PMC6041117_01
Images from preoperative axial T1-weighted imaging (A), T2-weighted imaging (B), gadolinium (Gd)-enhanced T1-weighted imaging (C), fluid-attenuated inversion recovery (FLAIR) (D), T2*-weighted gradient-recalled echo (T2*-GRE) (E), and susceptibility-weighted imaging (SWI) (F) show an area of abnormal intensity in the right occipital lobe. The lesion demonstrates no enhancement with Gd. T2*-GRE and SWI. images reveal multiple spotty cortical and subcortical hypointensities in the same region.
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In addition, T2*-weighted gradient-recalled echo (T2*-GRE) and susceptibility-weighted imaging (SWI) demonstrated extensive cortical microbleeds (Fig. 1).
Histopathology of the biopsy specimen. H&E staining shows reactive changes, including vacuolization suggestive of edema and astrocytosis (A-C). Most subcortical glial cells are small and pyknotic, and perivascular hemorrhage and infiltration of small inflammatory cells are detected (D). Magnification, A: x100. Scale bar, 1000 mum. B, C: x400. Scale bar, 100 mum. D: x200. Scale bar, 500 mum.
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Postoperative histopathology obtained from hematoxylin and eosin (H&E) staining demonstrated reactive changes including vacuolization, which suggests edema and gliosis, and thickened blood vessels (Fig. 2A-C). Fresh perivascular hemorrhage and several areas of hemosiderin deposition, and infiltration of small inflammatory cells were also present (Fig. 2D).
H&E staining shows lymphocytes and macrophages infiltrating not only around the blood vessels, but also in their walls (A). These immune cells show positive staining for CD68 (B) and CD3 (C), but negative staining for CD20 (D). Magnification, x400. Scale bar, 100 mum.
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Lymphocytes and epithelioid macrophages had infiltrated not only around the blood vessels, but also into the vessel walls (Fig. 3A). Perivascular inflammatory cells mostly comprised monocyte/microglial cells (positive staining for CD68) (Fig. 3B). T lymphocytes (positive staining for CD3) were also present (Fig. 3C), whereas a neoplastic increase in B lymphocytes was absent (negative staining for CD20) (Fig. 3D).
Pathological findings show thickened blood vessels with perivascular hemosiderin deposition on H&E staining (A). Direct fast scarlet (DFS) staining (B) and Congo red staining (C: bright field; D: polarizing microscope) after permanganic acid treatment shows amyloid deposition in the vascular walls, displayed as apple green in (D) (black arrow). Magnification, A: x200. Scale bar, 500 mum. B-D: x400. Scale bar, 100 mum.
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In addition, Congo red and DFS staining after permanganic acid treatment showed Abeta deposition in the vascular walls (Fig. 4).
Serial FLAIR images two weeks after treatment with dexamethasone. The right occipital subcortical lesion has clearly decreased in size.
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T2-WI (Fig. 5) and we stopped the administration of dexamethasone. The postoperative course was uneventful, with no relapse of epileptic symptoms.