A rare cause of first seizure

Abstract

A 52 year old man with no history of seizures presented following multiple generalized tonic-clonic seizures at home. He had a recent history of anorexia, weight loss and incoordination. Clinical examination revealed reduced level of consciousness, left-sided weakness and neglect. T2-weighted MRI (Fig. 1) and MRI SWAN (Fig. 2) are provided.Fig. 2MRI SWAN demonstrates widespread punctate hypodense foci.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A.Glioblastoma multiformeB.Acute Haemorrhagic EncephalomyelitisC.Intravascular lymphomaD.Primary CNS lymphomaE.Progressive multifocal leukoencephalopathy Answer: Intravascular lymphoma The MRI scan (Fig. 1) demonstrates T2 hyperintensity in right frontal lobe with central irregular enhancement and other foci of hyperintensity. MRI SWAN (Fig. 2) demonstrates multiple punctate hypointense foci consistent with microhemorrhages. Brain biopsy confirmed CD10+ Intravascular Lymphoma (IVL). IVL is a rare form of Non-Hodgkin lymphoma characterized by lymphocyte proliferation within blood vessels [[1]Ponzoni M. Ferreri A.J. Campo E. et al.Definition, diagnosis, and management of intravascular large B-cell lymphoma: proposals and perspectives from an international consensus meeting.J Clin Oncol. 2007; 25: 3168Crossref PubMed Scopus (345) Google Scholar]. Radiologic findings are largely nonspecific and brain biopsy is required for diagnosis. Although hemorrhagic infarcts are well described in the pathological literature, the potential for microhemorrhages on SWAN or T2 sequences has been rarely described [[2]Alexandrescu S. Orengo J.P. Toossi S. et al.CNS intravascular large cell lymphoma in a patient with autoimmune hemolytic anemia.Neuropathology. 2015; 35: 170-174Google Scholar]. This case well illustrates this finding, and adds to the differential diagnosis for multiple regional microhemorrhages. The patient in this case responded well to treatment with chemotherapy.