PMC5857578_01
Brain magnetic resonance imaging on first presentation (day 5) showing multiple areas of abnormal signals (white arrowheads): left midbrain high signal on FLAIR sequence (A), left midbrain hypersignal on T2 weighed (T2W) sequence (B), central gadolinium enhancement of left midbrain lesion on T1 sequence (C), and scattered supratentorial white matter foci of high FLAIR signal (D).
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F1
The initial brain magnetic resonance imaging (MRI) performed at D5 after onset of neurological symptom showed left midbrain and pontine edema with expansion of the brainstem, right caudate nucleus, and scattered supratentorial white matter foci of high T2/FLAIR signal (Figure 1).
Brain magnetic resonance imaging (MRI) (day 30) at the time of the relapse of the neurological manifestations showing left frontoparietal cortical and subcortical areas of isointense T1, high T2 (A), FLAIR (B), and restricted diffusion (C) signals (arrowhead) increasing in size along the MRI examination, due to an active hyperacute bleed [arrow (A) pointing at spot sign indicating active bleed]. Area of high T2 and FLAIR signal changes (arrowheads) in the head of the caudate nucleus (D) and of abnormal diffusion weighed images (DWI) in the subcortical right cerebellar white matter (arrowheads) (E). Previous left midbrain lesion has resolved with only a tiny residual of high FLAIR signal corresponding to minimal residual gliosis (arrowhead) (F). Follow-up brain MRI at D33 showing a necrotico-hemorrhagic lesion in the left hemisphere (G,I), interval evolution of cortical/subcortical lesions, with new lesions in the bilateral thalami (G), cerebellar hemispheres (H), and right cerebral hemisphere (I) (arrowheads indicate abnormal signals).
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F2
Brain MRA was normal (Figures 2A-F). MRI at D33 showed interval worsening with disseminated gray and white matter non-hemorrhagic lesions in the right cerebral and both cerebellar hemispheres, bilateral deep gray nuclei, as well as new necrotic non-hemorrhagic lesions in the left hemisphere (Figures 2G-I).
FLAIR sequences of brain magnetic resonance imaging (MRI) at day 39 showing interval evolution and improvement of thalamic (A), cerebellar (B), and right cerebral hemispheric lesions (C) with no additional lesions as compared to the previous MRI (arrowheads indicate hypersignal abnormalities).
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F3
Repeat MRI at D9 showed no new parenchymal hemorrhage and partial resolution of the non-hemorrhagic lesions (Figure 3).