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First magnetic resonance imaging at presentation (day 1). Diffusion-weighted imaging with apparent diffusion coefficient map, T1-weighted, T2-weighted and fluid attenuation inversion recovery images (as labeled) at the level of pons showing no signal alteration
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F1
No acute infarct, intracranial hemorrhage, or any focal lesion was seen in Figures 1 and 2.
First magnetic resonance imaging at presentation (day 1). Diffusion-weighted imaging, apparent diffusion coefficient map, T2-weighted and fluid attenuation inversion recovery images (as labelled) at the level of basal ganglia showing no signal alteration
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F2
No acute infarct, intracranial hemorrhage, or any focal lesion was seen in Figures 1 and 2.
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Magnetic resonance imaging brain findings on day 7. Diffusion-weighted imaging, apparent diffusion coefficient map, susceptibility-weighted imaging, fluid attenuation inversion recovery, T2-weighted and T1-weighted images (as labeled) at the level of pons. Arrows showing focal hyperintensity in the central pons on diffusion-weighted imaging with corresponding signal drop on apparent diffusion coefficient suggestive of restricted diffusion. susceptibility-weighted imaging, fluid attenuation inversion recovery, T2-weighted and T1-weighted images show no signal alteration
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F3
Magnetic resonance imaging brain findings on day 7. Diffusion-weighted imaging, apparent diffusion coefficient map, T1-weighted, T2-weighted, fluid attenuation inversion recovery and susceptibility-weighted imaging images (as labeled) at the level of basal ganglia. Arrows showing hyperintense signal on diffusion-weighted imaging and subsequent apparent diffusion coefficient image showing corresponding signal drop in bilateral caudate nuclei (upper arrows) and putamina (lower arrows), suggestive of restricted diffusion. Hyperintense signal in these areas (upper and lower arrows) on T2-weighted image and fluid attenuation inversion recovery image. No signal alteration on T1-weighted image and susceptibility-weighted imaging image
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F4
T1-weighted images [Figure 4]. The focal, central pontine diffusion restriction, on the other hand, showed no signal abnormality on other sequences [Figure 4]. This implied that the involvement of these areas was of recent onset.
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Magnetic resonance imaging brain findings on day 19. Diffusion-weighted imaging, apparent diffusion coefficient, T1-weighted, T2-weighted, fluid attenuation inversion recovery and susceptibility-weighted imaging images (as labeled) at the level of basal ganglia. Hyperintense signal on diffusion-weighted imaging in bilateral caudate nuclei (upper arrows) and putamina (lower arrows) without any signal drop on apparent diffusion coefficient. Subsequent images show symmetrical hypointense signal on T1-weighted and hyperintense signal on T2 and fluid attenuation inversion recovery images in bilateral caudate nuclei (upper arrows) and putamina (lower arrows)
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F5
These areas remained symmetrically hyperintense on FLAIR/T2 images with hypointense signal on T1-weighted images [Figure 5]. The involved areas also appear to be swollen on these images.
Magnetic resonance imaging findings on day 19. Diffusion-weighted imaging, apparent diffusion coefficient map, T1-weighted, T2-weighted, fluid attenuation inversion recovery and susceptibility-weighted imaging images (as labeled) at the level of pons. Arrows showing trident shaped pontine signal abnormality on diffusion-weighted imaging and apparent diffusion coefficient images with central restricted diffusion (hyperintense on diffusion-weighted imaging, hypointense on apparent diffusion coefficient) surrounded by rim of vasogenic edema (minimally hyperintense on diffusion-weighted imaging, thin hyperintense rim on apparent diffusion coefficient due to intrinsic T2 effect). Subsequent images with arrows depicting hypointense T1-weighted and hyperintense T2/fluid attenuation inversion recovery signal alteration in central pons. No abnormality is seen on susceptibility-weighted imaging images
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F6
T1-weighted images [Figure 6]. The pattern of these signal abnormalities is highly suggestive of CPM with extrapontine involvement in the basal ganglia.
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Magnetic resonance imaging findings on day 36. Diffusion-weighted imaging, apparent diffusion coefficient map, T1-weighted, T2-weighted, fluid attenuation inversion recovery and susceptibility-weighted imaging images (as labeled) at the level of pons. Arrows depict trident-shaped mild hyperintensity on diffusion-weighted imaging and apparent diffusion coefficient images, hyperintense signal on T2-weighted and fluid attenuation inversion recovery images with corresponding hypointensity on T1-weighted images in central pontine tegmentum and basis pontis sparing the ventrolateral pons. The extent of signal abnormalities has marginally decreased due to a reduction in vasogenic edema as compared to the previous magnetic resonance imaging
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F7
This MRI revealed that the central pontine involvement remained almost unchanged, although marginally smaller on FLAIR/T2 images due to reduction in the vasogenic edema [Figures 7 and 8].
Magnetic resonance imaging findings on day 36. T2-weighted sagittal and coronal sections (as labeled) at the level of pons. Arrows depict the extent of T2-weighted signal abnormality in central pons characteristically sparing the ventrolateral pons
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F8
This MRI revealed that the central pontine involvement remained almost unchanged, although marginally smaller on FLAIR/T2 images due to reduction in the vasogenic edema [Figures 7 and 8].
Magnetic resonance imaging findings on day 36. Diffusion-weighted imaging, apparent diffusion coefficient map, T1-weighted, T2-weighted, and fluid attenuation inversion recovery images (as labeled) at the level of basal ganglia. diffusion-weighted imaging image showing symmetrical hyperintense signal in bilateral caudate nuclei (upper arrows) and putamina (lower arrows) without any apparent diffusion coefficient reversal. Symmetrical corresponding T1 hypointense, T2 hyperintense, and fluid attenuation inversion recovery hyperintense signal in bilateral caudate nuclei (upper arrows) and putamina (lower arrows). There is a reduction in edema in these areas as compared to the previous magnetic resonance imaging
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F9
T2 and FLAIR images [Figure 9], with reduction in swelling.
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