Case Report Open Access Neurological Disorders J o u r n a l o f N e u r o l o g i c a l D i s o r d e r s ISSN: 2329-6895 Prasad, et al., J Neurol Disord 2015, 3:1 DOI: 10.4172/2329-6895.1000208 Volume 3 • Issue 1 • 1000208 J Neurol Disord ISSN: 2329-6895 JND, an open access journal Brain Metastasis with High Protein Content- An Extremely Rare Imaging Feature G Lakshmi Prasad 1 *, Rajesh Nair 1 * and Geetha Vasudevan 2 1 Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India 2 Department of Pathology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India Keywords: T1 hyperintense lesions; Metastatic papillary adenocarcinoma; High protein content Introduction Metastasis represents the most common brain malignancy. Solitary or multiple ring enhancing intra-axial lesions bordered on the gray- white matter junction with disproportionate edema is the usual pattern on imaging. No reports of high protein content parenchymal metastatic lesion can be found in literature till now. Authors here describe a case of 42 year old female presenting with features of intracranial hypertension and imaging suggestive of a high protein containing lesion. Gross total resection was performed and histopathological features were suggestive of metastatic papillary adenocarcinoma. Case Description A 42-year old woman without past medical history, presented to our clinic with a three-month history of holocranial headache and one week history of blurring of vision. Neurological examination revealed homonymous hemianopia with papilledema. A thyroid nodule was noted on general examination. Breast examination was normal. Biochemical examination showed evidence of mild hypothyroidism while tumour markers (CA 19.9, CA 125 and CEA) were within normal limits. Fine needle aspiration cytology (FNAC) from the thyroid nodule, preoperatively, featured a diagnosis of follicular neoplasm. CT brain showed features of a homogeneously hyperdense intra-axial lesion in the right occipital lobe with peri lesional edema and mass efect (Figure 1a). On MRI, it appeared to be consisting of 2 components- peripheral component of the lesion being hyper intense on T1, T2 weighted and FLAIR sequences and inner component being isointense on all these sequences (Figure 1b (a-d)). Te inner component showed restriction on difusion weighted images and also mild enhancement on contrast images (Figure 1b (e and f). On MR spectroscopy (MRS), there was low intratumoral Cho/Cr ratio with perilesional low NAA/Cho ratio (Figure 2). Tere was no fuid level noted. Based on these imaging patterns, radiologically, features were suggestive of a high protein-containing lesion. A diferential diagnosis of metastasis or an ependymoma was thought of, based on the location. A thorough clinical and radiological work-up (Tumor markers, Chest X-ray, Peripheral smear, Ultrasound abdomen and PET Scan) for the primary lesion was negative. Intra- operatively, the tumor was heterogeneous, was reaching up the surface and possessing solid and cystic components. Te cyst contained dark, thick, viscid fuid, possessing a “machinery oil” like consistency. Te solid component was moderately vascular, sof to frm in consistency and “easily suckable” [1]. Gross total resection was performed. Histopathology revealed nuclear atypia within malignant columnar cells arranged over a papillary fbrovascular core, features suggestive of metastatic papillary adenocarcinoma (Figure 3). Cytological examination of the proteinacious cyst content was also positive for malignancy. She was further referred for whole brain radiotherapy. Discussion Metastases represents the most common brain neoplasm worldwide [2-4]. Tey are usually multiple and well-demarcated with disproportionate surrounding edema. Cerebral hemispheres are the most common location followed by cerebellum. [2,5]. Tis is dictated by the size of the region and the proportion of blood fow [2,6]. Tey are usually located at the gray-white matter junction in water-shed areas [2,4,5]. Lung, breast, melanoma and renal carcinoma are the most common primary sites of brain metastases. [2,4]. Te advent of modern imaging techniques such as MRI has tremendously improved the diagnosis of intracranial lesions in recent years. Te appearance of these lesions on various MR sequences holds the key to such diagnoses [7]. On imaging, metastatic lesions usually appear hypointense on T1 and hyperintense on T2 weighted images (WI) with varying patterns of enhancement, ranging from homogeneous to a ring pattern [8]. Te main diferential diagnosis include, abscess, high grade gliomas such as glioblastoma multiforme (GBM), CNS lymphomas, demyelinating and infammatory lesions [2,8]. Additional sequences such as MR spectroscopy (MRS), MR perfusion (MRP) and difusion images also assist in closing onto the diagnosis of such lesions [8,9]. Although, tumoral MRS and MRP fndings are ofen equivocal for mets and GBM, evaluation of the peritumoral T2 hyperintense edema by MRS, MRP, DWI provide the best means of diferentiating between primary high grade tumours and solitary metastasis [8]. Abstract Metastasis forms the most common brain malignancy. Solitary or multiple ring enhancing intra-axial lesions bordered on the gray-white matter junction with disproportionate edema is the usual pattern on imaging. No reports of high protein content parenchymal metastatic lesion can be found in literature till now. Authors here describe a case of 42 year old female presenting with features of intracranial hypertension and imaging suggestive of a high protein containing lesion. Gross total resection was performed and histopathological features were suggestive of metastatic papillary adenocarcinoma. *Corresponding author: Lakshmi Prasad G, Rajesh Nair, Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India, Tel: 0091-9611519911; E-mail: rajeshnair39@yahoo.com Received January 07, 2015; Accepted January 28, 2015; Published January 30, 2015 Citation: Prasad GL, Nair R, Vasudevan G (2015) Brain Metastasis with High Protein Content- An Extremely Rare Imaging Feature. J Neurol Disord 3: 208. doi:10.4172/2329-6895.1000208 Copyright: © 2015 Prasad GL, et al. 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