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Endgames Case Review

Evaluation of a ring enhancing lesion

BMJ 2015; 351 doi: (Published 05 October 2015) Cite this as: BMJ 2015;351:h5033
  1. Christopher B Scoma, medical student1,
  2. Ashish H Shah, resident, neurological surgery1,
  3. Amade Bregy, director research support1,
  4. Ricardo J Komotar, assistant professor1
  1. 1University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, FL 33125, USA
  1. Correspondence to: R J Komotar

A 49 year old previously healthy woman presented to her general practitioner with a two week history of progressive headaches, forgetfulness, and decreased visual acuity. She had no other symptoms or findings of note. On examination, she was oriented to person, location, and time. Her heart rate was 78 beats/min, respiratory rate was 18 breaths/min, and blood pressure was 116/78 mm Hg. She was afebrile and had no meningeal signs. Physical examination identified a right homonymous hemianopsia but no other neurological or cognitive deficits. There was no evidence of papilloedema. Her electrolytes, complete blood count, and C reactive protein concentration were normal. Magnetic resonance imaging (MRI) showed a single ring enhancing lesion with irregular borders.


  • 1. On the basis of the clinical picture, where is the lesion and what is it likely to be?

  • 2. Given the clinical presentation and the MRI results, what is the diagnosis?

  • 3. What is the definitive management of the suspected diagnosis?

  • 4. What are the histological features of the suspected diagnosis?


1. On the basis of the clinical picture, where is the lesion and what is it likely to be?

Short answer

The lesion is probably in the left temporal lobe of the brain. The clinical picture suggests a primary central nervous system (CNS) tumor or brain abscess.


Given that the physical examination found no relevant findings except for a right homonymous hemianopsia, it is reasonable to suspect a lesion in the left optic tract. The two week history of forgetfulness and headaches, although not specific, suggests that the lesion affects the temporal lobe of the brain and not the eye itself. The lesion is probably small because the patient has no symptoms of raised intracranial pressure (such as Cushing’s triad of hypertension, bradycardia, and bradypnea) and she is alert and oriented to person, location, and time. The symptoms suggest that the lesion is rapidly growing, but ischemic or hemorrhagic small vessel …

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