A 20 y/o man with loss of consciousness

 

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Doctor's Information

Name : Hamidreza
Family : Haghighatkhah
Affiliation : Radiology Department,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Maryam babaie

 

Case Section

Neuroradiology

 

Patient's Information

Gender : Male
Age : 20

 

Clinical Summary

A 20 y/o man with acute onset of ataxia, vomiting and then loss of consciousness and history of blindness due to CMV retinitis

 

Imaging Findings

Magnetic Resonance Imaging (MRI) was done, and it revealed a diffusely swollen right cerebellar hemisphere without a well-defined mass, appearing hypointense on T1-weighted images, hyperintense on T2-weighted images, and Fluid-Attenuated Inversion Recovery (FLAIR)- weighted images. There was a significant mass effect over the fourth ventricle and the brainstem with hydrocephalous. No evidence of diffusion restriction was seen.in post GAD images enhancement in the lesion was seen , that mimic a tumoral lesion. Decrease of size and thickening of retina also were seen in bilateral globes. repeat MRI ( figure 5,6,7) performed after treatment revealed a decrease in the swelling and mass effect of the right cerebellar hemisphere, without significant atrophy . Signal abnormalities were much less severe. Few linear areas of T1 hyperintensity were seen in the affected cerebellum.

 

Differential Diagnosis

posterior fossa tumor, acute intoxication, demyelination/Acute Disseminated Encephalomyelitis (ADEM), infarct, and Lhermitte-Duclos disease.

 

Final Diagnosis

acute cerebellitis due to CMV infection (positive antibody and significant response to antiviral treatment)

 

Discussion (Related Text)

Acute cerebellitis is one of the major causes of cerebellar dysfunction in children, which may result from viral or autoimmune etiologies and has a benign course in majority of case. It has an unpredictable clinical course, and while some patients have no symptoms, others may have fulminant course leading to death. Rarely, surgical intervention may be necessary if complications such as tonsillar herniation, brainstem compression, and acute hydrocephalus develop. Clinical symptoms include positive cerebellar signs, headache, and altered mental state. Examination of the CSF is not obligatory for diagnosis and may be normal. MRI is the imaging modality of choice in acute cerebellitis and typically reveals a bilaterally symmetric disease or may be normal. Unilateral presentation of acute cerebellitis (hemicerebellitis) is rare, while pseudotumoral hemicerebellitis is exceptionally rare. serial MRI examinations are necessary in such cases to make the correct diagnosis, evaluate associated complications, and, therefore, avoid needless surgical interventions. In the presence of coagulopathy and other predisposing factors, hemorrhage can occur in the affected as well as normal cerebellar hemisphere. Thus, it raises the possibility of mild subclinical involvement of contralateral cerebellar hemisphere in hemicerebellitis, which may manifest at later stages in the presence of certain predisposing factors.

 

References

Singh P, Bhandal SK, Saggar K, Pooni PA, Jaswal RS.Pseudotumoral hemicerebellitis with hemorrhage. J Pediatr Neurosci 2012;7:49-51.

 

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