Hospital: Hospital Universitario Virgen Macarena.
Ciudad:
Nº:
Aut@r o Autores: T. Busquier Cerdán, M. Mayorga Pineda, D. De Araujo Martins-Romèo, M. Roquette Mateos, X.M. Cortés Sañudo, I. Avilés Vazquez.,
Presentación:
A 85 years old female patient anticoagulated, with hypertension and ancient heart attack personal history was admitted at the emergency room because of vertiginous syndrome. A non-contrast head CT showed a well demarcated hypodensity at the left cerebellar hemisphere (LCH) that depicted the appearance os an acute/subacute ischemic lesion (Fig.A). Further evaluation with Brain MRI (Fig.B) demonstrated a subacute intraparenchymal LCH hemorrhage compatible with hemorrhagic transformation of ischemic infarct. Due to this findings, anticoagulation drug was withdrawn. After twenty days of admission, she started with acute difuse abdominal pain that raised the suspition of mesenteric ischemia. The angio CT documented an intraluminal defect filling of 3cm in the abdominal aorta compatible with a floating thrombus(Fig.C). In order to restore anticoagulation, a non-contrast head CT was performed to asses the status of the subacute brain hemorrhage. Where we saw that the hemorrhage had similar size and shape and with peripheral enhancement because of the contrast used for the angio-CT (Fig.D).
Discusión:
Ring-enhancing lesions detected on contrast head CT at emergencies services could be challenging. Differential diagnosis is broad: metastasis, primary central nervous system tumours, abscesses, granulomas, demyelinating lesions, subacute intraparenchymal hematoma… So it is important to take into account the different features of the lesion, as well as clinical presentation. Ring-enhancing lesions pattern present a central cavity, homogeneous or heterogeneous, with a regular or irregular wall, of different thickness. Ring-enhancing lesions may be superficial, but they are usually subcortical or deep. Usually, when the ring is smooth and thin is typical of an organizing abscess, whereas thick and irregular ring suggests a necrotic neoplasm. A incomplete ring opened towars the cortex favours a demyelinating lesion. In this case, the contrast uptake occurs exclusively outside the hematoma itself, regualr and well denied, that is more tipical for subacute intraparenchymal hematoma. In addition, the clinical presentation and previous MRI helped confirm the diagnosis. Therefore the radiologist should be familiar with the patterns and mechanism of contrast enhancement. KEY points: -Peripheral enhancement detected on contrast enhanced CT is typically appreciated in subacute stage of intracranial haemorrhage wich can persist for several months.
Conclusión:
Ring-enhancing lesions detected on contrast head CT at emergencies services could be challenging. Differential diagnosis is broad: metastasis, primary central nervous system tumours, abscesses, granulomas, demyelinating lesions, subacute intraparenchymal hematoma… So it is important to take into account the different features of the lesion, as well as clinical presentation. Ring-enhancing lesions pattern present a central cavity, homogeneous or heterogeneous, with a regular or irregular wall, of different thickness. Ring-enhancing lesions may be superficial, but they are usually subcortical or deep. Usually, when the ring is smooth and thin is typical of an organizing abscess, whereas thick and irregular ring suggests a necrotic neoplasm. A incomplete ring opened towars the cortex favours a demyelinating lesion. In this case, the contrast uptake occurs exclusively outside the hematoma itself, regualr and well denied, that is more tipical for subacute intraparenchymal hematoma. In addition, the clinical presentation and previous MRI helped confirm the diagnosis. Therefore the radiologist should be familiar with the patterns and mechanism of contrast enhancement. KEY points: -Peripheral enhancement detected on contrast enhanced CT is typically appreciated in subacute stage of intracranial haemorrhage wich can persist for several months.
Bibliografía:
– Smirniotopoulos, J., Murphy, F., Rushing, E., Rees, J. and Schroeder, J. Patterns of Contrast Enhancement in the Brain and Meninges. RadioGraphics (2007), 27(2), pp.525-551. – Osborn, A., Hedlund, G. and Salzman, K. Osborn’s brain. (2018) 2nd ed.