0:01

This was a patient who had progressive

0:03

neurologic deficits, including left hemiparesis.

0:08

The patient had lupus and was a patient on

0:14

dialysis for end-stage renal disease

0:17

associated with the lupus.

0:20

The patient had had a previous lesion

0:23

identified in the cerebellum,

0:25

which was thought to represent an infarct.

0:27

As we scroll the case here,

0:30

what we see is a lesion that is affecting the

0:33

frontal opercular region down to the perinsular

0:36

region and lateral temporal lobe

0:39

on the left side.

0:41

However, more inferiorly,

0:43

we have a hippocampal lesion posteriorly

0:46

on the right side,

0:47

and then as we get into the posterior fossa,

0:51

we see involvement of the pons, the medulla,

0:55

as well as the cerebellum.

0:58

This does not look like an infarct.

1:00

It is crossing multiple vascular distributions,

1:03

and therefore is unlikely

1:05

to represent an ischemic lesion.

1:07

We can verify that on our ADC maps

1:10

to the far right,

1:11

which show no evidence of dark signal,

1:14

which would indicate restricted diffusion.

1:17

If we look at the scans post-contrast,

1:22

one found that the patient did not show evidence

1:26

of gadolinium-enhancing lesions.

1:29

Here is the FLAIR scan showing the extent

1:32

of the lesions in the posterior fossa,

1:37

the temporal frontal opercular region

1:42

on the left side,

1:43

as well as in that posterior temporal lobe,

1:46

hippocampal region.

1:49

Given that this patient has absence

1:52

of restricted diffusion,

1:55

multifocal lesions,

1:57

including ones in the posterior fossa

2:01

In a patient with end-stage

2:03

renal disease and lupus,

2:05

we have a setup for the possibility of

2:07

progressive multifocal leukoencephalopathy,

2:11

which was the final diagnosis.

2:13

Again, we would not expect restricted diffusion,

2:16

we would not expect contrast enhancement,

2:19

we would not expect hemorrhage,

2:21

and we would expect the potential

2:23

for resolution over time.