PMC8931735_01
Progression of MRI Findings (A) MRI brain with and without intravenous contrast; Axial diffusion-weighted imaging (DWI) (left), FLAIR (middle) and T1 post-contrast (right) images obtained at the time of initial presentation to our institution demonstrated cortically-based increased signal within the paramedical frontal lobes and insular cortices bilaterally. Additional diffusion restriction is present within bilateral caudate heads and the left putamen. (B) Follow up MRI brain without contrast; axial DWI) (left), FLAIR (middle) and T1 post-contrast (right) images obtained 4 days later demonstrate unchanged cortically-based and basal ganglia diffusion restriction. FLAIR images also reveal new patchy subcortical white matter hyperintensity with involvement of the subcortical U-fibers. Contrast enhancement of pachymeninges seen diffusely.
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F1
A repeat MRI on day two of IVIG treatment (Figure 1B) revealed unchanged diffusion restriction and FLAIR signal abnormalities within the paramedian frontal lobes, insular cortices, and basal ganglia.
EEG in anterior to posterior bipolar montage showing (A) left temporal discharges with maximal electronegativity at T3 as well as (A,B) left greater than right ~1 hertz sharply-contoured lateralized discharges, frontally predominant, mostly biphasic with occasional triphasic morphology consistent with Laterialized Periodic discharges (LPDs, formerly called PLEDs) though at times they have more of a bihemispheric representation.
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F2
R) (Figure 2). Repeat LP was performed which appeared non-infectious with lymphocytic pleocytosis, with negative oligoclonal bands, cytology and cytometry.