Primary CNS lymphoma vs. tumefactive multiple sclerosis: a diagnostic challenge

Primary CNS [central nervous system] lymphoma is a rare condition with the incidence of less than 1% of all non-Hodgkin lymphomas [NHLs] and approximately 2% of all primary brain tumours. Diagnosis can be challenging and necessitates brain biopsy for definitive diagnosis. A 41-year male presented with history of impaired cognition, facial asymmetry, visual impairment and left sided body weakness. MRI brain demonstrated multiple enhancing lesions with one larger lesion in right basal ganglia with surrounding oedema and mass effect. These findings suggested the differential diagnoses of tumefactive multiple sclerosis [MS], primary CNS lymphoma [PCNSL] and tuberculosis. The patient had normal CT chest, abdomen and pelvis, normal CSF examination and cytology, negative CSF oligoclonal bands [OCBs] and negative HIV screening. It was impossible to differentiate between tumefactive MS and PCNSL without undertaking brain biopsy. Diffuse large B cell lymphoma [DLBCL] was the final diagnosis. Diagnosing PCNSL can be challenging and brain biopsy should not be delayed for definitive diagnosis and targeted treatment

Artery of percheron infarct: a rarity not to be missed

Artery of Percheron [AOP] is a rare vascular variant of posterior cerebral circulation and it supplies blood to the bilateral paramedian thalami and the rostral midbrain. Artery of Percheron infarct requires a comprehensive clinical and radiological examination. It can be easily overlooked due to normal CT findings and wide range of differential diagnosis. Classic triad of presentation is altered mental status, memory impairment and the vertical gaze palsy. We report a case of a 66-year female who had sudden onset of severe vertigo, diplopia and ataxia. A non-contrast CT Brain was performed which was normal. Her MRI brain with diffusion weighted images [DWI] confirmed bilateral thalamic infarcts which were initially thought to be calcifications, as usually happens with diagnosing artery of Percheron infarcts. However, by reviewing and ruling out all other possible causes of such symptoms and further review of neuroimaging, lead us to the correct diagnosis

Concurrent intramedullary spinal cord and intracranial tuberculomas

Tubeculosis commonly involves the nervous system, but involvement of spinal cord in the form of intramedullary tuberculoma is rare and concurrent occurrence of cranial and intramedullary tuberculomas is extremely rare. We report a case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young girl from lslamabad, who presented with one month history of paraplegia and with a sensory level at TB. MRI spine showed a well circumscribed lesion opposite T6, which was diagnosed as intramedullary tuberculoma. On cranial imaging, she was found to have multiple round contrast enhancing lesions which were diagnosed as intracranial tuberculomas based on their typical MRI findings. She had complete recovery with conventional treatment of ATT and steroids, without any surgical intervention. The follow-up MRI of patient showed disappearance and complete resolution of most of the lesions