PMC10240550_01
(a) Axial T2 and (b, c, and d) 3D FLAIR images showing large confluent hyperintensities in the middle stem, pons extending into the upper cervical spinal cord (red arrows). It infiltrates the basal ganglia and the thalami, with some punctate hyperintensities "peppering" the medial aspects of cerebellar hemispheres.
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It showed an important brainstem extensive edema with abnormal fluid-attenuated inversion recovery (FLAIR) signal hyperintensities with a "pepper-like" appearance involving the brainstem, predominantly the pons and extending to the middle cerebellar peduncle, to basal ganglia, thalami, and supratentorial white matter (Figure 1).
T1 FAT SAT with gadolinium injection shows punctate and curvilinear foci of contrast enhancement. Note extension into supratentorial paraventricular white matter (red arrow).
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Post-contrast sequences (Figure 2) showed multiple associated patchy spot-like and curvilinear areas of enhancement "peppering" the pons.
(a) Axial SWI MIP shows multiple hemorrhagic foci in the middle brain. (b) and (c) Diffusion-weighted sequences with apparent diffusion coefficient (ADC) cartography showing scattered curvilinear restricted diffusion areas (arrows).
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Curvilinear restricted diffusion areas were found on diffusion-weighted images and multiple hemorrhagic foci in the affected areas were identified on susceptibility weighted imaging (SWI) sequences (Figure 3).