Presentation
Known metastatic choriocarcinoma.
Patient Data
A small, faintly enhancing, hemorrhagic lesion with surrounding edema is seen involving the central sulcus of the right hemisphere.
The patient went on to have surgery.
Histology
Paraffin sections show collections of markedly atypical cells within edematous and hemorrhagic brain parenchyma. These have irregularly shaped enlarged hyperchromatic nuclei, some with multiple nuclei and a variable amount of pale and vacuolated cytoplasm.
The tumor cells are AE1/3, CAM5.2, CK7, CK19 and EMA positive. They are BHCG, c-kit, PLAP, AFP, tyrosinase, GFAP, nestin and TTF-1 negative.
Final diagnosis
Metastatic choriocarcinoma.
MRI post intrathecal chemoRx
Patient was receiving intrathecal methotrexate and developed postural headache (worse on standing).
MRI demonstrates typical appearances of intracranial hypotension with diffuse dural enhancement, subdural effusions, small ventricles, plump pituitary gland and engorged intracranial veins and rounded dural venous sinuses.
The brainstem is slumped with reduced mamillopontine distance.
Case Discussion
This case demonstrates typical appearances of intracranial hypotension, in this case due to repeated lumbar punctures. The patient was treated with an epidural blood patch and symptoms resolved.