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Case presentation

Case presentation. Sharon H. de Kock August 2012. 33yr female Referred with hx of numbness of 1 st 2 digits of Rt hand, also focal convulsions affecting the Rt corner of her mouth. According to pt she was healthy before Feb ‘12. No other relevant hx / illnesses. CLINICAL HISTORY.

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Case presentation

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  1. Case presentation Sharon H. de Kock August 2012

  2. 33yr female • Referred with hx of numbness of 1st 2 digits of Rt hand, also focal convulsions affecting the Rt corner of her mouth. • According to pt she was healthy before Feb ‘12. • No other relevant hx/ illnesses. CLINICAL HISTORY

  3. GCS 15/15 • Orientated to place, person, time. • Higher functions in tact. CLINICAL EXAMINATION

  4. CXR • MRI of Brain & Spine • Scintigram SPECIAL INVESTIGATIONS

  5. Multiple high signal nodules and mass on T1. • Involving the cerebrum and cerebellum. • Intra-axial. • Largest in Lt parietal region approx 3.5 x 4 cm axially & 4.5 cm cranio-caudally. • Largest in post fossa on Lt approx 1.3 cm CC & 2 x 2.2 cm axially. • Spectroscopy of Lt large parietal mass: lactate peak suggestive of necrosis/ infection, no increased Ch/NAA ratios. MRI FINDINGS

  6. Vasogenic oedema surrounding mass cause mass effect on lat ventricle and midline. • Basal cisterns patent. • Prominent post C enhancement. • Central necrosis. • GE: blooming artefact suggestive of hemosiderin & chronic blood. MRI FINDINGS cont.

  7. No abnormal signal changes in the spinal cord. • Few high signal intensity lesions in the vertebral bodies- T4, T11 & L4- ?fat. MRI FINDINGS cont. (spine)

  8. Haemorrhagic mets. • Meningealmelanotosis • Neuro-cutaneousmelanosis. DIFF DX

  9. No convincing evidence of skeletal mets. SKELETAL SCINTIGRAM

  10. METASTATIC MALIGNANT MELANOMA ANATOMICAL PATHOLOGY

  11. T1 relaxation is the process of longitudinal magnetization recovery after applying a RFP/ excitation to invert the vector. • Occurs as energy from the spinning nuclei is dissipated into surrounding areas. • Substances with intrinsic shorter T1 relaxation times demonstrate higher signal intensity on T1WI. T1 PHYSICS

  12. Various natural occurring substances are responsible- (reduce T1 relaxation time) *methemoglobin, *melanin, * lipid, *protein, *calcium, *iron, *copper and *manganese. HIGH SIGNAL INTENSITY ON T1WI

  13. CLASSIFICATION

  14. CLASSIFICATION

  15. Physical Properties: - MRI appearance of haemorrhages & lesions containing blood depends on the age of the blood. - intracellular methemoglobin= early sub- acute phase haemorrhage, 3-7d after onset. - extracellular methemoglobin= late sub- acute phase, 8d-1mnth after onset. METHEMOGLOBIN-CONTAINING LESIONS

  16. - produce T1 shortening effects. - therefore have intrinsically high signal intensity on T1WI. - attributed to paramagnetic interactions. METHEMOGLOBIN-CONTAINING LESIONS, Physical Properties cont.

  17. Cavernous Malformations: - congenital/ acquired vascular anomalies. - occur in approx. 0.5% of general population. • Cerebral Venous Thrombosis: - unusual condition. METHEMOGLOBIN-CONTAINING LESIONS

  18. CAVERNOUS MALFORMATION

  19. CEREBRAL VENOUS THROMBOSIS

  20. Physical Properties: - demonstrate high signal intensity on T1WI because of the paramagnetic effects of stable free radicals and metal scavenging effects. MELANIN-CONTAINING LESIONS

  21. Metastatic Melanoma: - intracranial mets occur in nearly 40% of pts with malignant melanoma. - high signal intensity also can result from haemorrhage within these lesions. • Prim Diffuse MeningealMelanomatosis: - aggressive form of prim intracranial melanoma, extremely rare. MELANIN-CONTAINING LESIONS

  22. PRIMARY DIFFUSE MENINGEAL MELANOMATOSIS

  23. NeurocutaneousMelanosis: - uncommon congenital condition characterized by multiple giant or hairy nevi and melanin containing lepto- meningeal lesions without evidence of extracranial melanoma. MELANIN-CONTAINING LESIONS, cont.

  24. Physical Properties: - short T1 relaxation time of hydrogen nuclei within lipid molecules. - produces high signal intensity on T1WI. LIPID-CONTAINING LESIONS

  25. Intracranial Lipomas: - rare congenital malformation. - arise from abnormal differentiation of the persistent primitive meninx. - commonly occur in pericallosal region, often associated with disgenesis or agenesis of the corpus callosum. LIPID-CONTAINING LESIONS

  26. INTRACRANIAL LIPOMA

  27. Teratomas: - true neoplasms, usually contain tissue derived from all three germ cell layers. - mostly benign, malignant variants exist. - most frequently found in the cerebral hemispheres and pineal gland. • Dermoid Cysts: - rare, benign, congenital ectodermal inclusion cysts, commonly in midline. LIPID-CONTAINING LESIONS, cont.

  28. PINEAL TERATOMA

  29. Physical Properties: - high signal intensity of certain lesions on T1WI can be attributed to their protein content and the hydration layer effect. PROTEIN-CONTAINING LESIONS

  30. Colloid Cyst: - uncommon benign intracranial lesions. - contain gelatinous material. - occur characteristically at the antero- superior aspect of the 3rd ventricle. • Rathke Cleft Cyst: - common benign remnants of the Rathke cleft, may be located in sellar-/ supra- sellar compartment. PROTEIN-CONTAINING LESIONS

  31. COLLOID CYST

  32. RATHKE CLEFT CYST

  33. Physical Properties: - Calcium is a diamagnatic substance that may appear bright on T1WI. - Other minerals that have T1 shortening effects include manganese, copper and iron. MINERAL-CONTAINING LESIONS

  34. Hepatic Encephalopathy: - characteristically manifests as bilateral regions of high signal in the lentiform nucleus and substantianigra on T1WI. - related to the accumulation of manganese. • Wilson Disease: - rare autosomal recessive condition. - resultant abn copper metabolism & acc. - basal ganglia & thalami commonly affected. MINERAL-CONTAINING LESIONS

  35. HEPATIC ENCEPHALOPATHY

  36. WILSONS DISEASE

  37. Familiarity with substances and physical properties that contribute to T1 shortening is helpfull to formulate an appropriate Diff Dx. TAKE HOME POINT

  38. Could still not find the primary lesion. • Referred to Oncology. OUR PT?

  39. Intracranial Lesions with High Signal Intensity on T1-weighted MR Images: Differential Diagnosis, RadioGraphics 2012; 32:499-516. • Grainger & Allison’s Diagnostic Radiology, 5th Edition, Volume 2. REFERENCES

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