case_images: PMC11436272_01
case_images: Axial brain CT during the first admission. Demonstrating moderate hydrocephalus (black arrow), with interstitial edema and encephalomalacia (destruction of brain tissue) in the left lentiform nucleus (white arrow).
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case_images: fig1
case_images: Brian's computerized tomography (CT) revealed hydrocephalus and a hypolucent lesion in the left basal ganglia (Figure 1).
case_images: Brain MRI during the first admission. (a and b) T1 fat saturation with contrast showed intense nodular leptomeningeal enhancement in the basal, suprasellar, and prepontine cisterns and left Sylvian fissure. (c and d) FLAIR and T2W sequences showing a moderate hydrocephalus with asymmetrical lateral ventricle dilatation (right: 30 mm and left: 34 mm), leading to interstitial periventricular edema (white arrows). Black arrows show an old ischemic insult (encephalomalacia) of the left lentiform nucleus.
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case_images: fig2
case_images: Magnetic resonance imaging (MRI) demonstrated intense nodular leptomeningeal enhancement in the basal, suprasellar, and prepontine cisterns as well as left Sylvian fissure and a moderate degree of hydrocephalus with asymmetrical lateral ventricle dilatation causing interstitial periventricular edema associated with an old ischemic insult (encephalomalacia) of the left lentiform nucleus (Figure 2).
case_images: Brain MRA during the first admission. Revealing diffuse luminal narrowing of the left M1 to M4 segments of the middle cerebral artery (MCA), indicating significant arterial stenosis and vasculitis.
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case_images: fig3
case_images: M1 to M4 segments of the left middle cerebral artery (MCA), which suggests significant arterial stenosis and vasculitis (Figure 3). Magnetic resonance venography (MRV) was normal.
case_images: Axial brain CT scan without contrast taken during the second admission: (a) mild hydrocephalus with a ventriculoperitoneal (VP) shunt in the left lateral ventricle, (b) left lentiform nucleus encephalomalacia, and (c) arterial calcification along the left M1 segment of the middle cerebral artery (MCA).
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case_images: fig4
case_images: Therefore, a ventriculoperitoneal (VP) shunt placement surgery was performed to decrease the hydrocephalus level (Figure 4).
case_images: Follow-up MRI with various sequences. T2W/FLAIR sequences (a-d) reveal vasogenic edema in the left frontotemporal lobes, causing ventricular compression. Some round lesions are also visible, which appear hyperintense on T1W and isointense to the cortex on T2W. Following contrast administration (e, f) leptomeningeal enhancement and rim-enhancing nodules appear in the prepontine cistern and perisylvian fissure. Central diffusion restriction is seen on DWI/ADC (g, h), along with thickened pachymeningeal enhancement in the left frontoparietal region (i).
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case_images: fig5
case_images: However, after contrast administration, abnormal leptomeningeal enhancement with multiple rim-enhancing nodules was seen at the prepontine cistern and perisylvian fissure that was suggestive of caseating tuberculomas (Figure 5).