Wk 3, Case 5 - Review

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Report

Patient History
7 year old with B cell lymphoma post BMT and trisomy 21, altered mental status. Over the past couple days, he had tremors thought to be from tacrolimus.

Findings
These images demonstrate T2 hyperintense areas involving the periventricular, centrum semiovale and subcortical white matter bilaterally predominantly in the frontal parietal regions but also in the posterior temporal regions, with no mass effect or restricted diffusion. There is also interval appearance of a focal malacia in the central pons measuring 6 mm. There is T2 hyperintensity in the periventricular white matter around bilateral frontal and occipital horns.

There is minimal global brain volume loss with commensurate slight prominent size of the ventricles. There is small size to the cerebellar vermis. Otherwise there is no restricted diffusion to suggest acute or subacute infarction. There is no mass or mass effect. There is no extra-axial collections or midline shift. The basal cisterns are intact. The major intracranial arterial flow voids are preserved. The orbits are normal in appearance. There is mild mucosal thickening of the right sphenoid sinus, not significantly changed from the prior CT. The scalp and calvarium are grossly unremarkable. The mastoid cells are clear.

Impressions
There are T2 hyperintense areas involving the white matter bilaterally predominantly in the frontoparietal and posterior temporal regions, nonspecific. Tacrolimus (FK506) induced posterior reversible encephalopathy syndrome with a differential diagnosis including progressive multifocal leukoencephalopathy should be considered. Sepsis and GVH disease can also lead to PRES.

Focal encephalomalacia in the central pons.

Case Discussion

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Joshua P Nickerson, MD

Associate Professor of Neuroradiology

Oregon Health & Science University

Francis Deng, MD

Assistant Professor of Radiology and Radiological Science

Johns Hopkins University School of Medicine

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Wk 3, Case 5 - Review