Altered mental status: recently diagnosed lung adenocarcinoma with brain mets s/p radiation and steroids. MRI: There are new areas of restricted diffusion and high T2 signal in the left insula, perirolandic region, parietal lobe, and medial occipital lobe superimposed upon pre-existing areas of restricted diffusion in the left basal ganglia and lateral occipital lobe. There are multiple areas of peripheral and gyriform enhancement in the left cerebral hemisphere with an overall background of decreased perfusion. The largest peripherally enhancing lesion of the left cerebral hemisphere is located in the paracentral lobe, measuring up to 15 mm. Some of the lesions demonstrate susceptibility effect and intrinsic T1 hyperintensity, particularly in the left basal ganglia and occipital lobe. There are also ring-enhancing lesions in the left cerebral hemisphere, which measure up to 5 mm. There are scattered nonspecific foci of T2 hyperintensity without restricted diffuse in the cerebral white matter. There is an enhancing pituitary mass with suprasellar extension and mass effect upon the optic apparatus that measures up to 3 cm. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.MRA: There is an abrupt cut-off of flow-related enhancement in a left M2 branch proximally. There is also an abrupt cut-off of flow-related enhancement in a left P2 segment. The rest of the major cerebral arteries appear to be intact otherwise.
1. Acute upon subacute infarcts in the left middle and posterior cerebral artery territories associated with areas of microhemorrhage and enhancement. However, a portion of the enhancing lesions in the bilateral cerebral hemispheres likely represent underlying metastases.2. Abrupt cut-off of left M2 and P2 branches may be due to thromboembolic disease. Vascular imaging of the neck may be useful.3. A pituitary mass likely represents a macroadenoma.Discussed with Dr. GAJEWSKI at 3:15 PM on 7/10/15.