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Images in Neurology |

FDG-PET a Pivotal Imaging Modality for Diagnosis of Stroke-Onset Intravascular Lymphoma

Shigeki Yamada, MD, PhD; Ryuichi Nishii, MD, PhD; Satoshi Oka, MD, PhD; Tatsuya Higashi, MD, PhD; Miyuki Yagi, MD; Takeshi Satow, MD, PhD; Takayo Suzuki, MD, PhD; Masaaki Saiki, MD, PhD
Arch Neurol. 2010;67(3):366-367. doi:10.1001/archneurol.2010.6.
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Intravascular lymphoma (IVL) is a rare, fatal disease, often presenting with neurological deficits. Here we describe 2 patients initially diagnosed with recurrent atherosclerotic cerebral infarction followed by accurate diagnosis of IVL by positron emission tomography with 18fluorodeoxyglucose (FDG-PET).

Case 1 is a 65-year-old man with dysarthria and mild right hemiparesis. Two days later, he was diagnosed with left cerebral infarction and severe stenosis of intracranial left internal carotid artery on magnetic resonance imaging. His clinical course and radiological findings are summarized in Figure 1. While N-isopropyl-p-[123I]iodoamphetamine single-photon emission computed tomography (IMP-SPECT) studies revealed increased IMP uptake in the left frontal lobe, oxygen 15 gas PET did not reveal any abnormalities. We could not find any appropriate reasons for this discrepancy. Almost 100 days after onset, FDG-PET revealed high FDG uptake in the left frontal lobe. Brain biopsy was performed and revealed large B-cell IVL. The patient received whole-brain irradiation and steroid treatment, which transiently improved his symptoms, but he died 7 months after onset.

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Figure 1.

Summary of imaging for patient 1. Diffusion imaging on day 2 showed acute left cerebral infarction. Magnetic resonance angiography (MRA) showed severe stenosis at the cavernous segment of the left internal carotid artery. Positron emission tomography with 18fluorodeoxyglucose (FDG-PET) revealed high FDG uptake in the left middle frontal gyrus, corresponding to the area of increased N-isopropyl-p-[123I]iodoamphetamine (IMP) uptake on IMP–single-photon emission computed tomography (IMP-SPECT). Arrowheads indicate the most important findings. CBF indicates cerebral blood flow; CMRO2, cerebral metabolic rate for oxygen; FLAIR, fluid-attenuated inversion recovery; MRI, magnetic resonance imaging; and O15, oxygen 15. (To convert 30 Gy to rad, multiply by 100.)

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Figure 2.

Summary of imaging for patient 2. Three-dimensional (3-D) magnetic resonance angiography (MRA) on day 9 revealed irregular stenotic changes in the main trunk and branches of right middle cerebral artery. Positron emission tomography with 18fluorodeoxyglucose (FDG-PET) 10 days after the onset showed high FDG uptake in the territory of right middle cerebral artery and right basal ganglia, which corresponded to the area of gadolinium enhancement by magnetic resonance imaging (MRI). In addition, multiple high-accumulation spots were scattered throughout brain. On day 17, FDG-PET 1 week after the first course of CHOP (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate and prednisolone) chemotherapy and whole-brain radiation (total, 11 Gy [to convert to rad, multiply by 100]), revealed that the lesions of increased FDG uptake in bilateral cerebral hemispheres were fairly decreased, although 1 new lesion in the right temporal lobe showed an increase in FDG accumulation. Arrowheads indicate the most important findings. FLAIR indicates fluid-attenuated inversion recovery; R, rituximab.

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