PMC6232820_01
Imageological changes before admission. Diffusion-weighted imaging (DWI) performed in September 2017 showed hyperintense areas in the (A) right and left pons and (B) left insular cortex. DWI performed in November 2017 showed hyperintense areas in the (C) right pons and (D) left putamen. Magnetic resonance angiography performed in November 2017 showed (E, F) mild stenosis in the right middle cerebral artery.
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F1
She therefore underwent magnetic resonance imaging (MRI) of the brain, which revealed a lacunar infarction in the right and left pons and the left insular white matter (Figures 1A,B). She was diagnosed with cerebral infarction and treated with butylphthalide, aspirin, and atorvastatin calcium for 2 weeks. A brain MRI after the second episode showed new infarct lesions in the right pons and the left putamen (Figures 1C,D). Furthermore, brain magnetic resonance angiography (MRA) showed a minor stenosis in the right middle cerebral artery, which did not explain the infarct sites (Figures 1E,F).
Imageological changes after admission. Diffusion-weighted imaging (DWI) performed after admission to our hospital in December 2017 showed multiple scattered hyperintense areas in the (A) right and left cerebellar hemispheres and (B) the left basal ganglia and right frontal and temporal lobes. Repeat DWI after 8 days showed multiple scattered hyperintense areas (C, D) near the lateral ventricles. Magnetic resonance angiography performed at the same time showed multiple stenoses in the (E) right anterior cerebral artery, right middle cerebral artery, and distal branch of the left middle cerebral artery, and (F) the right and left posterior cerebral arteries.
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F2
A brain MRI at our clinic showed more ischemic lesions in the right and left cerebellar hemispheres, pons, and frontal and temporal lobes, the left basal ganglia, and the right thalamus (Figures 2A,B). A brain MRA examination after admission to our hospital showed multiple stenoses in the right anterior cerebral artery, right middle cerebral artery, distal branch of the left middle cerebral artery, right and left posterior cerebral arteries, and basilar artery (Figures 2E,F), which is obviously different from the findings of the previous MRA. A repeat brain MRI after admission in our hospital (Figures 2C,D) revealed patchy foci of infarction in the right and left thalamus, cerebellar hemispheres, and pons, the right frontotemporal lobe, and the left basal ganglia.
Minor labial salivary gland biopsy. Lymphocytic foci were found in the salivary gland tissue under 200 times microscope. The total area of the glands was 4 mm2 (hematoxylin and eosin).
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F3
Several lymphocytic foci were observed in the biopsy specimen (Figures 3).