Wk 4, Case 3 - Review

Patient History

An 81-year-old man with a history of rectal cancer presents to the emergency department with symptoms concerning for stroke.

Findings

CT Head:

Brain Parenchyma:

3.1 x 2.3 x 2.4 cm (anteroposterior by transverse by craniocaudal) hyperdense mass within the anterior left frontal lobe. Surrounding hypodensity reflective of vasogenic edema causing minimal rightward midline shift.

2.3 x 2.2 x 2.4 cm hyperdense mass within the left temporal lobe circumferentially encasing a portion of the left temporal horn, with dilatation of the distal aspect of the left temporal horn. Surrounding hypodensity reflective of vasogenic edema.

Additional periventricular and subcortical hypodensities, likely reflecting sequelae of chronic microvascular disease.

Ventricles and Sulci: Normal for age.

Extra-Axial Spaces: No extra-axial fluid collection.

Orbits: Right lens replacement. Orbits appear otherwise unremarkable.

CTA Head and Neck:

Extracranial:

Arch & Subclavian Arteries: Standard three-vessel arch. Subclavian arteries are normal bilaterally.

Common Carotids: Normal bilaterally.

Cervical ICAs: 50% narrowing of the right and less than 25% narrowing of the left internal carotid arteries immediately distal to the carotid bulbs.

Intracranial:

No flow limiting stenosis or aneurysm.

Intracranial ICAs: Patent bilaterally from the skull base to the carotid terminus.

MCAs: Normal bilaterally.

ACAs: Normal bilaterally.

ACom: Normal

P-Comms: Visualized bilaterally.

Vertebral arteries: Moderate stenosis at the takeoff from the subclavian artery on the left. Otherwise patent.

Basilar artery: Moderate stenosis, though remains patent.

PCAs: Normal bilaterally.

CT Perfusion Head:

Markedly elevated cerebral blood volume with mildly increased cerebral blood flow to both masses in the left cerebral hemisphere.

Conclusion

1. Two metastases within the anterior left frontal lobe and left temporal lobe, with the latter encasing the left temporal horn and causing ventricular entrapment. Minimal rightward midline shift without transtentorial or cerebellar tonsillar herniation. The hyperdensity of the masses could reflect hemorrhage versus dense cellular makeup.

2. 50% narrowing of the right and less than 25% narrowing of the left proximal cervical ICAs. Moderate stenosis at the origin of the V1 segment of the left vertebral artery. Moderate stenosis of the basilar artery, likely atherosclerotic in etiology, though remaining patent. Major arteries of the head and neck are otherwise patent. No occlusion, aneurysm, or dissection.