Age: 69
Sex: Male
Indication: Altered mental status, history of melanoma
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Case #21
Findings
- Multifocal cortical T2/FLAIR signal hyperintensity and nodular cortical and leptomeningeal enhancement with gyral expansion, most avidly involving the bilateral parafalcine frontal lobes, right greater than left banks of the sylvian fissures, and along the superior vermis
- Diffuse nodular thickening and enhancement of the pial surfaces of the brainstem as well as involving the cerebellar tentorium bilaterally
- Few intermixed areas of T1 signal hyperintensity, particularly along the pial surface of the paramedian cerebral hemispheres
- No evidence of acute ischemia, hemorrhage, mass effect, or hydrocephalus
- Enhancing lesion in the right frontal sinus with otherwise mild scattered mucosal thickening of the paranasal sinuses
Diagnosis
- Leptomeningeal disease
Sample Report
Findings consistent with extensive leptomeningeal disease, most prominently along the bilateral medial frontal lobes and sylvian fissures, but also involving multiple structures in the posterior fossa. Given history, this appearance is thought most likely to represent tumor dissemination with granulomatous disease such as sarcoidosis, tuberculosis, and fungal infections considered less likely alternative diagnoses. Recommend correlation with CSF analysis and consideration of total spine MRI with and without contrast for further evaluation.
A few intermixed areas of T1 signal hyperintensity, particularly along the pial surface of the paramedian cerebral hemispheres, may represent associated trace hemorrhage or proteinaceous debris.
No evidence of acute ischemia, organized hematoma, mass effect, or hydrocephalus
Enhancing lesion in the right frontal sinus which may represent a polyp or possibly localized fungal colonization.
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