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Blood–fluid levels in the brain

Department of Radiology, K E M Hospital, Acharya Dhonde Marg, Parel, Mumbai-400012, India

View larger version (80K): [in this window] [in a new window]   Figure 1. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. (a) The preliminary CT of a 45-year-old man with frontal lobe signs and intractable seizures reveals a wedge-shaped hypodensity in the right fronto-parietal region with predominant involvement of the white matter. As erosion of the inner table of the skull was overlooked, the lesion was misdiagnosed as an arterial infarct. (b) A CT done 26 months later reveals a lesion of mixed attenuation with an enhancing solid and a larger septated cystic component in the fronto-parietal region, which extends across the midline along white matter tracts of the corpus callosum. Scalloped erosion of the inner skull table adjacent to the tumour and nodular calcification (seen on the higher sections) suggested an oligodendroglioma.

View larger version (67K): [in this window] [in a new window]   Figure 2. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. (a) A post-contrast axial T1 weighted image through the posterior fossa of an 18-year-old woman reveals a cystic lesion with a small mural nodule displacing the fourth ventricle. A smaller unencapsulated cyst in the right cerebellum shows enhancement of the dependent component creating an uneven interface within the lesion. At histopathology the lesion was found to be a haemangioblastoma which was part of a larger spectrum of findings in a case of Von Hippel–Lindau syndrome. (b,c) CT following resection of the midline tumour reveals a persistence of the smaller right cerebellar cyst. Enhancement of the dependent isodense solid component of the lesion by contrast creates an interface, which simulates leakage of contrast into a cyst thereby exemplifying a spurious fluid level within an intracranial lesion.

View larger version (129K): [in this window] [in a new window]   Figure 3. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. A contrast enhanced CT of a 40-year-old man with a history of seizures for the past 4 years reveals an ill-defined grade 3 glioma which crosses the midline along white matter tracts with distortion of the lateral ventricles. A cystic component with a fluid level is seen within the tumour.

View larger version (58K): [in this window] [in a new window]   Figure 4. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. (a) Plain and (b) post-contrast images of the posterior fossa in a 21-year-old man reveal a heterogeneously enhancing mass centred at the right cerebello-pontine angle. Intense and homogeneous enhancement of the solid component of the tumour is seen following contrast administration. The thin-walled peripherally enhancing cystic component has a blood–fluid level and shows no appreciable enhancement of its contents. Sections at a more caudal level reveal gross widening of the ipsilateral internal acoustic canal (not shown) typical of an acoustic schwannoma.

View larger version (100K): [in this window] [in a new window]   Figure 5. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. A plain CT reveals a fluid interface within a cystic lesion in the frontal cortex of a 65-year-old woman with carcinoma of the breast. There was no enhancement of the wall or contents of the cyst, which was thought to be a secondary deposit.

View larger version (55K): [in this window] [in a new window]   Figure 6. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. On a plain CT metastatic cysts with fluid interfaces are seen in the (a) basifrontal and (b) medial temporal regions of a 70-year-old woman with hepatocellular carcinoma. The cause of subarachnoid haemorrhage was not established.

View larger version (83K): [in this window] [in a new window]   Figure 7. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. Cystic secondary deposits from an ovarian malignancy in a 46-year-old woman are widely seeded throughout the brain on (a) a pre-contrast CT. The cystic lesions have imperceptible walls and show fluid interfaces. (b) Lower attenuation values of the dependent components of two of these lesions (one in the midline posterior fossa; the other in the high parietal deep white matter on the right side) suggest sedimentation of particulate matter rather than the presence of frank blood.

View larger version (99K): [in this window] [in a new window]   Figure 8. CT and MRI images showing blood–fluid levels in cases of primary intracranial malignancies and metastases to the brain. On a post-contrast CT of a 35-year-old man diagnosed with bronchogenic carcinoma, two of four cystic lesions in the high parietal region demonstrate fluid levels. Differential levels are seen in the largest cyst located posteriorly on the left side.

View larger version (93K): [in this window] [in a new window]   Figure 9. CT and MRI images in lesions of a vascular aetiology. A haemorrhagic venous infarct presents as a thin-walled cystic lesion with a blood–fluid level in the deep right cerebral hemisphere. There is subfalcine herniation with gross distortion of a blood-filled ventricular system. A CT venogram of a 23-year-old man revealed evidence of thrombosis of the superior sagittal sinus (not shown).

View larger version (118K): [in this window] [in a new window]   Figure 10. CT and MRI images of lesions of a vascular aetiology. A 35-year-old man with rheumatic heart disease had undergone an open mitral commisurotomy 20 years earlier. A CT done for right-sided paresis of recent origin revealed multiple fluid levels within an amorphous focus of haemorrhage in the left parietal region. In the light of these findings, the bleed was thought to represent a haemorrhagic arterial infarct.

View larger version (80K): [in this window] [in a new window]   Figure 11. CT and MRI images of lesions of a vascular aetiology. The CT brain of a 13-year-old boy with a haemolytic uraemic syndrome reveals a circumscribed but unencapsulated haemorrhagic focus in the posterior parietal region. Components of the lesion with different attenuation values have linear demarcations and did not show appreciable enhancement on the post-contrast scan (not shown).

View larger version (141K): [in this window] [in a new window]   Figure 12. CT and MRI images of lesions of a vascular aetiology. In a 65-year-old man a haemorrhagic infarct in the territory of the middle cerebral artery shows hyperperfusion of the gyri and a focus of haemorrhage in the parietal region with a horizontal anterior margin which appears gravity dependent but without a frank fluid-fluid level.

View larger version (135K): [in this window] [in a new window]   Figure 13. CT and MRI images of lesions of a vascular aetiology. There are multiple fluid levels within the haemorrhagic component of an arterial infarct in a 75-year-old woman. Gross subfalcine herniation was thought to result from an accompanying subdural bleed, the presence of which could not be explained.

View larger version (123K): [in this window] [in a new window]   Figure 14. CT and MRI images of lesions of a vascular aetiology. The CT brain of a 75-year-old man with deep vein thrombosis of the lower limb reveals multiple fluid levels within a large focus of haemorrhage in the right cerebral hemisphere. Extension into the ventricles has led to obstructive hydrocephalus. The bleed was attributed to anticoagulants that were given as a prophylaxis against pulmonary thrombo-embolism.

View larger version (67K): [in this window] [in a new window]   Figure 15. CT and MRI images of lesions of a vascular aetiology. CT brain of a 67-year-old woman who was a known hypertensive reveals a cerebellar and vermian bleed with an isodense component on the right side. The horizontal anterior margin of this component of the bleed suggests a probable gravity-dependent level. (a) T1 weighted and (b) T2 weighted images of an MR done 3 days later show a large cerebellar and vermian bleed. A fluid level and varying signal intensities within the bleed indicate blood products at different stages of degradation.

View larger version (114K): [in this window] [in a new window]   Figure 16. CT in traumatic brain lesions. CT in a 42-year-old man who sustained a traumatic injury to the skull reveals a contusion in the frontal and parietal regions. A fluid level within the bleed with graded attenuation levels suggests sedimentation of erythrocytes. There is a shift of the midline to the right despite an epidural haematoma in the contralateral parietal region.

View larger version (138K): [in this window] [in a new window]   Figure 17. CT in traumatic brain lesions. A fluid level is seen in the largest focus of bleed in a case of traumatic bifrontal haematomas. Similar to the previous image, there is evidence of sedimentation of particulate matter within the bleed in the left frontal region.