case_images: PMC4785783_01
case_images: 65-year-old Italian woman, after chemotherapy (Escherichia coli L-asparaginase, daunorubicin, vincristine, intrathecal methotrexate) for a B-acute lymphoblastic leukemia, developed a comatose state. Brain axial computed tomography scan at the level of (a) occipital lobe, (b) parietal lobe and (c) centrum semiovale of frontal lobes showed subcortical white matter hypodensity (*).
case_images: JCIS-6-7-g002.jpg
case_images: PMC4785783_01_JCIS-6-7-g002.jpg
case_images: F1
case_images: Brain computed tomography (CT) scan showed diffuse hypodense areas in the bilateral cerebral and cerebellar lobes with no intracranial bleeding [Figure 1].
case_images: 65-year-old Italian woman, after chemotherapy (Escherichia coli L-asparaginase, daunorubicin, vincristine, intrathecal methotrexate) for a B-acute lymphoblastic leukemia, developed a comatose state Brain axial magnetic resonance imaging (a and b) fluid-attenuated inversion recovery sequences showed increased signals in the subcortical occipital (*) and frontal ( ) white matter. Brain axial (c and d) diffusion weighted imaging revealed light hyperintensity of the affected areas (arrows) with an increased apparent diffusion coefficient value (arrows) (e and f), indicating vasogenic edema. Diffusion-weighted imaging should always be combined with the study of the apparent diffusion coefficient map that allows us to differentiate the vasogenic oedema (increased signal in apparent diffusion coefficient, i.e., posterior reversible encephalopathy syndrome, as in the present case) from the cytotoxic edema (decreased signal in apparent diffusion coefficient, i.e., ischemic lesion).
case_images: JCIS-6-7-g003.jpg
case_images: PMC4785783_01_JCIS-6-7-g003.jpg
case_images: F2
case_images: Whereas MRI fluid attenuated inversion recovery and T2-weighted fast spin echo sequences evidenced abnormal signal in the subcortical occipitoparietal white matter and more confluent areas of signal hyperintensity in the bihemispheric frontal region, thalamus and cerebellar hemispheres [Figure 2a and b]. Diffusion-weighted images evidenced signal isointensity or slight hyperintensity of the affected areas with an increase in the apparent diffusion coefficient indicating vasogenic edema [Figure 2c-f].
case_images: 65-year-old Italian woman, after chemotherapy (Escherichia coli L-asparaginase, daunorubicin, vincristine, intrathecal methotrexate) for a B-acute lymphoblastic leukemia, developed a comatose state Brain axial magnetic resonance imaging fluid-attenuated inversion recovery sequences performed 14 days later showed persistently increased signals ( ) in the subcortical occipital (a) and frontal (b) white matter, that disappeared 1 month later (c and d).
case_images: JCIS-6-7-g004.jpg
case_images: PMC4785783_01_JCIS-6-7-g004.jpg
case_images: F3
case_images: A control brain MRI at 14 days after the clinical onset of the neurological picture [Figure 3a and b] evidenced persistent subcortical and cortical hyperintensity in the bilateral parietal, occipital, and frontal lobes, which were no longer present at a further MRI control 1 month later [Figure 3c and d].