Male, 78 years old, with right hand spasms and shaking, calcified left cerebral lesion on prior outside imaging. An ill-defined T2 hyperintense, somewhat bubbly appearing lesion is evident centered on the left perirolandic gyri. Thickened and nodular infiltrative tissue also extends inferiorly along the left periatrial region causing pinching of the atrium, as well as anteriorly into the left thalamus.The core of the lesion is coarsely mineralized as evident on CT, and there is corresponding susceptibility effect on MRI. The lesion is persistently and faintly diffusion restricting, particularly an oval component in the left paracentral lobule.On comparison with prior examinations, certain lobular components of the lesion may be slightly increased in size. However, the overall geographic involvement is not significantly changed.Portions of the lesion core are intrinsically T1 hyperintense which may reflect the known mineralization. However, clear superimposed enhancement is observed, and on comparison to the prior contrast-enhanced examination from 2015, multiple curvilinear and fingerlike areas of enhancement are new or larger.Elsewhere, numerous scattered foci of periventricular and subcortical white matter T2 hyperintensity are demonstrated. No additional enhancing lesions are seen. No acute intracranial hemorrhage is suspected. Ventricles and sulci are mildly prominent compatible with parenchymal volume loss.
Redemonstrated is a coarsely mineralized, ill-defined and somewhat infiltrative lesion occupying the left perirolandic gyri, the periatrial tissues and the thalamus. Although the geographic extent of the lesion has not significantly changed when compared to prior examinations, individual components of the lesion may be slightly larger. In any event, several areas of curvilinear and fingerlike enhancement have progressed. Several components of the lesion demonstrate persistent diffusion restriction which raises concern for a hypercellular process.The differential diagnosis would include a primary brain tumor with slow progression or degeneration to a more malignant grade. Oligodendroglioma, ependymoma, and glioneuronal histologies could present in this way. Although somewhat atypical, an astrocytic tumor can also be considered. Nonneoplastic etiologies, such as a smoldering inflammatory process or a burned out vascular malformation, would be diagnoses of exclusion.