PMC6437310_01
PMC6437310_02
Hyperpigmentation and skinny figure due to Addison's disease.
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F1
Five years ago, she noticed hyperpigmentation (Figure 1).
Cerebral magnetic resonance imaging (MRI) findings during the stay in the intensive care unit because of stroke like episodes. The MRI showed a subacute left parieto-occipital cortical/subcortical lesion involving the precentral gyrus with T2-weighted FLAIR signal increase and diffusion restriction without respecting vascular territories and the multiple right-hemispheric chronic posttraumatic lesions. The former subdural hemorrhage showed complete resolution. In the lesion, an increased lactate peak was registered (uncorrected data).
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F2
There was a clear lactate peak in the lesion (Figure 2). The EEG showed an intermittent slowing temporoparietal on both sides (stronger on the left) and singular spike-wave complexes temporal (once temporoparietal) on the left.
Neuropsychological findings showed significant impairments in divided attention for visual and auditory stimuli combined. The recorded intelligence level was in the lower normal range (IQ = 86), which appeared discrepant with the patient's educational background (this may also be attributed to fluctuations in attention). A detailed description of all test results can be found in Table 2 in the bottom column on neuropsychological test results.
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F3
Cognitive performance showed partially below-average results (Figure 3).
Magnetic resonance imaging findings a half year after the stroke-like episodes showed a chronic cortical to subcortical parieto-occipital brain lesion on the left side involving the posterior margin of the precentral gyrus with signs of chronic hemorrhagic transformation.
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F4
The follow-up cMRI 6 months after the stroke like events showed a chronic cortical to subcortical parieto-occipital brain lesion on the left side involving the posterior margin of the precentral gyrus with signs of chronic hemorrhagic transformation and the known multiple post-traumatic right hemispheric lesions (Figure 4).
Single-voxel magnetic resonance spectroscopy imaging. Presented is a MEGA-sLASER difference spectrum from the orbitofrontal cortex (OFC) of the patient, with indicated lactate (Lac)+ resonance. In the OFC, a Lac+/Creatine concentration ratio of 0.182 was found compared to a control group (N=6; 5 males and 1 female; 28 +- 2 years) with 0.159 +- 0.01.
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F5
Single-voxel magnetic resonance spectroscopy results show slightly increased lactate (Lac)+/creatine ratios in the dorsal anterior cingulate cortex (dACC), dorsolateral prefrontal cortex (DLPFC), and orbitofrontal cortex (OFC; Figure 5).