PMC8710892_01
MRI of the brain. (A) T2 weighted image shows a round-to-oval-shaped hyperintense lesion involving the left cerebellar hemisphere. (B) Another similar lesion is seen in the right temporal lobe. (C) Bilateral thalami, left insular cortex and left occipital lobes also show the typical lesions. (D) Fluid-attenuated inversion recovery image shows hypointense lesion with eccentric nodule and surrounding hyperintense signal suggestive of perilesional oedema. MRI, magnetic resonance imaging.
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F1
The patient was advised for a magnetic resonance imaging (MRI) of the brain in April 2018 (figure 1). The MRI showed multiple T2 hyperintense round-to-oval-shaped lesions with surrounding hyperintense signals on fluid-attenuated inversion recovery images in the bilateral cerebral hemisphere and cerebellar hemisphere as depicted in figure 1.
CT of the brain. (A) Multiple tiny intra-axial hyperdense foci (white solid arrow) are seen in the frontal and parietal lobes on both sides. (B) Two hyperdense foci are seen in the right frontal and parietal lobes. (C) Tiny hyperdense focus in the left frontal lobe. (D) Another hyperdense focus in the right temporal lobe. CT, computed tomography.
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F2
In July 2018, when manic symptoms were resolved, computed tomography (CT) scan showed multiple diffusely scattered tiny calcified lesions in the bilateral cerebral hemisphere as depicted in figure 2.
MRI of the brain. (A, B) Tiny susceptibility artefacts as hypointense foci on susceptibility-weighted imaging suggestive of calcifications in the temporal lobe, occipital lobe, frontal and parietal lobes in the right cerebral hemisphere. (C) T1 weighted fat-saturated post-contrast image shows a faintly ring-enhancing lesion in the left cerebellar hemisphere. (D) T1 weighted fat-saturated post-contrast image shows another ring-enhancing lesion in the left thalamus. MRI, magnetic resonance imaging.
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F3
Another MRI in 2020 was done to look for the resolution of the disease, which showed multiple lesions as calcified (including the right temporal lobe lesion) and some of them were showing surrounding perilesional oedema but no enhancement suggestive of granular nodular stage and some of them were in the colloidal vesicular stage, which were showing enhancement and perilesional edema as depicted in figure 3.
Timeline of the key events.
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F4
Figure 4 shows the chronology of events in summary.