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Clinical Neuroradiology–Neuropathology Conference. December 2010. Patrick Farley, MD (Neuroradiology Fellow) and Thomas Bouldin, MD ( Neuropathologist ). Case #1. CLINICAL HISTORY: 59-year-old man with history of altered mental status and hearing loss. Differential diagnosis.

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December 2010

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december 2010

Clinical Neuroradiology–Neuropathology Conference

December 2010

Patrick Farley, MD (Neuroradiology Fellow) andThomas Bouldin, MD (Neuropathologist)


Case #1

CLINICAL HISTORY: 59-year-old man with history of altered mental status and hearing loss.

differential diagnosis
Differential diagnosis
  • Infectious Meningitis
  • Neoplastic Meningitis
    • Breast, lung most common extracranial sources
    • Most common primary brain tumors are GBM, medulloblastoma, pineal tumors, and choroid plexus tumors
  • Neurosarcoidosis
    • Lacy leptomeningeal enhancement
    • May have ventricular or dural-based enhancing masses

Brain biopsy revealed a poorly differentiated neoplasm within the leptomeninges and around several intracortical blood vessels. The immunophenotype of the neoplastic cells was consistent with a melanoma. The histologic features do not permit distinction between metastatic melanoma (common) and primary leptomeningeal melanoma (rare).

case 2
Case #2

CLINICAL HISTORY: 21-year-old postpartum woman with a sellar mass.

differential diagnosis8
Differential Diagnosis
  • Adenoma
  • Pituitary hyperplasia
    • 25–50% of females 18–35 years old have upwardly convex pituitary
    • Usually < 10 mm unless pregnant, lactating
  • Aneurysm
    • Usually eccentric, not directly suprasellar
    • Pituitary gland visible and identified as separate from mass
    • Flow-related artifacts on MRI are common
  • Meningioma
    • Pituitary gland may be visible and identified as SEPARATE from mass
differential diagnosis continued
Differential Diagnosis (continued)
  • Metastasis
  • Lymphocytic hypophysitis
    • Can mimic adenoma clinically and on imaging studies
    • May show zones of very low T2 signal peripherally
    • Most common in peripartum female
  • Craniopharyngioma
    • Ca++, cysts more common, Children > adults
    • Rim/nodular > solid enhancement
    • May be indistinguishable from Rathke cleft cyst

Biopsy revealed a dense lymphoplasmacytic infiltrate within the anterior pituitary. The gland also showed interstitial fibrosis and a loss of secretory cells. The remaining secretory cells form the clusters of larger, more eosinophilic cells in the photomicrograph.

lymphocytic hypophysitis
Lymphocytic hypophysitis
  • Females > males, with a ratio of approximately 5:1
  • Often during last months of pregnancy or first few months postpartum
  • Often have family history of autoimmune disease
  • Sometimes associated with Hashimoto’s thyroiditis or Graves’ disease
  • No adverse effect on fetus
  • Presents as hypopituitarism and/or mass effect—headache or visual field cuts
  • If unrecognized, may cause death from panhypopituitarism
  • Treatment includes hormonal replacement and surgery to reduce mass effect.
lymphocytic hypophysitis12
Lymphocytic hypophysitis
  • Diagnostic signs:
  • Thick non-tapered stalk, with or without pituitary mass
  • Supra, intrasellar mass
  • Areas of low T2 signal peripherally or/and in cavernous sinuses
  • Usually < 10 mm but may be up to 2-3 cm
  • Rounded pituitary gland with infundibulum that appears thickened, nontapering, or bulbous
clinical history 73 year old female with acute headache and right sided weakness


CLINICAL HISTORY: 73-year-old female with acute headache and right-sided weakness.

differential diagnosis15
Differential Diagnosis
  • Hypertensive hemorrhage
  • Deep structures (basal ganglia, thalami, cerebellum) but may also occur in cortex and subcortical white matter
  • Hemorrhagic infarct
  • Hemorrhagic metastases
  • Cerebral amyloid angiopathy

Postmortem examination of the brain in this case revealed numerous cortical and leptomeningeal vessels infiltrated by amorphous, eosinophilic amyloid. Inset shows the immunohistochemical staining of the amorphous material for beta amyloid.

Beta Amyloid IHC

cerebral amyloid angiopathy caa
Cerebral amyloid angiopathy (CAA)
  • Deposition of beta amyloid in cortical and leptomeningeal vessels
  • Common in older patients
  • Often associated with Alzheimer’s disease
  • Complications of CAA include intracerebral lobar hemorrhage, microbleeds, subarachnoid hemorrhage, cerebral infarcts, inflammatory CAA, and white-matter abnormalities.
caa imaging
CAA Imaging
  • Look for:
  • Lobar hemorrhage(s) of different ages
  • Multifocal areas of susceptibility artifacts corresponding to chronic microbleeds, particularly in cortex
  • Hemorrhage may extend to subarachnoid space or into ventricles
  • Acute lobar hemorrhage tends to be large
  • Protocol advice:
  • Recommend T2*-weighted sequence in all patients > 60 years of age
case 4

CLINICAL HISTORY: 65-year-old man with history of renal cell carcinoma first diagnosed in 1994. He has since had numerous surgeries for metastases to the brain. He also had stereotactic radiosurgery for an olfactory groove-based lesion, which was presumed to be a meningioma.

Case #4
case 421
Case #4

CLINICAL HISTORY (continued): A few months later the presumed meningioma developed surrounding edema, became larger, and demonstrated areas of different enhancement intensity and T2 signal.


Biopsy of the olfactory-groove lesion revealed a meningioma (right half of photomicrograph). Also present within the meningioma was a focus of metastatic renal cell carcinoma (left half of photomicrograph).

tumor to tumor metastasis
Tumor-to-tumor metastasis
  • Metastasis of a systemic cancer to an intracranial tumor is rare.
  • Most often, the CNS tumor is a meningioma. Other reported types of intracranial tumors harboring a metastasis include 8th-nerve schwannoma, glioma, hemangioblastoma, and pituitary adenoma.
  • Breast and lung are the most common primary sites, with breast being the most common site.
  • Renal cell carcinoma metastatic to a meningioma has been reported only rarely. Renal cell carcinoma may also metastasize to a hemangioblastoma in the context of the von Hippel-Lindau syndrome.

Lanotte M, et al. Systemic cancer metastasis in a meningioma: Report of two cases and review of the literature. Clinical Neurology and Neurosurgery 111 (2009) 87–93.

case 5
Case #5

CLINICAL HISTORY: 2-year-old African-American girl with left eye strabismus for 9 months.

differential diagnosis27
Differential Diagnosis
  • Retinoblastoma
  • Calcifications, enhancement, mass of low T2 signal intensity
  • Persistent hyperplastic primary vitreous
  • Coat’s disease
  • Retinal astrocytoma
  • Rare; isolated or in association with tuberous sclerosis (TSC)
  • Ocular toxocariasis
  • Congenital
  • Due to incomplete regression of embryonic ocular blood supply
  • Imaging
  • Best diagnostic clue: Hyperdenseor hyperintense small globe, retrolental soft tissue, no Ca++
  • Retinal detachment common
  • Central linear structure: Cloquet’scanal
  • Layering blood or debris may be present
  • PHPV is the most common intraocular abnormality to be confused with retinoblastoma

The intraocular lesion is a small blue cell tumor with neuroblastic (Homer Wright) rosettes (arrows). The histological features of the tumor are typical of a retinoblastoma.



  • Calcified intraocular mass
  • Unilateral in 70-75%


  • T2 Hypointense relative to vitreous
  • Moderate to marked heterogeneous enhancement
  • Best for assessing extraocular and intracranial disease