The Clinical Problem Solvers Episode 338 – RLR – Brain Mass
Jun 3, 2024
Rabih (Robbie), a clinician who excels at synthesizing diagnostic data, and Aaron Berkowitz, a clinician with neuroradiology expertise, walk through a puzzling brain mass case. They dissect MRI features, debate blood versus calcification, weigh infectious mimics like TB, and prioritize imaging, pleural analysis, and timing of biopsy versus empiric cancer therapy.
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Imaging Clues Point To Metastasis
- A tiny ring-enhancing lesion that respects the gray-white junction strongly suggests metastasis rather than stroke.
- Aaron used FLAIR, T1 post-contrast, GRE susceptibility, and DWI to identify enhancement, blood products, and lack of diffusion restriction.
Susceptibility Signal Suggests Bleeding
- Hemorrhagic signal on susceptibility imaging without CT calcification favors blood over calcium and raises suspicion for hemorrhagic metastasis.
- Melanoma, renal cell carcinoma, choriocarcinoma and thyroid are classically hemorrhagic, while lung remains common overall.
Search Systemically Before Doing An LP
- For a solitary parenchymal lesion, prioritize CT chest/abdomen/pelvis over lumbar puncture to search for systemic primary cancer.
- CSF cytology has low yield for parenchymal lesions and may require multiple LPs.