A. HRICHI, S. KOUKI, M. LANDOULSI,R. AOUINI, I. GANZOUI, S.BOUGUERRA, Y. AROUS, H. BOUJEMAA, N. BEN ABDALLAH Radiology service, Main Military hospital of Instruction of Tunis, Tunisia CH7

Inroduction: Several diseases can present with multi-cystic brain lesions:  True cysts  Abscess formations  Cysticercosis  Fungal infections  Cerebral tumors  Metastases…

Radiologist role? 1- Positive diagnosis easy! 2- Approach of etiologic diagnosis: the main question!

Case report: A rare case of cystic intracerebral metastases from adenocarcinoma of the lung

♂♂  49 years old  No medical histories  Smoking patient  Presented with progressive dizziness and equilibrium disorders that had developed for 5 days.

Neurological examination:  cerebellar syndrome  no other focal signs Biology:  Lymphocytes:  ↓  Alkaline phosphatase: ↑  Other laboratory studies: normal CT brain Scan was indicated

CT brain scan without(a) and with(b) injection of iodinated contrast: multifocal hypodense lesions(a) with partial peripheral contrast enhancement(b) but without significant perifocal oedema. Imaging findings: a1 b1 a2 b2

Further brain MRI was performed and allowed to objectify: multifocal cystic lesions with partial peripheral contrast enhancement but without significant perifocal oedema.

Axial T1-weighted with (a1, a2, a3) and without gadolinium (b1, b2, b3): nodular hypointense multiple extra- axial lesions, with partial peripheral contrast enhancement. a1 a2 a3 b1 b2 b3

Axial T2- weighted (a1, a2, a3) and FLAIR (b1, b2, b3): Multiple hyper-T2 hypo- FLAIR extra- axial lesions (cystic lesions). a1 a2 a3 b1 b2 b3

axial diffusion (a1, a2, a3) and ADC (b1, b2, b3): Multiples nodular lesions hyperin tense in diffusion with a low ADC. a1 a2 a3 b1 b2 b3

In total: ♂♂  49 years old  No medical histories  Smoking patient  Lc ↓, PAL ↑  multi-cystic brain lesions (CT – MRI) ????

In total:  ♂  49 years old  No medical histories  Smoking patient  Lc ↓, PAL ↑  multi-cystic brain lesions (CT – MRI) ???

In total:  ♂  49 years old  No medical histories  Smoking patient  Lc ↓, PAL ↑  multi-cystic brain lesions (CT – MRI) ??

In total:  ♂  49 years old  No medical histories  Smoking patient  Lc ↓, PAL ↑  multi-cystic brain lesions (CT – MRI) ?

Lung cancer? In total:  ♂  49 years old  No medical histories  Smoking patient  Lc ↓, PAL ↑  multi-cystic brain lesions (CT – MRI)

 a CT-chest-scan revealed a lungular small nodule not exceeding 12mm of main line with no other secondary locations  Stereotaxic brain biopsy confirmed a well-differentiated lung adenocarcinoma

Discussion:  Brain lesions in patients with known malignancies are suspicious for metastases; → usually: as well-circumscribed densely enhancing masses with surrounding vasogenic edema.  Cystic brain lesions are unusual; → can be misdiagnosed as: brain abscesses, primary cerebral tumors, or parasitic infections, especially in patients without a history of malignancy.

Cystic cerebral metastases have been described in carcinomas of :  Thymus  Breast  Prostate  Pancreas

However, and in reviewing the literature: -We have only found 2 similar cases reports of lung adenocarcinoma with cystic cerebral metastases. -In both of them, the patients were already followed for bronchial adenocarcinoma. - while in our case, cystic cerebral metastases revealed the disease.

Conclusion: This case demonstrates an unusual pattern of cerebral metastases of a bronchial adenocarcinoma. This constellation should be considered in the differential diagnosis of cerebral cystic lesions even in patients without a history of malignancy, and wich is necessary to evoke at every smoking adult's of about forty. The exact nature of which might be difficult to assess without biopsy.

Check the lungs Cystic cerebral lesions ♂ smoking No medical histories Age: about forty

References: 1-Monabati A, Kumar PV, Kamkarpour A. Intraoperative cystodiagnosis of metastatic brain tumors confused clinically with brain abscess (A report of three cases). Acta Cytol. 2000;44:437–441 2-Nieder C, Grosu AL, Grzadziel A, et al. Brain metastases in renal cell cancer: diagnostic and therapeutic aspects. Am J Clin Oncol. 2004;27:632–634 3-White AC, Dakik H, Diaz P. Asymptomatic neurocysticercosis in a patient with AIDS and criptococcal meningitis. Am J Med. 1995;99:101–102 4-Cosgrove SE. Cases from the Osler Medical Service at Johns Hopkins University. Am J Med. 2002;113:158–160 5-Ersahin M, Kilic K, Gögüsgeren MA, et al. Multiple brain metastases from malignant thymoma. J Clin Neurosci. 2007;14:1116– Tsai V, Kim S, Clatterbuck RE, et al. Cystic prostate metastases to the brain parenchyma: report of two cases and review of the literature. J Neurooncol. 2001;51:167–173 7-De Shields MS, Ruether J. Lung carcinoma presenting as multiple cystic lesions in the brain. Del Med J. 1998;70:77–80 8-A.Surov, M Hainz, M Kornhuber. Multiple cystic metastases in the brain from adenocarcinoma of the lung.The American Journal of Medicine. 2009;122:3-4