PMC3794448_01
A) Computed tomography appearance at the time of initial development of encephalopathic changes; B) three dimensional reconstruction of coronal T2 sequences obtained with magnetic resonance imaging revealing the extensively confluent subcortical white matter signal hyper-intense change.
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After this continued for approximately 5 days without any improvement, she was evaluated at the Emergency Dept. and admitted after a CT head exam disclosed marked and diffuse hypointensity throughout the subcortical white matter (Figure 1A). T2 weighted sequences (Figure 1B), with hyper-intensity also noted on diffusion weighted imaging. The unusual feature though was that the cerebellar white mater had been spared, and that the change was a strictly supratentorial effect (Figure 2A) without altering signal intensity for the white matter tracts in the internal capsule and brain stem area.
A) Axial T2 weighted image reveals extensive confluent hyper-intense signal abnormality throughout the subcortical white matter with no obvious signal change within the cortex. The white box within the left semi-centrum ovale subcortical white matter represents the voxel used for generating magnetic resonance spectroscopy, shown in figure two; B) magnetic resonance spectroscopy of the subcortical white matter revealing an abnormally high peak for creatinine and choline downstream and to the left of the main central NAA peak with a small yet abnormal presence of a lactic acid peak upstream from the NAA peak.
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T2 weighted sequences (Figure 1B), with hyper-intensity also noted on diffusion weighted imaging. The unusual feature though was that the cerebellar white mater had been spared, and that the change was a strictly supratentorial effect (Figure 2A) without altering signal intensity for the white matter tracts in the internal capsule and brain stem area. Using large voxels placed over the semi-centrum ovale, MR spectroscopic analysis at 1.5 Tesla showed elevated abnormal elevations in the choline and creatinine peaks with a small peak seen for lactic acid as well (Figure 2B).
Resolution of symptoms over the next few months with follow-up brain 18FFDG PET scan showing normal uptake patterns for the cerebral cortex and sub-cortical white matter.
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Follow-up evaluation revealed substantial improvement both clinically and radiographically, with a normal mental status and normal MR imaging of the brain within one year of the event, with normal metabolism of both the gray and white matter of the brain, as assessed by 18F-FDG PET imaging (Figure 3).