PMC7468463_01
Cerebral MRI presenting the temporal evolution within 3 days (from left to right) and EEG excerpt. First row: axial T2-weighted FLAIR images showing increasing bilateral confluent widespread hyperintensities of the supratentorial white matter predominantly on the left. Second row: axial T2-weighted FLAIR images revealing new hyperintensities of the left cerebellar peduncle. Third row: axial SWI demonstrating subtle and small susceptibility artifacts in the splenium of the corpus callosum. Fourth row: axial pre- and post-contrast T1-weighted MPRAGE showing enhancement of the left parieto-occipital region. FLAIR, Fluid-Attenuated Inversion Recovery; SWI, Susceptibility Weighted Imaging; MPRAGE, Magnetization-Prepared Rapid Acquisition with Gradient Echo.
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F2
Cerebral MRI 1 day after first symptoms mainly demonstrated left-hemispheric hyperintense lesions of the white matter (Figure 2; left part of the first row) and an enhancement of the left parieto-occipital regions (Figure 2; fourth row). Repeat cerebral MRI 3 days later revealed a progression of the white matter lesions now involving the cerebellum, the ponto-medullar region, and both hemispheres with cerebral edema resulting in a mild midline shift (Figure 2; right part of the first row). The electroencephalogram (EEG) showed intermittent epileptiform activity in both hemispheres with left fronto-temporal predominance (Figure 2; lower part).
(A,B) Histologic workup of the biopsy of the left frontal lobe and the cerebral autopsy. (A) Histology of the biopsy of the left frontal lobe showing perivascular infiltrates (arrow) of neutrophils, eosinophils, and macrophages (Hemalaun Eosin [HE] stain). (B) Histology of the cerebral autopsy revealing diffuse generalized inflammation and acute hemorrhages (arrow) (Hemalaun Eosin [HE] stain).
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F3
A biopsy of the left frontal lobe showed infiltrates with neutrophilic and eosinophilic granulocytes as well as macrophages, acute focal hemorrhages, and vasculitis-like vessel lesions compatible with AHLE (Figure 3A).