PMC9929651_01
Head MRI findings. Brain FLAIR/T2-weighted imaging performed at another hospital within 1 month after symptom onset revealed high-intensity lesions in the left middle cerebellar peduncle (a, b). Brain axial FLAIR/T2-weighted imaging at the time of the patient's first visit to our hospital showed high-intensity lesions from the left middle cerebellar peduncle to the entire brainstem (c), and post-contrast T1-weighted imaging demonstrated contrast enhancement in the left middle cerebellar peduncle (d). In addition, coronal FLAIR/T2-weighted imaging showed diffuse high-intensity lesions from the pons to the midbrain, medulla oblongata, left-dominant middle cerebellar peduncle, right-dominant, posterior limb of the internal capsule, and upper cervical spinal cord (e-h), and post-contrast T1-weighted imaging showed faint enhancement effects in the left middle cerebellar peduncle and upper cervical spinal cord (i-l).
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F1
Head magnetic resonance imaging (MRI) with diffuse FLAIR/T2-weighted imaging showed high-intensity areas from the pons to the midbrain, medulla oblongata, left-dominant middle cerebellar peduncle, right-dominant posterior limb of the internal capsule, and right-dominant upper cervical spinal cord (Fig. 1c-h); post-contrast T1-weighted imaging showed faint enhancement in the left middle cerebellar peduncle, cerebellum, and upper cervical spinal cord (Fig. 1i-l). MRI performed at the previous hospital 1 month after the onset of gait disturbance showed subdural hematoma that was almost completely absorbed, but FLAIR/T2-weighted imaging showed high-intensity lesions in the left middle cerebellar peduncle (Fig. 1a, b).
Histological findings of the pons, middle cerebellar peduncle, and cerebellar white matter. There was severe perivascular lymphocyte and macrophage infiltration (a, c, e: hematoxylin-eosin staining, g: CD68 immunostaining). There was severe demyelination (b, d, f: Kluver-Barrera staining), although the axons were relatively well preserved (h: Bodian staining).
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F2
These findings were also seen in the basal ganglia, right posterior capsule, left thalamus, left cerebral peduncle, and medullary reticular formation (Fig. 2a-f).
Histological findings around the anterior horn of the lateral ventricle and of the white matter just below the calcarine sulcus. There were demyelinating lesions, but little inflammatory cell infiltration (a, c: Kluver-Barrera staining, b, d: Manlow's staining).
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F3
Similar lesions were also seen in the periventricular cerebral white matter and white matter just below the calcarine sulcus, although the lesions were smaller and had milder inflammation and more progressive gliosis (Fig. 3a-d).