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Man with left-sided facial droop.

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.

Click for galleryClick for galleryClick for galleryClick for galleryPlease 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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Man with left-sided facial droop.



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).Click for galleryClick for galleryClick for galleryClick for gallery
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Man with left-sided facial droop.

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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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Man with left-sided facial droop.


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

References

  1. StatDx,  August 8, 2011
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Man with left-sided facial droop.


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