Age: 44
Sex: Male
Indication: Diffuse large B-cell lymphoma on treatment
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Case #6
Findings
- Infratentorial and supratentorial patchy T2/FLAIR hyperintensities involving the bilateral middle cerebellar peduncles, left superior cerebellar peduncle, left greater than right midbrain and cerebral peduncles, right greater than left lentiform nuclei, and the periventricular white matter, particularly in the bilateral temporal and left parietal lobes
- No significant associated mass effect, restricted diffusion, or enhancement
- No evidence of acute infarct, hemorrhage, or hydrocephalus
- Mild generalized cerebral volume loss
- Mild diffuse smooth dural thickening
- Trace mucosal thickening of the right maxillary sinus
Diagnosis
- Progressive multifocal leukoencephalopathy (PML)
Sample Report
Asymmetric bilateral patchy infratentorial and supratentorial patchy T2/FLAIR hyperintensities predominantly involving white matter without significant associated mass effect, restricted diffusion, or enhancement. This imaging appearance is most suggestive of progressive multifocal leukoencephalopathy (PML). Lymphoma is considered less likely given lack of mass effect, restricted diffusion, and enhancement, though lack of enhancement can be seen in the setting of steroid treatment.
No evidence of acute infarct, hemorrhage, or hydrocephalus.
Mild diffuse smooth dural thickening, which is nonspecific and could relate to prior intrathecal access, intracranial hypotension, or less likely, involvement by lymphoma.
Mild generalized cerebral atrophy.
Discussion
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References
- Berger JR, Aksamit AJ, Clifford DB, Davis L, Koralnik IJ, Sejvar JJ, Bartt R, Major EO, Nath A. PML diagnostic criteria: consensus statement from the AAN Neuroinfectious Disease Section. Neurology 2013; 80(15): 1430-1438.
- Maas RP, Muller-Hansma AH, Esselink RA, Murk JL, Warnke C, Killestein J, Wattjes MP. Drug-associated progressive multifocal leukoencephalopathy: a clinical, radiological, and cerebrospinal fluid analysis of 326 cases. J Neurol 2016 Oct; 263(10): 2004-2021.
- Smith AB, Smirniotopoulos JG, Rushing EJ. From the archives of the AFIP: central nervous system infections associated with human immunodeficiency virus infection: radiologic–pathologic correlation. Radiographics 2008; 28: 2033-2058.
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