Fluid--fluid level in cystic cerebral metastatic melanoma

An unusual case of metastatic melanoma in subcutaneous tissue presenting as a solitary cystic mass with fluid levels

Malignant melanoma is a common and often aggressive neoplasm of the skin arising from melanocytes. Metastatic melanoma is known for its diverse clinical manifestations, and can present with atypical features prior to diagnosis of the primary lesion, which can pose a diagnostic challenge. We report a rare case of metastatic melanoma in a 67 year-old male who presented with a painless, enlarging mass in the right axilla over a 4 week period. Ultrasound and magnetic resonance imaging (MRI) scans revealed a well-defined solitary, cystic appearing lesion in the right axilla with a distinct fluid-fluid level. An ultrasound guided biopsy of the lesion diagnosed a metastatic melanoma. While haemorrhagic distant metastases are a well-recognised complication of malignant melanoma, particularly in the brain and lung, soft tissue metastases presenting with fluid-fluid levels is not well described in the literature. The case highlights the importance of considering the differential of melanoma metastasis when encountered with such a lesion and importance of ultrasound guided biopsy for histopathological confirmation, as the imaging features can mimic that of a haemorrhagic soft tissue sarcoma, the management of which differs substantially from that of melanoma.

Fibroblastic meningioma mimicking an intracerebral hemorrhage: case report

A 50-year-old woman presented to the emergency room complaining of severe headache. A non-contrasted head CT was obtained, which demonstrated a hyperdense image compatible with an intracerebral hemorrhage in the posterior region of the left temporal lobe. The patient displayed no neurological deficit during the consultation and a subsequent MRI showed a temporoinsular bleeding lesion that was suggestive of an atypic meningioma or a metastatic lesion. Afterwards, neck, chest and abdomen CT scans were performed, and the imaging ruled out a secondary neoplasm. The patient underwent surgical resection of the lesion, and a solid tumor was found with no bleeding associated. The pathology reported a WHO I fibroblastic meningioma.

Sensitivity and specificity of blood-fluid levels for oral anticoagulant-associated intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a life-threatening emergency, the incidence of which has increased in part due to an increase in the use of oral anticoagulants. A blood-fluid level within the haematoma, as revealed by computed tomography (CT), has been suggested as a marker for oral anticoagulant-associated ICH (OAC-ICH), but the diagnostic specificity and prognostic value of this finding remains unclear. In 855 patients with CT-confirmed acute ICH scanned within 48 h of symptom onset, we investigated the sensitivity and specificity of the presence of a CT-defined blood-fluid level (rated blinded to anticoagulant status) for identifying concomitant anticoagulant use. We also investigated the association of the presence of a blood-fluid level with six-month case fatality. Eighteen patients (2.1%) had a blood-fluid level identified on CT; of those with a blood-fluid level, 15 (83.3%) were taking anticoagulants. The specificity of blood-fluid level for OAC-ICH was 99.4%; the sensitivity was 4.2%. We could not detect an association between the presence of a blood-fluid level and an increased risk of death at six months (OR = 1.21, 95% CI 0.28-3.88, p = 0.769). The presence of a blood-fluid level should alert clinicians to the possibility of OAC-ICH, but absence of a blood-fluid level is not useful in excluding OAC-ICH.

Melanotic cyst of L5 spinal root: A case report and review of literature

Till date, 85 cases of melanotic schwannoma and 11 cases of spinal root melanoma have been reported in literature. We are reporting a case of a 45-year-old lady who presented with primary low back pain, and magnetic resonance imaging of lumbo-sacral spine showed at left L5-S1 foraminal lesion extending to the para-spinal compartment. Hemi-laminectomy, facetectomy, and excision of the lesion were done. It was primarily a cystic lesion with attachment to the exiting spinal nerve root. Histopathology of the cyst wall showed a fibro-collagenous stroma with no specific cell lining containing melanin pigment suggestive of a melanotic cyst. The patient was completely relieved of the back pain, and had no recurrence over a follow-up period of one and half years. This case is probably the first reported predominantly cystic, pigmented lesion, affecting the spinal root.

Blood-fluid levels in the brain

17 cases reviewed prospectively over a period of 4 months highlight the varied appearance of blood-fluid levels in intracranial cystic lesions of different aetiologies; a finding which has not featured significantly in the medical literature. Four types of intracranial cysts demonstrating blood-fluid levels have been categorised according to the nature of the pathology, i.e. primary neoplasms of the brain, metastatic deposits to the brain in cases of extraneural malignancies, lesions of vascular aetiology and intraparenchymal bleeds secondary to trauma. The group of four primary intracranial neoplasms lists an oligodendroglioma, a recurrent tumour in a case of Von Hippel-Lindau syndrome, a Grade 3 astrocytoma and an acoustic schwannoma. Four cases of metastatic deposits to the brain were each secondary to primary malignant neoplasms of the breast, liver, ovary and lung. Of seven cases of a vascular aetiology, three resulted from arterial infarction, two from hypertension and one each from venous infarction and following anticoagulant therapy. Intracranial cysts within tumours have been postulated to occur secondary to a breakdown of the blood-brain barrier (BBB) rather than as a result of tumoural degeneration, as was thought probable earlier.

A rare case of intracranial metastatic amelanotic melanoma with cyst

A rare case of intracranial metastatic amelanotic melanoma with cyst is presented. The patient was a 51 year old woman with a malignant melanoma arising on her right chest. Two years after a wide excision, skin and brain metastasis occurred. Brain magnetic resonance images demonstrated a tumour with a cyst in the left occipital lobe. Because the tumour showed low intensity on T1 weighted images and high intensity on T2 weighted images, the metastatic melanoma was identified as an amelanotic melanoma. Intracranial amelanotic melanoma is very rare, and there have been few reports of melanoma with cyst.

The fluid-blood level in intracranial haematoma due to anticoagulant medication

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Significance of the fluid-blood interface in intracranial hematomas in anticoagulated patients

Six patients receiving anticoagulant medication who had laboratory evidence of impaired hemostasis as manifested by laboratory parameters exceeding the therapeutic range developed intracranial hemorrhages. None of these patients had a history of preceding trauma. None of the 6 anticoagulated had CNS symptoms prior to initiation of anticoagulant medication. Within the intracranial hemorrhage there was a fluid-blood interface in these 6 patients; this finding was seen only in hemorrhages in anticoagulated patients. In 3 cases the fluid-blood interface changed to a homogeneous hyperdense lesion when adequate hemostasis was achieved. In one case there were multiple hemorrhages and in the other there was a solitary intracerebral hemorrhage.

Supratentorial ependymomas. Neuroimaging and clinicopathological correlation

In 10 patients with supratentorial ependymomas, the tumors exhibited hyperdensity on computerized tomography (CT) scanning prior to contrast infusion and, with one exception, all tumors were mixed lesions with the low densities suggesting cystic or necrotic portions. Eighty percent of the tumors contained small calcifications. Characteristically, the tumors were well demarcated and demonstrated moderate to marked enhancement after the intravenous administration of contrast material. Angiograms obtained in some patients showed mild hypervascular tumor staining and absence of large feeding arteries. The degree of contrast enhancement, angiographic vascularity, and tumor stain was compared to the pathological anaplasia of the tumors. No correlation was observed. Of four patients who were still alive during a follow-up period of 4 years or longer, three had recurrences with inoperable tumors; the remaining patient is without recurrence after craniospinal radiation. This same patient belonged to a group of five patients with a diagnosis of high-grade ependymoma, four of whom had recurrence. Follow-up CT accurately recorded the clinical course of each patient. Annual routine follow-up examinations are proposed for patients with low-grade ependymomas, and for those with high-grade ependymomas follow-up CT should be performed every 6 months. The characteristic appearance and behavior of these tumors include several distinctive features on angiographic and CT images.

Intracranial fluid-blood levels in the anticoagulated patient

This report documents that anticoagulation may cause multiple intracranial fluid-blood levels.

Blood-fluid levels in multiloculated cystic brain metastasis of a hypernephroma. A case report

A case of brain metastatic hypernephroma presenting as multiloculated blood-fluid levels is described and the mechanism of their formation discussed.