PMC5214676_01
Following MRI in a 59-year-old patient with Bickerstaff encephalitis (FLAIR axial images). Admission MRI showed an irregular hyperintensity area in the dorsal pons spreading towards the medulla (A). MRI repeated after 5 months showed a significant regression of changes (B). After 1.5 year MRI showed recurrence of the previously stated lesions, with involvement of the pons, cerebral and cerebellar peduncles (C). Subsequent MRI showed a considerable increase in the extension of hyperintensity involving the brain stem and spreading towards the hemispheres of the cerebellum (D).
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In the area of brainstem - mostly in the dorsal pons - MRI showed an irregular area of hyperintensity on T2-weighted images, spreading towards the medulla on the left, slightly enhancing in the central area after injection of the contrast medium and slightly modelling the fourth ventricle (Figures 1A, 2A). After discharging the patient from the Clinic his neurological state systematically improved, and MR repeated after 5 months (Figures 1B, 2B) showed significant regression of changes in the brainstem. Brain MRI showed (Figures 1C, 2C) an expansion of the previously stated lesions, which now covered the pons and the cerebral and cerebellar peduncles. Subsequent MRI examination (Figures 1D, 2D) showed considerable increase in the extension of hyperintensity involving the pons, cerebral and cerebellar peduncles, and spreading towards the hemispheres of the cerebellum.
Following MRI in a patient with Bickerstaff encephalitis; T1-weighted images after contrast enhancement. In initial MRI, a small central area slightly enhancing after injection of the contrast medium (A). Regression of changes in the brainstem and no significant enhancement lesion in MRI after 5 months (B). MRI after 1.5 year revealed irregular areas of enhancement after injection of the contrast medium (C). An intensive, irregular area with strong enhancement after injection of the contrast in a subsequent MRI (D).
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In the area of brainstem - mostly in the dorsal pons - MRI showed an irregular area of hyperintensity on T2-weighted images, spreading towards the medulla on the left, slightly enhancing in the central area after injection of the contrast medium and slightly modelling the fourth ventricle (Figures 1A, 2A). After discharging the patient from the Clinic his neurological state systematically improved, and MR repeated after 5 months (Figures 1B, 2B) showed significant regression of changes in the brainstem. Brain MRI showed (Figures 1C, 2C) an expansion of the previously stated lesions, which now covered the pons and the cerebral and cerebellar peduncles. Subsequent MRI examination (Figures 1D, 2D) showed considerable increase in the extension of hyperintensity involving the pons, cerebral and cerebellar peduncles, and spreading towards the hemispheres of the cerebellum.
Initial single voxel proton MR spectroscopy showed the correct proportions of the main metabolites (NAA/Cr, Cho/Cr and mI/Cr) in the changed area, with the presence of lactate and lipid bands (A). Control MRS in the second episode after 1.5 year showed a slight reduction of NAA/Cr and an increase in Cho/Cr and mI/Cr with still present lactate and lipids (B). Subsequent MRS showed a considerable progressive reduction of NAA/Cr and a clear increase in Cho/Cr and mI/Cr with a significant increase of lactate and lipid peaks (C).
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Proton spectroscopy (1H MRS), using a single-voxel method (PRESS, TE=35 ms, TR=1500 ms, nex=192) showed the correct proportions of the main metabolites in the changed area, NAA/Cr, (N-acetylaspartate/creatine) Cho/Cr (choline/creatine) and mI/Cr (myoinositol/creatine), with the presence of lactate (Lac) and lipid (Lip) bands (Figure 3A). MRS showed a slight reduction of NAA/Cr proportions, a bit higher (in comparison to the previous MRS) values of Cho/Cr and mI/Cr, with a higher content of Lac/Cr and Lip/Cr (Figure 3B). The next MRS showed considerable reduction of NAA/Cr and clear increase in Cho/Cr and mI/Cr with considerable accentuation of lactate and lipid bands (Figure 3C).