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case_images: 57-year-old man with multiple cranial neuropathies. Coronal (A) and axial (B and C) contrast-enhanced T1-weighted MR images showing a nodular enhancing lesion within the anterior right cavernous sinus (arrows) (B-cell lymphoma on biopsy).
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case_images: Magnetic resonance imaging (MRI) of the brain revealed asymmetric prominent enhancement of the right seventh cranial nerve at the mastoid segment, extending into the right parotid space, and asymmetric thickening and enhancement of the right cavernous sinus and right foramen rotundum (Figure 1).
case_images: Biopsy of the right cavernous sinus lesion. The biopsy of the right cavernous sinus lesion comprises multiple fragments of nerve with the diffuse interstitial infiltrate of large, atypical cells (A and B, x 20 and x 40; respectively). The large, atypical cells are diffusely positive for PAX-5 (C, x 40) and CD20. The proliferative rate by Ki-67 is high (80%) (D, x 40). The findings confirmed a high-grade B cell lymphoma involving the cranial nerve.
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case_images: He underwent a right craniotomy and biopsy of the enhancing right cavernous sinus lesion, which was consistent with a large B-cell lymphoma involving nerve fibers (Figure 2).
case_images: Follow up MRI of the cervical spine (A and B) and brain (C and D) after 1-year of initial presentation with progression of neurolymphomatosis. Axial (A and B) contrast-enhanced T1-weighted MR images of the cervical spine with thickening and enhancement of multiple dorsal and ventral nerve roots. Contrast-enhanced T1-weighted MRI of the brain reveals nodular enhancing lesion with ependymal involvement in the right peritrigonal region (C, arrow). Lesion shows restricted diffusion (D, arrow) suggesting high cellularity.
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case_images: MRI of the cervical spine also showed multilevel cervical nerve root enhancement (Figure 3), whereas MRI of the lumbar spine showed enhancement of the cauda equina. However, MRI three months post-CAR-T showed disease progression with leptomeningeal and ependymal involvement (Figure 3).
case_images: Diagram depicting the clinical timeline of our patient.
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case_images: The clinical timeline is shown in Figure 4.