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An 84-year-old woman was admitted to another hospital 4 days earlier for weakness of her left arm and leg that had begun 2 days prior to that admission. A head CT was performed and she was diagnosed as having a stroke. Her family became concerned that “nothing was being done.” They signed her out of that hospital and transported her to the ED.

The CT obtained in the ED is shown in Figure 1.

  • What was the patient’s likely diagnosis?
  • What other tests are needed to confirm the diagnosis?

Although this patient presented with a focal neurological deficit and the CT showed cerebral edema in the corresponding region of the right cerebral hemisphere, the patient’s disorder was not an ischemic stroke. The subcortical white mater has a very low attenuation, while the gray matter is relatively normal in appearance. There is an accentuation of the gray/white matter interface, as opposed to the loss of the gray/white interface seen with an acute ischemic stroke (cytotoxic edema) (Figure 2, and see also Patient 9).

Figure 2

Patient 10—Noncontrast CT.

In addition, there is considerable mass effect due to the cerebral edema, although its effect is moderated by the patient’s underlying age-related cerebral atrophy. The cortical sulci are effaced in comparison to the wide cortical sulci and atrophic gyri of the opposite cerebral hemisphere. The right lateral ventricle is compressed, although there is no midline shift (Figure 2).

This is the typical appearance of cerebral edema associated with tumors and abscesses and is known as peritumoral vasogenic edema. Tumor angiogenesis promotes the formation of immature blood vessels with abnormal permeability that leak edema into the surrounding interstitial tissues (...

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