PMC8556508_01
Chest radiographic images taken at the following time points: (A) initial diagnosis, (B) after drainage, and (D) after 10 weeks of osimertinib treatment. High-resolution computed tomography taken at the following time points: (E) after drainage and (G) after 10 weeks of osimertinib treatment. (C) 18F-labeled fluorodeoxyglucose (FDG) positron emission tomography before osimertinib treatment revealed an abnormal accumulation of FDG in the right upper lobe mass, mediastinal lymph nodes, and multiple bones. (F) Brain magnetic resonance imaging before osimertinib administration shows a small contrast-enhancing lesion and an endocranium thickening in the left cranial vault (white arrows).
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Plain chest radiography revealed massive right pleural effusion (Fig. 1A), which was drained to improve his dyspnea. Chest radiography and computed tomography (CT) revealed an irregularly shaped lung mass in the right upper lobe with pleural effusion and air space limitation due to poor lung expansion (Fig. 1B and E). An 18F-labeled fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET) scan revealed an abnormal accumulation of FDG in the right upper lobe mass, mediastinal lymph nodes, and multiple bones (Fig. 1C). Magnetic resonance imaging (MRI) showed a small contrast-enhancing lesion and a thickened endocranium in the left cranial vault, indicating meningeal dissemination (Fig. 1F). Although chest radiography and high-resolution CT revealed a partial response of the primary tumor, bilateral infiltrates were detected (Fig. 1D and G). Further evaluation with magnetic resonance angiography revealed a left middle cerebral artery (MCA) M1 segment occlusion (Fig. 1C).
Diffusion-weighted magnetic resonance imaging revealed (A) subacute small infarcts in the right hemisphere (white arrows) with (B) no evidence of infarction in left hemisphere. (C) Magnetic resonance angiography revealed a left middle cerebral artery M1 segment occlusion (white arrows). (D and E) Endovascular therapy completely recanalized the left middle cerebral artery (white arrows).
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Diffusion-weighted magnetic resonance imaging revealed small subacute infarcts in the right hemisphere (Fig. 2A). However, these radiologic findings were not consistent with his symptom laterality (Fig. 2B). Endovascular therapy was administered 3 hours and 40 minutes after symptom onset, following which, the complete recanalization of the left MCA was achieved (Fig. 2D and E) and the NIHSS score improved to 1.