ROMANIAN JOURNAL OF NEUROLOGY – VOLUME XVI, NO. 4, 2017 175 REVIEWS MULTIPLE CEREBRAL MELANOMA METASTASES WITH UNKNOWN PRIMARY TUMOR LOCATION: A CASE REPORT Liviu Cozma 1 , Delia Tulba 1 , Maria Barsevschi 1 , Cristina Mitu 1 , Laura Dumitrescu 1,2 , Radu Tanasescu 1,2 , Bogdan Ovidiu Popescu 1,2,3 1 Department of Neurology, “Colentina” Clinical Hospital, Bucharest 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest 3 Department of Molecular Medicine, “Victor Babes” National Institute of Pathology, Bucharest ABSTRACT Introduction. Diagnostic and therapeutic approach of multiple cerebral lesions is often challenging. Case report. A 66-year-old man with unremarkable medical history was admitted to our hospital for recent inability and stereotyped movements of the left upper limb. Brain MRI identified eight tumoral masses with contrast enhance- ment and marked SWI signal loss that displayed increased metabolic activity on 18F-FDG PET/CT scan. Cerebral biopsy led to the diagnosis of melanoma with BRAF V600E mutation. Stereotactic radiosurgery and molecular ther- apy were planned afterwards. Conclusion. Brain MRI is an useful tool in guiding diagnosis of cerebral metastases of unknown origin. Keywords: cerebral metastases, unknown primary tumor, melanoma, BRAF mutation, SWI hypointensity, fluid-blood level Author for correspondence: Liviu Cozma, “Colentina” Clinical Hospital, 19-21 Stefan cel Mare Street, Bucharest E-mail: cozma.liviu89@yahoo.com IMAGES IN NEUROLOGY INTRODUCTION Mutiple cerebral lesions without identified pri- mary tumor often raise diagnostic and therapeutic dilemmas. In this report, we present a mild sympto- matic case of multiple melanoma brain metastases and discuss the importance of brain MRI in distin- guishing different neoplasms, as well as the thera- peutic strategies for melanoma brain metastases. CASE REPORT A 66-year-old man was admitted to our hospital for persistent left hand inability with sudden onset two weeks earlier. He had recently experienced two episodes of stereotyped movements of the left up- per limb. Apart from a right shoulder melonocytic nevus of unknown significance that had been ex- cised 5 years prior, the patient reported irrelevant medical history. Clinical examination identified global hypopro- sexia and left upper limb motor deficit (4/5 MRC scale). Blood tests were within normal range, in- cluding serology for parasitoses (Echinococcus, Taenia, Toxocara and Toxoplasma) and HIV infec- tion. Cerebral MRI was performed, showing eight lesions with contrast enhancement, marked SWI signal loss and peri or intratumoral bleeding (de- tails in Table 1 and Figures 1, 2 and 3). On 18 F-FDG PET/CT scan increased metabolic activity of brain lesions was noticed, indicating metastases with un- known primary site. Cerebral biopsy from the right frontal lesion was performed, histopathological ex- amination identifying a poorly differentiated carci- noma. Furthermore, immunohistochemistry tests and molecular testing by PCR were applied, diag- nosing melanoma with BRAF V600E mutation. Remission of neurologic deficit was achieved with symptomatic treatment (i.e. intravenous dexa-