A Lobar Hematoma Mimicking a Brain Tumor in a Patient With Two Mechanical Heart Valves: The Value of Serial Magnetic Resonance Imaging

Subacute intracerebral hemorrhage can resemble a neoplasm on imaging, particularly when it is heterogeneous, surrounded by edema, and lacks a typical hyperacute appearance.We describe the case of a 76-year-old woman with mechanical aortic and mitral prostheses on warfarin who presented with right hemiparesis and an international normalized ratio (INR) of 4.5.Brain computed tomography showed a 2.3 cm heterogeneous left frontal parasagittal lesion with surrounding edema, without contrast enhancement.Magnetic resonance imaging (MRI) revealed a 24 × 23 × 15 mm lesion with peripheral T1 hyperintensity, a cystic/necrotic center, marked susceptibility artifact, and finger-like perilesional edema, along with scattered cerebral and cerebellar microbleeds.Primary or metastatic tumor, infection, septic embolism from prosthetic endocarditis, and cerebral amyloid angiopathy were considered.Thoraco-abdominopelvic computed tomography, infectious serologies, blood cultures, and transesophageal echocardiography did not support neoplastic or infectious causes.Serial MRI at six weeks showed near-complete resolution of edema with signal changes typical of late subacute blood products, and at seven months, a small residual hemosiderin-lined cavity without mass effect.The patient recovered independent gait.After a complete systemic workup and neurosurgical referral, serial MRI showing the expected evolution of blood products established the diagnosis before a biopsy was required, which was particularly relevant in a patient at high thrombotic and bleeding risk.