PMC9747139_01
Brainstem and Cerebellar MRI Hyperintensities and Punctate Enhancement at First Presentation. Pontine and cerebellar hyperintensities (A, axial T2-weighted FLAIR sequence) with a perivascular pattern of punctate enhancement (B, axial T1 post gadolinium contrast), extending into the medulla and midbrain (C, parasagittal T1 post gadolinium contrast).
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MRI revealed diffuse serpiginous and nodular enhancement accompanied areas of T2 fluid attenuated inversion recovery (FLAIR) hyperintensity in the midbrain, pons, right cerebellum (Figure 1), and adjacent to the hypothalamus. Unfortunately, 2 attempts to wean prednisone lower than 30 mg daily at 6 months and 1 year after diagnosis resulted in worsening of diplopia, at which point MRI scans were repeated, demonstrating persistent gadolinium enhancement similar to the initial presentation depicted in Figure 1.
Repeat MRI on Day 7 After Presentation Showed Improvements in Abnormalities After Steroids. Following initiation of steroids, there were improvements in the pontine and cerebellar hyperintensities (A, axial T2-weighted FLAIR sequence) and perivascular pattern of punctate enhancement (B, axial T1 post gadolinium contrast; C, parasagittal T1 post gadolinium contrast).
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Follow-up imaging on Day 7 showed reduced abnormal T2 FLAIR hyperintensity and enhancement (Figure 2).