D/D BIATERAL BASAL GANGLIA HYPERINTENSITIES

By Dr. Piyush Ojha, DM Resident, GMC Kota
under the guidance of Prof. Dr. Vijay Sardana (HOD, Neurology)

1. BILATERAL BASAL GANGLIA HYPERINTENSITIES – IMAGING IN AUTOIMMUNE ENCEPHALITIS DR. PIYUSH OJHA DM RESIDENT DEPARTMENT OF NEUROLOGY GOVT MEDICAL COLLEGE, KOTA

2. Mesial temporal hyperintensities , either unilateral or bilateral with or without enhancement after gadolinium administration, are classic autoimmune limbic encephalitis findings. The lateral temporal lobe and insula less commonly involved Basal ganglia, in contrast, are frequently involved - distinguish it from HSV encephalitis which characteristically spares the basal ganglia  Normal imaging is common, particularly in the early illness stages Extratemporal abnormalities sometimes observed. If lesions are not in a typical distribution or have avid enhancement, other inflammatory ( eg . neurosarcoidosis ) or oncologic ( eg . lymphoma) diagnoses should be considered.

3. FUNCTIONAL IMAGING : Global hypometabolism is the most common feature encountered in patients with autoimmune encephalopathies . However, focal hypometabolism can also be encountered. In instances where the patient has seizures, hypermetabolism can occur.

4. Anti-glutamic acid decarboxylase encephalitis . A 61-year-old woman presented with headaches, mild confusion, and nystagmus without development of psychosis, severe encephalopathy, or seizures. MR imaging of the brain demonstrates T2-FLAIR hyperintensity in the right >left hippocampus (A and B), right > left insular cortex (B), and bilateral cingulate gyrus (C and D) without restricted diffusion (not shown), hemorrhage (not shown), or postcontrast enhancement (not shown).

5. Anti-N-methyl D-aspartate receptor encephalitis . A 32-year-old woman presented with headaches, vertigo, and psychosis with subsequent development of encephalopathy and seizures. MR imaging of the brain performed after the onset of seizures 2 weeks after initial presentation demonstrates T2-FLAIR hyperintensity in the left inferior temporal lobe (A), left > right insular cortex (B and C), and left > right cingulate gyrus (B–D), without restricted diffusion (not shown), hemorrhage (not shown), or postcontrast enhancement (not shown).

6. DIFFERENTIAL DIAGNOSIS of Bilateral Basal Ganglia Hyperintensities in an adult Hypoxic-Ischemic Injury – Near drowning, cardiac arrest, Viral Encephlitis – West Nile, HSV, Japanese Encephalitis Osmotic Demyelination Syndrome Toxin exposure – CO poisoning - Globus pallidus involvement Wilson disease CJD CVT Metabolic – Hepatic Encephalopathy

7. Carbon monoxide poisoning in a 33-year-old man who was found in a coma after a suicide attempt . Axial T2-weighted (a) and coronal fluid-attenuated inversion recovery (b) MR images obtained 4 weeks after the poisoning depict symmetric hyperintense foci in the globus pallidus (arrows). Symmetric hyperintense areas in the deep white matter (arrowheads in b) are consistent with delayed leukoencephalopathy.

8. Acute hyperammonemia in a 70-year-old cirrhotic man with acute decompensated hepatic failure who presented with altered mental status. T2-weighted (a) and diffusion-weighted (b) MR images reveal bilaterally symmetric swelling, hyperintensity , and restricted diffusion in the caudate heads (white arrows in a), putamina (black arrows in a), and insular cortices (arrowheads in b).

9. Hypoglycemic brain injury in an 18-year-old comatose man with a random blood sugar level of 2.1 mmol /L. Axial T2-weighted (a) and diffusion-weighted (b) MR images demonstrate diffuse hyperintensity and restricted diffusion in the heads of the caudate nuclei (arrowheads in a), lentiform nuclei (arrows in a), and cerebral cortex, with sparing of the subcortical white matter and thalamus.

10. HIE in a 38-year-old woman who was resuscitated after being involved in a traffic accident . (a) T2-weighted MR image demonstrates bilaterally symmetric hyperintense areas in the thalamus (white arrowheads), basal ganglia, and cerebral cortex. Black arrow-heads = caudate nuclei, arrows = lentiform nuclei. (b) T2-weighted MR image obtained at a higher level more clearly depicts diffuse cortical involvement.

11. Wilson disease in a 9-year-old boy with tremors and dystonia . T2-weighted MR image depicts bilaterally symmetric areas of abnormal T2 prolongation in the ventrolateral thalamus (arrowheads), putamina (white ar - rows), and caudate nuclei (black arrows).

12. Osmotic myelinolysis in a 59-year-old alcoholic man who presented with confusion and pseudobulbar palsy. (a) T2-weighted MR image depicts bilaterally symmetric hyperintense areas in the thalamus (arrowheads) and putamina (arrows). (b) T2-weighted MR image obtained inferior to a demonstrates an ill-defined hyperintense area in the central pons (*), with sparing of the rim.

13. Wernicke encephalopathy in a 36-year-old alcoholic man with impaired consciousness. (a) Axial T2-weighted MR image shows bilaterally symmetric areas of T2 prolongation in the paramedian thalamus along the third ventricle (white arrowheads), the caudate nuclei (black arrow-heads), and the putamina (arrows). (b) Axial T2-weighted MR image shows ill-defined hyperintense areas in the periaqueductal region (arrow).

14. Deep CVT in a 37-year-old woman with headache and drowsiness . (a) T2-weighted MR image shows bilateral hyperintense areas in the thalamus (arrowheads) and caudate heads (arrows). (b) Phase-contrast MR venogram shows absence of normal flow in the internal cerebral veins, vein of Galen, and straight sinus (arrows), with preservation of the superior sagittal and transverse sinuses.

15. Seropositive Japanese B encephalitis in a 14-year-old boy with fever and malaise. T2-weighted (a) and diffusion-weighted (b) MR images reveal asymmetric ill-defined hyperintense areas in the thalamus (arrows in a) and the left frontal and parieto-occipital cortex (arrowheads in a).

16. THANK YOU