A 47-year-old woman with a history of diabetes mellitus, hypertension, and peripheral vascular disease presented with headache, emesis, dysarthria and fluctuating left facial and upper extremity weakness for 3 months. Head CT showed hyperdensity in the right central sulcus concerning for acute subarachnoid blood products (Figure 1A). MRI brain without contrast was also initially interpreted as subarachnoid hemorrhage (Figure 1B). However, her subacute clinical course prompted cerebrospinal fluid analysis which revealed malignant epithelioid neoplasm. Subsequently, a MRI of the brain with contrast was obtained and revealed leptomeningeal enhancement of the right central sulcus on the post contrast images. Malignancy workup identified an enlarged axillary lymph node, which upon biopsy was consistent with metastatic breast adenocarcinoma. Due to increased protein, highly cellular tumors can appear hyperintense on brain imaging mimicking subarachnoid hemorrhage. 1 Thus, it is important to keep malignancy on the differential for increased attenuation on CT head particularly in those with a progressive or atypical course. Furthermore, breast cancer is the most common cause of leptomeningeal disease, although only seen in 5% of patients with breast cancer. 2
Figure 1.
(A) Axial CT head showing hyperattenuation in the right central sulcus. (B) Axial MRI FLAIR image showing hyperintensity in right central sulcus. Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; FLAIR, fluid attenuated inversion recovery.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Kanita Beba Abadal https://orcid.org/0000-0002-5694-7725
Swetha Renati https://orcid.org/0000-0001-6479-3634
References
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