case_images: PMC4604639_01
case_images: (a) Brain computed tomography scan showed multiple small intra-axial nodules with slightly high density. (b) Magnetic resonance imaging demonstrated that the signal of the nodules was hypointense to isointense on the T1-weighted image. (c) The magnetic resonance T2-weighted image revealed significant edema around multiple nodular lesions showing hypointensity. (d) The magnetic resonance susceptibility-weighted image showed numerous low-intensity spots, indicating old hemorrhages. (e) Magnetic resonance T1-weighted image with gadolinium enhancement demonstrated little enhancement in most lesions but a weak enhancement in some nodules (arrow)
case_images: SNI-6-156-g001.jpg
case_images: PMC4604639_01_SNI-6-156-g001.jpg
case_images: F1
case_images: A brain CT scan revealed multiple 5-15 mm high-density nodules with perifocal edema in the bilateral cerebrum and cerebellum [Figure 1a]. MRI demonstrated that the signal of nodules was hypointense to isointense on T1-weighted images [Figure 1b] and hypointense on T2-weighted [Figure 1c]. Susceptibility-weighted images [Figure 1d] showed numerous low-intensity spots, indicating old hemorrhages. Postcontrast studies revealed little enhancement in most lesions, but a weak enhancement in some nodules [Figure 1e].
case_images: (a) Chest computed tomography scan showed multiple nodules with hemorrhage in the lung. (b) Abdominal computed tomography demonstrated hypodense nodules without intralesional hemorrhage in the liver. (c) Lesions in the liver were homogeneously enhanced with contrast medium
case_images: SNI-6-156-g002.jpg
case_images: PMC4604639_01_SNI-6-156-g002.jpg
case_images: F2
case_images: Under the suspicion of multiple brain metastasis from malignancies in other organs, chest CT scan was performed, which revealed multiple small nodules with bleeding in the lung [Figure 2a]. An abdominal CT scan showed a similar-sized mass without intralesional hemorrhage in the liver [Figure 2b]. The hepatic lesions were enhanced homogeneously [Figure 2c].
case_images: Intraoperative view. The tumor was elastic, hard, and moderately hemorrhagic
case_images: SNI-6-156-g003.jpg
case_images: PMC4604639_01_SNI-6-156-g003.jpg
case_images: F3
case_images: The tumor was moderately hemorrhagic, presenting a reddish-brown color [Figure 3].
case_images: (a) Hematoxylin and eosin staining showing diffuse cellular proliferation, fine vascular channels, hemorrhage, and hemosiderosis. (b) Cells with a round and slightly coarse nucleus and a large volume of clear cytoplasm including large and small balloon-like lesions and erythrocytes were noted. (c) Immunostaining for CD31 revealed a significant staining of the cell membrane and cytoplasm. (d) The MIB-1 labeling index was <3% in the tumor cells
case_images: SNI-6-156-g004.jpg
case_images: PMC4604639_01_SNI-6-156-g004.jpg
case_images: F4
case_images: Fine vascular channels, hemorrhage, and hemosiderosis were observed in the tissue [Figure 4a]. Cells contained a round and slightly coarse nucleus and a large volume of clear cytoplasm including large and small balloon-like lesions and erythrocytes [Figure 4b]. Immunohistochemical staining showed positivity for vimentin and CD31 of the cell membrane and cytoplasms [Figure 4c] and mild positivity for CD34 of the cytoplasm. Mitotic nuclei were rare, and the MIB-1 labeling index was <3% in the tumor cells [Figure 4d].
case_images: (a) T2-weighted image at 3 months after biopsy demonstrated aggravation of peritumoral edema without apparent enlargement of each nodule. (b) The bilateral ambient cisterns had narrowed, suggesting increased intracranial pressure
case_images: SNI-6-156-g005.jpg
case_images: PMC4604639_01_SNI-6-156-g005.jpg
case_images: F5
case_images: MRIs demonstrated aggravation of peritumoral edema without apparent enlargement of each nodule [Figure 5a]. The bilateral ambient cisterns had narrowed, suggesting increased intracranial pressure [Figure 5b].