A 73-year-old male with history of a lung mass on recent chest radiograph presents with headaches.

Acute demyelination of multiple sclerosis

Answer: C. Brain metastasis (metastatic lung cancer to brain)

Multiple sequences from contrast enhanced brain MR: axial FLAIR, axial T1 post contrast, diffusion weighted image, axial T1, and axial T2.

There is an approximate 2 cm area of enhancement in right occipital cortical and subcortical region. Imaging findings show a solitary, enhancing intra-axial mass with surrounding vasogenic edema, and associated hemorrhage. In a patient with underlying malignancy, this most likely represents a solitary brain metastasis. Glioblastoma multiforme is also possible, and can sometimes mimic solitary metastasis, though GBM tends to be more infiltrative and central in location.

 Imaging findings show a solitary, enhancing intra-axial mass with surrounding vasogenic edema, and associated hemorrhage. In a patient with underlying malignancy, this most likely represents a solitary brain metastasis. Glioblastoma multiforme is also possible, and can sometimes mimic solitary metastasis, though GBM tends to be more infiltrative and central in location.

No hyperintense signal on DWI to suggest acute infarct. Brain abscess typically demonstrate rim enhancement with restricted diffusion centrally. Active demyelinating plaque of multiple sclerosis classically shows incomplete rim enhancement, and is typically associated with other cerebral white matter lesions, some of which may be longitudinal in orientation. 

Brain metastases are typically round enhancing masses at grey-white matter interface.  Half of all brain masses are metastasis and half of all brain metastasis are solitary. Most common causes of brain metastasis include lung, breast, melanoma and renal cell carcinomas.

Patients commonly present with headache, seizure, focal neurologic deficit, but can also be asymptomatic. Treatment typically includes steroids, radiation therapy or local surgical resection.  

1. Osborn AG, Salzman KL, Barkovich AJ. 2010. Diagnostic Imaging: Brain. 2nd ed. Amirsys.

2. Atlas SW. 2009. Magnetic Resonance Imaging of the Brain and Spine. 4th ed. Wolters Kluwer Health/Lippincott Williams and Wilkins.

Image IQ: 73-year-old with History of Lung Mass Suffers Headaches