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Progressive cognitive decline in two patients with severe MRI brain changes

Published:March 08, 2021DOI:https://doi.org/10.1016/j.jocn.2020.11.028

      Highlights

      • Contrast enhancing/non-enhancing ‘sentinel lesions’ described in Primary CNS lymphoma can recede spontaneously or following corticosteroids.
      • Histological finding can reveal lymphocyte-rich inflammation, often with demyelination and may delay diagnosis.
      • ‘Sentinel lesions’ of PCNSL should be considered in this spontaneously remitting clinicoradiological syndrome.

      1. Clinical background

      A 46-year-old female (Fig. 1) and 32-year-old man (Fig. 2) presented with progressive cognitive decline, altered behaviour and seizure. CSF was acellular, with normal biochemistry and no abnormal cells on cytology. Limbic encephalitis and antineuronal antibody panels were negative. MRI brain was performed at presentation and repeated 3 weeks later.
      Figure thumbnail gr1
      Fig. 1Multifocal hyperintensities on FLAIR (A1), with patchy contrast enhancement on T1-weighted sequences (A2, A3). Progress imaging after 3 weeks demonstrated regression of some lesions and reduction in enhancement (B1, B2, B3) (arrows). Progress MRI identified new lesions with contrast enhancement (C2, C3) (arrow heads).
      Figure thumbnail gr2
      Fig. 2Multifocal hyperintensities on FLAIR (A1), with patchy contrast enhancement on T1-weighted sequences (A2, A3). Progress imaging after 3 weeks demonstrated regression of some lesions and reduction in enhancement (B1, B2, B3) (arrows). Progress MRI identified new lesions with contrast enhancement (C2, C3) (arrow heads).

      2. Question

      What is the most likely diagnosis?
      • a)
        Acute disseminated encephalomyelitis
      • b)
        Tumefactive multiple sclerosis
      • c)
        Sentinel lesion in primary CNS lymphoma
      • d)
        High grade glioma
      Answer on page: 172.

      Author contributions

      Sophie Waller: study concept and design, first draft, literature review. Tien Lee Ong: study concept and design, first draft, literature review. Khairul Azmi Ibrahim: data acquisition, revising manuscript and critical review of manuscript. Zariah Abdul-Aziz: data acquisition, revising manuscript and critical review of manuscript. Neil Mahant: data acquisition, revising manuscript and critical review of manuscript. Victor SC Fung: study concept and design, critical review of manuscript for intellectual content, literature review.

      Study funding

      No targeted funding reported.

      Disclosure

      The authors report no disclosures relevant to the manuscript.

      Conflict of interest

      The authors report no conflict of interest relevant to the manuscript.

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