Thanks for the hard work and keeping our minds active.
    • I thhink is very probably that it is a case of lung cancer with metastasis to the brain After biopsy is necesary to give quemotherapy and surgery of the lesions with aplication of medicine like gliadel.
    • Would be nice to have a CBC, temp for consideration of infection
    • Maybe a cardíac ecography
    • Maybe a cardíac ecography
    • Articles like these put the consumer in the driver seat-very imoprtnat.
    • I practice in Puerto Rico. You should include the central america/Caribbean area, or include PR in the US list
    • metastases from melaonoma
    • please send the statistics responses
    • testing this feature
    • I believe that best treatment option for the patient includes, stereotactic biopsy followed by stereotactic radiosurgery of the lesions
    • I think its better to proceed treatment with stereotactic radiosurgery using Gamma knife
    • none
    • Resect symptomatic central lesions.
    • Not sick enough for septic emboli...no mention of fever or other symptoms other than crackles in chest. All such patients should have chest Xray or Ct. Melanoma even with clean margins is possible as is primary in chest.
    • start steroid,anticonvulsant
    • with a previous history of melenoma, my diagnosis would be a melanotic metastasis. considering the multiple lesions, surgical resection is out of question. a definite tissue biopsy and appropriate adjuvant therapy would be the course to take.
    • Neurocysticercosis
    • Body PET scan
    • If extracranial lesions found, they might be an easier biopsy. If the only lesions available, I would consider navigation assisted biopsy of one of the right parietal lesions. Multiple septic lesions would be rare in the absence of endocarditis. I would suspect a lung primary, or perhaps recurrence of melanoma.
    • The primary step for this patient should be steroids. Then a CT CAP and then (probably) stereotactic radiotherapy for the brain mets.
    • High probability for NSCLC
    • despite a long latency, melanoma mets is still a possibility, CT of chest/abso/pelvis will help to detect systemic mets/second primary as a staging procedure
    • metastatic melanoma or bronchogenic carcinoma may be the cause, still small multiple brain abscess is apossibility
    • Looks like multiple metastatic lesions with presently unknown primary. Requires GKRS once biopsy proves this.
    • Metastatic Mellanoma
    • Need tissue to determine whether recurrent melanoma or mets from new (probably lung)primary. Resect temporal lesion closest to cortex.

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