case_images: PMC10244657_01
case_images: Brain MRI T1 post-contrast, pre- and post-intrathecal rituximab. (A, B) January 2021, before intrathecal rituximab. (C, D) March 2022, after two cycles of intrathecal rituximab. There was mild improvement in enhancement and pachymeningeal bulk after cycle 1, but not after cycle 2.
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case_images: F1
case_images: Brain MRI showed dural-based enhancing nodules involving the prepontine and perimesencephalic cisterns (Figures 1A, B). At January 2022 follow-up, she reported no headaches nor falls saying, "I feel like I am enjoying life the way I am supposed to." November 2022 brain MRI was stable (Figures 1C, D).
case_images: Brain FDG-PET, pre- and post-intrathecal rituximab. (A) Sagittal image from 18F-FDG PET before intrathecal rituximab demonstrates diffuse, patchy cerebral cortical hypometabolism and intense nodular uptake along the retroclival region, corresponding to areas of pachymeningeal disease. (B) Follow-up imaging after intrathecal rituximab demonstrates interval resolution of previously seen cortical hypometabolism and abnormal retroclival uptake.
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case_images: F2
case_images: Brain FDG-PET showed hypermetabolism in areas of pachymeningitis (Figure 2A). Brain PET showed nearly resolved hypermetabolism of the pachymeninges (Figure 2B).
case_images: Flowchart of the patient's clinical course of treatment.
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case_images: F3
case_images: Figure 3 provides a summary of the patient's history, testing and treatment over time.