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Images in Neurology
June 2004

Punched-out Skull

Arch Neurol. 2004;61(6):958. doi:10.1001/archneur.61.6.958

A 73-year-old woman with a history of multiple myeloma was initially seen with fever, weakness, and confusion. The patient was found to have a right lower lobe pneumonia and renal failure. Despite aggressive treatment, the patient had an acute respiratory decompensation and died. Premortem computed tomography of the head showed multiple lytic lesions throughout the entire calvarium (Figure 1, A). Gross examination of the calvarium, which was removed at autopsy, revealed extensive "punched-out" lesions. A radiographic image of the removed calvarium shows a unique view of the lucent or lytic lesions that cannot be obtained before death (Figure 1, B). Pathologic examination of the lytic lesions revealed characteristic features of plasmacytoma with numerous monomorphic plasma cells. These cells are mature and possess round nuclei with coarsely clumped chromatin, eccentric basophilic cytoplasm, and a perinuclear halo of clearer cytoplasm (Figure 1, C and D). Blood lakes, proteinaceous precipitates, or amyloid can form within plasmacytomas and result in a pseudoangiomatous appearance.