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Our appreciation is extended to Dr. Chucky Ashraf,
Indiana University Department of Radiology,
for contributing this case.

History: Man with left-sided facial droop.

Click these images to enlarge them.

Please respond to the following with TRUE or FALSE regarding the salient findings.

Multifocal

True or False

Hemorrhagic

True or False

Associated edema

True or False

Enhancing masses

True or False

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Same images are again shown below. Given the overall appearance, can you select the presenting clinical history?

Melanoma.Acute bacterial endocarditis.Osler-Weber-Rendu syndrome.Hypertension.Trauma (found down).

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Findings: Multiple hyper dense foci with surrounding edema seen throughout cerebral parenchyma of multiple variable arterial distribution

Differential diagnosis:

Multiple embolic (paradoxical vs. cardiac) infarctions with hemorrhagic transformation
Hypertensive intracranial hemorrhage
Parenchymal metastases
Amyloid angiopathy
Cavernous malformations
Lymphoma, primary CNS
HUS/TTP

Actual diagnosis: Multiple septic embolic infarctions with hemorrhagic transformation secondary to bacterial (S. aureus) endocarditis

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Key points:

Hyper dense parenchymal lesions – Increased attenuation to normal brain
- Clotted blood, most common
- Nonhemorrhagic hypercellular mass (usually contrast-enhancing)
Pattern of distribution:
- Random and diffuse cerebral parenchymal foci of various arterial distribution
Etiology:
- Multiple and random diffuse location suggests cardioembolic (atrial fibrillation, septic emboli), paradoxical emboli, metastatic disease, cavernous malformation hemorrhage, HUS/TTP
Narrowing differential diagnosis:
- Hypertensive intracranial hemorrhage:
  - Solitary>multifocal hemorrhage
  - Usually deep lesions (e.g. basal ganglia)
Amyloid angiopathy:
- Elderly affected
- Classically lobar hemorrhages of different ages