PMC5985100_01
(a) MRI brain with and without contrast on admission (T2-FLAIR image) demonstrating focal mass in the dorsal left insular cortex and subcortical white matter. There is surrounding edema with little mass effect. (b) MRI brain at a 10-day interval follow-up demonstrating marked improvement in the dorsal left insular brain lesion (T2-FLAIR image).
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fig1
Brain MRI with and without contrast showed a focal mass with surrounding edema but no mass effect and reduced peripheral T2-weighted signal (Figure 1(a)). MRI scan of the brain with and without contrast and magnetic resonance venogram (MRV) 10 days after the initial imaging showed significant improvement in the "mass" with patent dural venous sinuses and cortical veins (Figure 1(b)). Multiple blood and urine cultures, including fungal cultures and cultures for Mycobacterium, remained negative.
Axial FLAIR (a) representative image demonstrates large area of FLAIR hyperintensity involving the left frontoparietal region representing edema with mass effect, new/significantly increased compared to the prior study. There is associated restricted diffusion (as evidenced by DWI hyperintensity (b) and ADC hypointensity (c)) compatible with evolving acute infarct.
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fig2
A large hemorrhagic venous infarct in the left frontal and parietal lobes (Figure 2) with abrupt cutoff of the vein of Trolard and superficial draining veins was evident on MRV with a 7 mm midline shift (Figure 3).
Contrast-enhanced MRV of the brain is performed on day 10 (a) and day 16 (b). There is patent left vein of Trolard on day 10 with good collateral flow involving the left frontoparietal region. However, on day 16, there is thrombosis of the left vein of Trolard with slight decrease in collateralization within the left frontoparietal region, compatible with venous thrombosis and hemorrhagic venous infarct.
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fig3
A large hemorrhagic venous infarct in the left frontal and parietal lobes (Figure 2) with abrupt cutoff of the vein of Trolard and superficial draining veins was evident on MRV with a 7 mm midline shift (Figure 3).
On day 16, corresponding axial T1 precontrast (a) and postcontrast image (b) does not demonstrate rim enhancement or a fluid cavity to suggest an abscess. Additionally, except for some thin patchy postcontrast enhancement in the region of the vasogenic edema (which could represent some venous engorgement secondary to mass effect), no mass-like postcontrast enhancement is noted to suggest an enhancing tumor. (c) Corresponding susceptibility-weighted image demonstrates ill-defined areas of hemosiderin deposition in the left frontoparietal region representing areas of hemorrhage.
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fig4
Corresponding axial T1 pre- and postcontrast imaging was not suggestive of an underlying enhancing tumor but rather hemorrhage with hemosiderin deposition in the left frontoparietal region on susceptibility weighted imaging (Figure 4).