Case 3

This is an MRI study of the brain, showing multiple focal space occupying lesions within the cerebral hemispheres, in the right frontal, bilateral parietal and left occipital lobes. The lesions are surrounded by a large degree of high T2 and FLAIR signal intensity which shows a finger like distribution along the white matter- this indicates vasogenic oedema, which is disproportionately high in degree related to the size of the lesions.  The lesions are rounded, and show heterogeneous signal intensity with low signal intensity in the periphery plus internal foci of low signal intensity, alternating with high SI; heterogenous high signal intensity can be appreciated on the T1 images. Notably, there is prominent dark signal which appears larger than the lesions on the susceptibility weighted imaging, indicating blooming artefact. This is evidence of bleeding.

The post contrast images show ring enhancement in most of these lesions, with one of the lesions showing solid round enhancement.

These findings are characteristic of haemorrhagic brain metastases.

Incidentally, there is FLAIR / T2 hyperintensity in the periventricular white matter, indicating chronic small vessel ischemic changes.

I would ask the referring physician if the patient has a known malignancy. If not, whole body imaging / PET CT / upper and lower endoscopy would be warranted to detect the primary. The patient can be flagged for discussion at neuro-oncology MDT.