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CASO 17 - Scott W. Atlas, M.D.

Scott W. Atlas, M.D.
Médico Radiologista
more info.



Felipe B.  - personagem virtual  

extra axial lesion causing edema and contra-lateral displacement of midline structures



Giulia M.  - personagem virtual  

Meningioma.



Leonardo Furtado Freitas  

no pathognomonic features in this case. ddx: meningioma, sarcoma, linfo / mieloproliferatitve disease; mets, IgG4 disease (idiopathic), etc.



Dra Abd Elrady - Acesso via Facebook  

Extra axial leptomenigeal mass and fax cerebri mostly mets



Imtiaz Ahmad - Acesso via Facebook  

Atypical meningioma.



Imtiaz Ahmad - Acesso via Facebook  

Further require contrast enhanced image.



Roberto Cunha  

I agree Imtiaz. Atipical Meningeoma!



DrVijay Borse - Acesso via Facebook  

enplaque meningioma,dd mets, lymphoma..



Scott W. Atlas, M.D.  

Thank you for the replies. This is a very important case because it illustrates again that simply seeing the lesion is not enough. Yes, it is important to give the diagnosis and list the possible diagnoses when you cannot be specific, but sometimes more important information, crucial for best patient care, is visible on the images that goes beyond the diagnosis. This is such a case. First, everyone sees the large mass lesion in the right frontal region. The mass at first looks like it is extra-axial, located along the innner table of the skull and pushing the brain. It is associated with a lot of meningeal enhancement along the right frontal-parietal region and along the falx. extensive edema is present, which is not specific for anything. At least along parts of the interface of the mass with the brain, there is a visible cleft of CSF between the mass and the brain (see the T2 images). The mass is isointense to gray matter, implying that is hypercellular. This makes the differential diagnosis include meningioma, lymphoma, sarcoidosis, hypercellular metastases, and then other rarer lesions (for example, histiocytic lesions, and others). I cannot see definite hyperostosis, which if present would give me the specific diagnosis of meningioma. I do not see bone destruction.



Scott W. Atlas, M.D.  

But let's look closer at this lesion. Some of you said "atypical" so let's understand why. What is different about this mass? The first thing to see is the irregular edge of the lesion where it pushes the brain. Most extra-axial masses are more "regular" or smooth at its interface with the brain. This is especially true for slow-growing lesions. The second thing to notice is that part of the mass touches the edema (see the second image on the T2 slide). At the middle portion of the mass, I do not see any cleft of CSF, and the tumor touches the high signal edema (this means there is no cortex between the tumor and the white matter, since the edema is in the white matter). The third finding makes the diagnosis of the most important point definite - there is enhancement inside the perivascular spaces of the brain. These findings show us that this lesion is NOT isolated to the extra-axial compartment. In fact, this mass has invaded the brain itself. And the most common way an extra-axial tumor invades the brain is via the perivascular spaces, shown in this case. The most important point of the case is the invasion of the brain, because this means the tumor cannot be surgically removed easily, even though (in this case) the tumor is benign. If stripped away from the brain, there is a high likelihood that the procedure would result in an infarction (venous or arterial). Therefore, the radiologist must be certain to notify the surgeon immediately. While we cannot be certain about the histology, the most common extra-axial tumor to invade the brain is a benign meningioma. Invasive meningiomas are not necessarily histologically malignant. Other extra-axial tumors that can invade the brain include malignant meningeal tumors, metastases and lymphoma.



Raza Sirwan - Acesso via Facebook  

Will that person survive or it leads to death soon ?



Rafa Lima Santos - Acesso via Facebook  

very good Dr.Atlas.



Bruno Lima - Acesso via Facebook  

Great





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