TWiP solves the case about the female who traveled to Brazil and upon returning home felt movements under her scalp on the back of her head, and present another case for your solving, a man with abnormal brain MRI.

Hosts: Vincent Racaniello, Daniel Griffin, and Christina Naula

Guest: Eyal Leshem

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New Case

Man in his 40s, married with 2 children, on Eliquis for a prior DVT, diet-controlled diabetes, who is admitted for evaluation of an abnormal brain MRI. He left AMA but then developed vomiting and returned.

CT- Large peripherally enhancing mass lesion in the deep left cerebral hemisphere is associated with considerable vasogenic edema/infiltrative nonenhancing tumor. Mass effect results in left-to-right subfalcine herniation and entrapment of the right lateral ventricle. Findings are typical for glioblastoma. Intracranial abscess tumefactive multiple sclerosis and brain metastasis may mimic this appearance. Recommend supplemental imaging evaluation including gadolinium-enhanced MR brain.

MRI- Dominant heterogeneously enhancing mass in the left basal ganglia/peri-insular region measuring 3.1 cm AP by 2.8 cm TR by 2.9 cm cc, with surrounding vasogenic edema resulting in mass effect and midline shift, as detailed above, concerning for high grade glial neoplasm versus metastasis. Additional leptomeningeal nodule in the right postcentral sulcus. Additional smaller peripherally enhancing lesion in the right lateral temporal region with suggestion of leptomeningeal component and measures approximately 0.8 x 0.8 cm, with mild surrounding vasogenic edema.

They do a biopsy and pathology comes back as: – Brain tissue with extensive necrosis acute chronic inflammation, and rare microorganisms (on permanent section)

-Brain, designated "left brain lesion", excision:

– Brain tissue with extensive necrosis acute and chronic inflammation, reactive gliosis and occasional microorganisms

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TWiP 267: It dropped from her scalp