Neuroradiology #6 – Long case

A 48-year-old male patient:
* HIV (+)
* Presented to emergency with headache, confusion, N/V

Axial T2W Image
Axial T2W Image
Axial T2W Image

What do you see?

Axial T2W Image: T2 hyperintense lesions of left caudate nucleus, left putaminal and right dentate nucleus , with perilesional edema
(a) Axial FLAIR image
(b) Axial FLAIR image
(c) Axial FLAIR image
(d) Coronal post-contrast T1W image
e) Coronal post-contrast T1W image

Small corticomedullary hyperintense lesions (a-c) with faint enhancement (d-e)

Caudate and putaminal lesions demonstrate faint peripheric contrast enhancement on coronal post-contrast T1W image (a), whereas cerebeller lesion has strong peripheric and central nodular enhancement on coronal post-contrast T1W image (b)
Caudate and cerebellar lesions have tiny microhemorrhages on SWI (a-b), a clue for diagnosis

Toxoplasmosis

* Most common opportunistic CNS infection and most common cause of a mass lesion in AIDS

* Basal ganglia, thalamus, corticomedullary junction and cerebellum frequently involved

* Microhemorrhages can be seen on SWI; lesions may have ring or nodular enhancement

* Major ddx is lymphoma
– Lymphoma is usually solitary, whereas solitary lesions are uncommon in toxoplasmosis
– Microhemorrhages are uncommon in lymphoma

2 thoughts on “Neuroradiology #6 – Long case

  1. Shouldn’t we include fungal and TB infection in the differential list also? Due to hemorrhagic component, nodular and ring enhancing lesion?

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