Unbearable

A 63-year-old man complains of a severe right-sided headache since waking up two hours ago, in association with nausea, and two episodes of vomiting. The headache is worse upon straining.

He has experienced recurrent right-sided headaches and dizziness for the preceding two weeks. No other symptoms were present. There is no history of recent trauma.

His medical history is significant for essential hypertension for 8 years, which is uncomplicated, and well controlled on lisinopril alone. There are no known allergies. He has a 10 pack-year history of smoking cigarettes but stopped smoking around 20 years ago. He only drinks socially.

A complete blood count, serum electrolyte panel, and liver and renal profiles are all normal.

Select Relevant Investigations
MRI Brain

Performed

T1 weighted images show a low intensity, heterogeneous, biphasic mass in the right parietal lobe, with areas of flow voids, focal high signal intensities, and areas of necrosis. There is a 6mm right to left midline shift.

T2 images show the lesion to have a high signal intensity, with surrounding vasogenic edema, and internal necrosis and hemorrhage.

Subsequently, gadolinium contrast is administered. This reveals irregular and intense ring enhancement around the lesion, with cystic areas, hemorrhagic foci, and surrounding vasogenic edema.
Lumbar Puncture

Performed

You realize that a lumbar puncture is not advisable currently.
18F-FDG PET

Performed

There is an area of markedly elevated uptake in the right parietal lobe.
Full-Body CT

Performed

Full-body CT imaging of the thorax, abdomen, and pelvis shows no abnormal findings.

Select Relevant Management
Antibiotics
Corticosteroids
Surgery
Radiotherapy