PMC3816295_01
Noncontrast head CT (a) demonstrating an ill-defined hypodense lesion in the right cerebellar hemisphere causing compression of the 4th ventricle. Contrast-enhanced head CT (b) demonstrating an ill-defined, mildly enhancing right cerebellar lesion. The indistinct appearance of cystic structures can be appreciated surrounding the area of enhancement
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F1
Head CT demonstrated a hypodense right cerebellar lesion that minimally enhanced with contrast [Figure 1a and b], prompting further investigation with magnetic resonance imaging (MRI).
Noncontrast brain MRI (a) demonstrating an indistinct, heterogeneous lesion in the right cerebellar hemisphere causing mass effect and compression of the 4th ventricle. A cystic component can be seen laterally. Contrast-enhanced T1-weighted MRI (b-d) demonstrating a strongly enhancing lesion in the right cerebellar hemisphere. Innumerable, peripherally enhancing cystic structures are seen mostly surrounding, but also within, the area of enhancement. T2-weighted MRI (e) demonstrating diffuse hyperintensity within and surrounding the lesion. Contrast-enhanced T1-weighted MRI (f) demonstrating evidence of obstructive hydrocephalus with marked dilation of the lateral and third ventricles
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F2
This revealed an enhancing right cerebellar mass with surrounding cystic lesions causing compression of the 4th ventricle and dorsal medulla resulting in obstructive hydrocephalus [Figure 2a-f].
Gross specimen of the right cerebellar lesion (a) corresponding to the enhancing portion seen in Figure 2b-d. Hematoxylin and eosin preparation (b-c) demonstrating granulomatous inflammation with yeast-like organisms. Grocott's methenamine silver preparation (d) demonstrating budding spores
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F3
Pathology and microbiologic analysis revealed fungal elements and budding yeast consistent with blastomycosis [Figure 3a-c].
Contrast-enhanced T1-weighted MRI performed 1 month after the patient's operation. There is no evidence of the cystic lesions seen in Figure 2. There is resolution of the patient's obstructive hydrocephalus (b)
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F4
His MRI performed 1 month after surgery demonstrated expected postoperative changes and improvement in ventricular dilation seen preoperatively; there was no evidence of recurrent infection [Figure 4].