PMC9282754_01
Initial images of CT and MRI. (a) CT showing a low-density area in the right temporal lobe with a midline shift. (b) Fluid-attenuated inversion recovery image of MRI showing a high-intensity area (HIA) in the cortex of the right temporal lobe and occipital lobe combined with an HIA in the white matter indicating vasogenic edema. Periventricular HIAs were also shown in both the anterior and occipital horn of bilateral lateral ventricles. (c) T2 star-weighted MR image showing several low-intensity spots at the margin of the HIA in the right occipital lobe.
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F1
Computed tomography (CT) revealed a large low-density area in the right temporal, parietal, and occipital lobes [Figure 1a]. The lesion was demonstrated as a low-intensity area on T1-weighted images, while an HIA was observed on T2-weighted and FLAIR images [Figure 1b] without enhancement by gadolinium on MRI. Several MBs were observed on T2*WI in the bilateral temporo-occipital region, which was not predominant in the lesion above [Figure 1c].
Intraoperative macroscopic view and pathological examination of biopsy specimen (a) Intraoperative macroscopic view of the occipital lobe showing swelling of the cortex. (b) A histopathological examination (Hematoxylin and eosin staining, x40) showing the thickened cortical artery wall. (c) An immunohistochemical stain of the same section (Congo red staining, x40) showing the deposition of amyloid-beta proteins at the arterial wall. (d) Another immunohistochemical stain (Direct fast scarlet staining, x40) also showing the deposition of amyloid-beta proteins.
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Macroscopic findings of the brain surface suggested brain edema, but they differed from those of a glioma [Figure 2a]. Rapid intraoperative pathological examination did not reveal any neoplastic findings indicative of a glioma [Figure 2b]. In addition, Congo red staining [Figure 2c] and direct fast scarlet staining [Figure 2d], which are more specific than Congo red staining, suggested the deposition of amyloid-beta proteins in the cortical arterial wall consisting of CAA-I.
Follow-up images of the fluid-attenuated inversion recovery image of MRI. (a) Image on the 22nd day after admission. The high-intensity area (HIA) in the right temporal and occipital lobes was improved compared with the initial image [Figure 1b]. (b) Image on the 55th day after admission. The HIA in the right temporal and occipital lobes almost disappeared.
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The HIA on FLAIR decreased gradually in the following 2 months [Figures 3a and b], while her neurological symptoms further improved to clear consciousness with slight left hemiparesis on MMT 4/5.