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An immunocompetent woman in her mid-60s initially presented with episodes of spasms and tremors in her right hand and forearm. She was suspected of having carpal tunnel syndrome and underwent carpal tunnel release surgery. However, the tremors recurred. She was referred to a neurologist about 7 months later. Magnetic resonance imaging (MRI) of her brain revealed either a prior stroke or demyelination, and she was treated with levetiracetam. Over the subsequent 3 months, she developed progressive right-sided weakness, dysarthria, hand tremors, slurred speech, and gait instability. She was referred to our institution for a brain biopsy. T2-weighted fluid-attenuated inversion recovery MRI revealed hyperintensities throughout the bilateral cerebral hemispheric white matter, corpus callosum, basal ganglia, thalami, midbrain, upper pons, and middle cerebellar peduncles (Figure, A). T1-weighted fluid-attenuated inversion recovery MRI with contrast showed the absence of contrast enhancement (Figure, B). Given the multifocal distribution of the lesions and the lack of contrast enhancement, the main differential considerations were demyelinating disease, infection, and encephalitis.
Hatanpaa KJ, Fuda F, Koduru P, Young K, Lega B, Chen W. Lymphomatosis CerebriA Diagnostic Challenge. JAMA Neurol. 2015;72(9):1066-1067. doi:10.1001/jamaneurol.2015.1149