Teaching NeuroImages: Burkitt dural lymphoma mimicking a subacute subdural hematoma

A 59-year-old woman with no history of trauma presented with severe headaches and right-sided weakness. A CT scan showed a left hemispheric isodense subdural collection thought to be consistent with a subacute subdural hematoma (figure 1A). The patient underwent a single parietal burr hole for evacuation, but the neurosurgeon found subdural fleshy tissue and performed a biopsy. Immediate postoperative MRI showed a homogeneous hypercellular subdural mass (figure 1, B–F).¹ Pathology was consistent with Burkitt lymphoma (figure 2). Retrospectively, the homogeneous density of the collection argued against hematoma. In nonemergent situations, an atypical radiologic appearance of a subdural hematoma may suggest the need for further radiologic investigations before surgical evacuation.²

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Figure 1 CT and MRI findings

Homogeneous crescent-shaped lesion. Isodense CT (A), iso–fluid-attenuated inversion recovery MRI (B), iso-T1 MRI (C). Restricted diffusion on MRI diffusion-weighted imaging (D) and apparent diffusion coefficient maps (E). Strong postcontrast enhancement on MRI (F).

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Figure 2 Pathology

Hematoxylin & eosin stain, 200× (A) and 400× (B) magnification: “starry sky” pattern: medium-size tumor cells and macrophages ingesting apoptotic cells. Immunostaining: CD20+ (C), Ki67: 95% (D).

• © 2013 American Academy of Neurology