case_images: PMC11179521_01
case_images: Brain magnetic resonance imaging of the first episode showed on coronal T2: (a) Axial T2-fluid-attenuated inversion recovery. (b) Images of hyperintense lesions of the right hemispheric cortex, subcortical, and periventricular white matter (WM) responsible for a significant mass effect on median structures associated with subtle subcortical hypointensity of corona radiata. Cortical hypersignal on axial diffusion-weighted imaging (c) and an overlying leptomeningeal enhancement (arrows) on axial T1-weighted post-gadolinium (d) Images.. Perfusion image obtained by arterial spin labeling shows hyperperfused areas in the right cerebral hemisphere with an inflammatory spectrum on spectroscopy (e): high choline peak, reverse Chol/Cr ratio, decreased NAA (N-acetyl aniline) peak and also prominent lactate (Lac) and lipids (Lip) resonance, represented as a doublet peak in the magnetic resonance spectra at 1.31 ppm.
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case_images: PMC11179521_01_10.1177_2050313X241261021-fig1.jpg
case_images: fig1-2050313X241261021
case_images: The first cerebral MRI with gadolinium showed significant right hemispheric hyperintensity on T2-fluid-attenuated inversion recovery (FLAIR), cortical hyperintensity on diffusion-weighted imaging (DWI) with overlying leptomeningeal enhancement, perfusion image obtained by arterial spin labeling (ASL) technique revealed hyperperfused areas in the right cerebral hemisphere (Figure 1) raising suspicions of MELAS (mitochondrial encephalomyopathy, lactic acidosis, stroke-like episodes).
case_images: One-month follow-up magnetic resonance imaging on axial T2: (a) Diffusion-weighted imaging, (b) T1 post-gadolinium injection, (c) axial images and coronal T2 fluid-attenuated inversion recovery, and (d) image showed no abnormality.
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case_images: One-month follow-up brain MRI showed complete resolution of previously described abnormalities (Figure 2).
case_images: Magnetic resonance imaging after the second admission of the patient showed resolution of right temporal cortical abnormalities, extension of left occipital lesions, and persistence of leptomeningeal enhancement on all sequences (a to e); normal spectroscopy on an unaffected region of cerebral parenchyma (h and i).
case_images: 10.1177_2050313X241261021-fig3.jpg
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case_images: fig3-2050313X241261021
case_images: The unaffected parenchyma evaluated by the second voxel showed normal spectra (Figure 3).