AJR Integrative Imaging
LIFELONG LEARNING
Imaging of Metastatic Malignant Melanoma to the Head:
Self-Assessment Module
Ashok Jayashankar1, Stephen M. Sabourin, and Mark E. Mullins
ABSTRACT
The educational objectives for this self-assessment mod-
ule on the imaging of metastatic malignant melanoma to
the head are for the participant to exercise, self-assess, and
improve his or her understanding of the features used to
differentiate hemorrhagic neoplasms from benign nonneo-
plastic hematomas on MRI and to gain familiarity with the
varied appearances of melanoma metastases to the head.
INTRODUCTION
This self-assessment module has an educational compo-
nent and a self-assessment component. The educational
component consists of three required articles that the par-
ticipant should read and two recommended articles that
may provide additional information and perspective. The
self-assessment component consists of five multiple-choice
questions with solutions. All of these materials are avail-
able on the ARRS Website (www.arrs.org). To claim CME
and SAM credit, each participant must enter his or her re-
sponses to the questions online.
EDUCATIONAL OBJECTIVES
By completing this educational activity, the participant will:
A. Exercise, self-assess, and improve his or her understanding
of the MRI features used to attempt to differentiate hem-
orrhagic neoplasms from nonneoplastic hematomas.
B. Gain familiarity with the varied appearances of mela-
noma metastases to the head.
C. Improve his or her understanding of the current concepts
in the imaging of intracranial metastatic melanoma.
Keywords: hemorrhagic neoplasms, intracranial hemorrhage, intracranial metastases, metastatic melanoma, MRI
DOI:10.2214/AJR.07.7041
Received September 11, 2007; accepted after revision April 25, 2008.
1
All authors: Department of Radiology, Emory University School of Medicine, B-115, 1364 Clifton Rd. NE, Atlanta, GA 30322. Address correspondence to A. Jayashankar
(ajayash@emory.edu).
AJR 2008;191:S22–S24 0361–803X/08/1913–S22 © American Roentgen Ray Society
S22 AJR:191, September 2008
FOR RADIOLOGY
REQUIRED READING
(available at www.arrs.org)
1. Escott EJ. A variety of appearances of malignant mela-
noma in the head: a review. RadioGraphics 2001; 21:
625–639
2. Destian S, Sze G, Krol G, Zimmerman RD, Deck MD. MR
imaging of hemorrhagic intracranial neoplasms. AJR
1989; 152:137–144
3. Jayashankar A, Sabourin SM, Mullins ME. AJR teaching
file: acute onset headache. AJR 2008; 191[suppl]:S25–S27
RECOMMENDED READING
1. Isiklar I, Leeds NE, Fuller GN, Kumar AJ. Intracranial
metastatic melanoma: correlation between MR imaging
characteristics and melanin content. AJR 1995; 165:
1503–1512
2. Gaviani P, Mullins ME, Braga TA, et al. Improved detec-
tion of metastatic melanoma by T2*-weighted imaging.
AJNR 2006; 27:605–608
INSTRUCTIONS
1. Complete the required reading.
2. Visit www.arrs.org and select Publications/Journals/SAM
Articles from the left-hand menu bar.
3. Using your member login, order the online SAM as directed.
4. Follow the online instructions for entering your responses
to the self-assessment questions and complete the test by
answering the questions online.
 Metastatic Malignant Melanoma
QUESTION 1
Which of the following primary neoplasms is
NOT typically associated with hemorrhagic
brain metastases?
A. Lung carcinoma.
B. Prostate carcinoma.
C. Melanoma.
D. Thyroid carcinoma.
E. Choriocarcinoma.
QUESTION 2
Hemorrhagic neoplasms constitute
approximately what percentage of intra­
parenchymal hematomas?
A. 15%.
B. 30%.
C. 50%.
D. 80%.
E. 90%.
QUESTION 3
Which of the following statements regarding
the MRI features of hemorrhagic neoplasms as
compared with nonneoplastic intraparenchymal
hematomas is FALSE?
A. Hemorrhagic neoplasms are more likely to show
an incomplete hemosiderin rim than nonneoplastic
hematomas.
B. Hemorrhagic neoplasms are more likely to exhibit
prolonged T2 hypointensity than nonneoplastic
hematomas.
C. Hemorrhagic neoplasms are more likely to be
associated with persistent edema than nonneoplastic
hematomas.
D. Hemorrhagic neoplasms are more likely to show
heterogeneous signal intensity than nonneoplastic
hematomas.
E. Hemorrhagic neoplasms are more likely to show
methemoglobin formation initially at the periphery
than nonneoplastic hematomas.
Solution to Question 1
Hemorrhagic brain neoplasms include both primary
brain tumors and metastases. A hemorrhagic neoplasm is
far more likely to be metastatic than primary [1]. Metasta-
ses that are most likely to hemorrhage include lung, breast,
thyroid, renal cell, choriocarcinoma, and malignant mela-
AJR:191, September 2008 S23
QUESTION 4
Which structure is most commonly involved
by melanoma that metastasizes to the head?
A. Brain.
B. Meninges.
C. Orbit.
D. Internal auditory canal.
E. Nasopharynx.
QUESTION 5
The melanotic imaging pattern of metastatic
melanoma is most typically associated with
which of the following signal characteristics?
A. T1 hyperintensity, T2 hyperintensity.
B. T1 hyperintensity, T2 hypointensity.
C. T1 hypointensity, T2 hyperintensity.
D. T1 hypointensity, T2 hypointensity.
E. T1 hypointensity, T2* hypointensity.
noma [1]. Options A, C, D, and E are not the best responses.
Metastases to the brain from prostate cancer are rare and
are not typically associated with hemorrhage. Option B is
the best response.
Solution to Question 2
Hemorrhagic neoplasms constitute approximately 1–14%
of all intraparenchymal hematomas [2]. Option A is the best
response. The differential diagnosis for the remainder of in-
traparenchymal hematomas includes primarily hyperten-
sive hemorrhage, vascular anomalies (including arterio-
venous malformation and cavernous malformation),
hemorrhagic infarction, amyloid angiopathy, and trauma.
Solution to Question 3
Imaging features on MRI that suggest hemorrhagic neo-
plasm rather than benign intraparenchymal hematoma in-
cludes a heterogeneous or mixed intensity pattern (Option
D); an incomplete hemosiderin rim (Option A); dispropor-
tionately large amount of edema compared with hematoma
size, persistence of or increase in the edema over several
days or weeks (Option C); persistence of T2 hypointensity
beyond the expected time for a nonneoplastic hematoma
(Option B); and initial appearance of T1 hyperintensity
(subacute methemoglobin) centrally or eccentrically in the
hematoma. Options A, B, C, and D, are not the best re-
sponses since they are true statements. In contrast, non-
neoplastic hematomas usually show initial methemoglobin
formation at the periphery of the hematoma [2, 3]. Al-
though the precise mechanisms for the formation of meth-
emoglobin have not been elucidated, it has been hypothe-
 Jayashankar et al.
sized that low oxygen tension levels favor the formation of
methemoglobin. In a hemorrhagic neoplasm, low oxygen
tension levels are found centrally, presumably in the necrot-
ic portions of the tumor. For this reason, it is thought that
methemoglobin formation initially occurs centrally (or ec-
centrically) in a hemorrhagic neoplasm rather than at the
periphery [2]. Therefore, Option E, which is not true, is the
best response.
Solution to Question 4
Melanoma metastatic to the head can involve virtually
any intracranial or extracranial structure, including the
meninges, orbit, nasopharynx, internal auditory canal,
choroid plexus, bone, muscle, and meninges. However, the
brain is the most common site of metastases to the head
from melanoma [4]. Option A is the best response. Options
B, C, D, and E are not the best responses.
Solution to Question 5
Two classic imaging patterns have been described for mela-
noma metastatic to the brain based on signal intensity char-
acteristics. The melanotic form is characterized by T1 hyper-
intensity and T2 hypointensity. Option B is the best response.
The amelanotic form is characterized by T1 hypointensity
S24 AJR:191, September 2008
and T2 hyperintensity. Although some studies have shown
high specificity of the melanotic imaging pattern for melanin-
containing metastases [5], the association nevertheless re-
mains controversial. The amelanotic imaging pattern is non-
specific. Gaviani et al. [6] studied the use of T2* images
(susceptibility sequences) in the imaging of metastatic mela-
noma to the brain and reported a high specificity of combined
T1 hyperintensity and T2* hypointensity for melanoma me-
tastases. The classically described melanotic pattern, howev-
er, is based on the T1 and T2 signal characteristics only. Op-
tions A, C, D, and E are not the best responses.
References
1. Mandybur TI. Intracranial hemorrhage caused by metastatic tumors. Neurology
1977; 27:650–655
2. Destian S, Sze G, Krol G, Zimmerman RD, Deck MD. MR imaging of hemor-
rhagic intracranial neoplasms. AJR 1989; 152:137–144
3. Atlas SW, Grossman RI, Gomori JM, et al. Hemorrhagic intracranial malignant
neoplasms: spin-echo MR imaging. Radiology 1987; 164:71–77
4. Escott EJ. A variety of appearances of malignant melanoma in the head: a re-
view. RadioGraphics 2001; 21:625–639
5. Isiklar I, Leeds NE, Fuller GN, Kumar AJ. Intracranial metastatic melanoma:
correlation between MR imaging characteristics and melanin content. AJR
1995; 165:1503–1512
6. Gaviani P, Mullins ME, Braga TA, et al. Improved detection of metastatic mela-
noma by T2*-weighted imaging. AJNR 2006; 27:605–608