PMC4899848_01
4-year-old girl with hepatoblastoma. Initial MRI performed from the emergency department (A-E) demonstrating multiple lesions containing acute and subacute hemorrhage and minimal, if any, contrast enhancement. DWI (A) demonstrates no reduced diffusion associated with the lesion to suggest hemorrhagic infarct. MPGR (B) demonstrates bosselated hemorrhage within the dominant lesion in the left occipital lobe. Of note, a second hemorrhagic lesion is also present in the righ occipital lobe. Axial T2WI (C) demonstrates hemorrhage of varying degrees of T2 intensity, consistent with hemorrhage of different chronicity. Surrounding vasogenic edema in the white matter may be indicative of acute hemorrhage, or edema secondary to an underlying mass. Axial T1WI (D) and after contrast (E) demonstrate minimal if any enhancement and intrinsic T1 shortening consistent with hemorrhage.
gr1.jpg
PMC4899848_01_gr1.jpg
fig1
The initial imaging examination ordered through the emergency department was a head MRI (Fig. 1), which demonstrated multiple hemorrhagic lesions, the majority with essentially no contrast enhancement.
4-year-old girl with hepatoblastoma. A: 400 x H&E staining demonstrates extensive cellularity of the resected left parietal mass with immunostaining for cytokeratin AE1/AE3 (a pan-cytokeratin stain that includes both low and high molecular weight CKs) as well as a stain for alpha-fetoprotein (B).
gr2.jpg
PMC4899848_01_gr2.jpg
fig2
After palliative resection, pathology confirmed the diagnosis of metastatic hepatoblastoma (Fig. 2). The sheetlike appearance of tumor cells demonstrated on pathology (Fig. 2) would seem atypical, given the paucity of enhancement on MRI.