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22b - Answer: 56-year-old male presents with possible stroke

Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
Includes DICOM files

HISTORY: 

This 56-year-old male presents with possible stroke. Biopsy of tumor 10 years ago. Previous surgery for seizures.

(QUIZ ANSWER) NOT A FINDING IN THIS CASE: 

Complete empty sella.

Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.

FINDINGS:

Gliosis and encephalomalacia involving the left middle and inferior frontal gyri as well as the left subinsula. Serpiginous postcontrast enhancement within the insula and base of inferior frontal gyrus with an area of central hypointensity was present on the MRI five months prior (NOT SHOWN HERE). There is a new bilobed area of ring enhancement which is thick-walled within the left insula. The left insula is increased in volume in comparison to the right. Mild edema. Area of volume loss at the level of the left posterior operculum was present on the MRI five months prior (NOT SHOWN HERE).

No meningeal enhancement or evidence of basilar meningitis.

Subtle area of hyperintensity at the base of the left inferior frontal gyrus on diffusion-weighted images was present on the MRI five months prior (NOT SHOWN HERE), but may be slightly more conspicuous on the present examination. Finding is associated with T2 hyperintensity on FLAIR images. 

Paranasal sinuses are clear. 

Masticator, parapharyngeal, pharyngeal mucosal, prevertebral and parotid spaces are without masses or adenopathy. 

No extra-axial collections or hemorrhage. 

Parietotemporal pattern of cerebral atrophy with preservation of the hippocampi. Venous sinuses are patent. 

7th and 8th nerve complexes are intact. Cochleae and vestibules are intact. Otomastoid air spaces are clear. 

Partial empty sella. 

CONCLUSION: 

1. Left hemispheric gliosis, encephalomalacia and volume loss was present on the MRI five months prior (NOT SHOWN HERE). Serpiginous enhancement at the base of the left inferior frontal gyrus and subinsula was also present on the earlier examination. However, there has been interval development of additional areas of ring enhancement. The left insular volume is increased in relation to the right with increased T2 signal. Subtle 4mm hyperintensity on diffusion-weighted images in this area was present on the earlier MRI.The interval development of ring enhancement and presence of increase in left insular volume and signal abnormality on both the present and prior scan is most suggestive of neoplasm of infiltrating type such as GBM or gliomatosis cerebri. Stroke is felt to be less likely. Followup imaging is recommended to monitor lesion evolution. 

2. Parietotemporal pattern of cerebral atrophy with preservation of the hippocampi and entorhinal cortices. 

3. No obstructive hydrocephalus. 

4. No acute parenchymal hemorrhage.

LESSON 2, TOPIC 66

Case Challenge: Sella MRI Cases

Case Challenge

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Content reviewed: July 15, 2021

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