Clinical question: History of prostate cancer. Failure lesion seen on outside imaging. Signs and symptoms: Vertigo. Pre-and post-enhanced brain MRI:Negative diffusion weighted series.Examination demonstrates few punctate foci of flair hyperintensity primarily in the left frontal subcortical and periventricular white matter which are nonspecific and non-hemorrhagic and without evidence of enhancement. Possibility of mild chronic small vessel ischemic strokes should be considered in a patient of this age group. There is normal anatomical morphology and signal intensity of brain parenchyma otherwise and without detectable abnormal enhancement to suggest presence of a mass/metastatic lesion. There is however enhancement of a small high convexity right anterior parietal developmental venous anomaly.Examination demonstrate a punctate focus of T2 signal changes in the right complexity anterior parietal with significant well demarcated susceptibility signal pattern. The finding is highly suggestive of a tiny metallic fragment. Recommend follow up with head CT for further evaluation.Susceptibility MRI images in addition demonstrate multiple small varying sized foci of susceptibility consistent with multiple foci of microhemorrhages. None of the findings is detected on the flair or T2-weighted images and are not associated with any surrounding edema or mass effect.The signal void in the major intracranial arterial branches are identified.Calvarium demonstrate an irregularly shaped foci of T2 hyperintensity in high convexity left paramedian frontal bone with erosion of the inner table of the skull. The lesion demonstrates a very thin rim of enhancement. There is a second tiny similar type lesion immediately posterior to the larger lesion and measures at approximately 7.5 mm. The lesions do not have the typical signal pattern, morphology or pattern of enhancement of metastatic lesions.Follow up with a non-enhanced head CT may be helpful for further assessment. Unremarkable calvarium and soft tissues of the scalp otherwise.Unremarkable images through the orbits and including axial fat sat post enhanced series. Next all paranasal sinuses and bilateral mastoid air cells and middle ear cavities demonstrate normal pneumatization signal patterns.
1.No diffusion weighted abnormalities.2.Findings suggestive of minimal chronic nonhemorrhagic small vessel ischemic strokes.3.Multiple foci of susceptibility in the supratentorial and infratentorial brain parenchyma which are not identified in any other MRI sequence and likely representing multiple chronic microhemorrhages.4.Small right parietal developmental venous anomaly as detailed.5.Left frontal calvarial lytic changes without solid enhancement are not typical for metastatic lesions. Recommend follow-up with CT exam for further assessment.6.A right high convexity punctate foci of metallic artifact in the right posterior frontal -- parietal region which can also be further evaluated with head CT.