A 62-year-old man with mild hypercholesterolemia described intermittent episodes of vertigo, visual illusions with colored images and shadows at night, diplopia, left-sided hearing loss, and aphasia. Three weeks after debut of the symptoms, the findings from neurological examination, hematological analysis, and T1-weighted, T2-weighted, fluid-attenuated inversion recovery, and diffusion-weighted magnetic resonance imaging were normal. The symptoms escalated, with fluctuating cognitive impairment, apraxia, cortical blindness, and vertigo. Five weeks later, T2-weighted and fluid-attenuated inversion recovery magnetic resonance imaging showed bilateral infarction-like lesions in the cerebellar hemispheres and parieto-occipital regions of the cerebrum (Figure 1). No abnormalities were demonstrated by angiography of the precerebral and cerebral arteries or by ultrasonographic examination of the heart and precerebral arteries. An extensive search was negative for systemic malignancy. Vasculitis was suspected, but high-dose corticosteroid pulse therapy had no clinical or radiological effect.
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A T2-weighted and fluid-attenuated inversion recovery magnetic resonance image in the coronal plane shows symmetrical cortical lesions in the cerebellar hemispheres.
Intravascular large B-cell lymphoma. A, Atypical lymphocytes fill the vessel (arrow) in this biopsy specimen from the cerebellar granule cell layer (hematoxylin-eosin, original magnification ×20). B, The large lymphoma cells (arrow) are positive (brown) for the B-cell marker CD20 after immunohistochemical staining with the L26 antibody (original magnification ×20).
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