Cytotoxic lesions of the corpus callosum (CLOCCs) represent a collection of disparate conditions that can cause signal change in the corpus callosum, usually involving the splenium.
The term cytotoxic lesions of the corpus callosum (CLOCCs) has been proposed recently 12 as a more precise description of this phenomenon which has previously been known by a variety of terms including transient lesions of the splenium of the corpus callosum, mild encephalitis/encephalopathy with a reversible isolated SCC lesion (MERS), reversible splenial lesions and reversible splenial lesion syndrome (RESLES). CLOCCs not only better reflects current understanding of the underlying pathophysiology of these lesions but also does not explicitly imply that these lesions are confined to the splenium. As such it is probably a better term to use.
Clinical presentation relates to the underlying pathology (see below) rather than to the callosal lesion itself. Unlike many other lesions of the corpus callosum, CLOCCs do not demonstrate convincing signs or symptoms of hemispheric disconnection, such as pseudo-neglect, alien hand syndrome, apraxia of the left hand, agraphia, alexia, and visual apraxias 4.
Although numerous underlying etiologies have been identified, these lesions appear to result from a stereotyped cascade of cytokines and stimulated cells. An initial insult results in macrophages releasing inflammatory cytokines (IL-1 and IL-6) which in turn result in a cascade of changes including recruitment T-cells, break-down of the blood-brain barrier, production of TNF-α, and activation of astrocytes. The end result is a massive increase in glutamate in the extracellular fluid which, via interactions with a number of cell membrane receptors, results in an influx of water into both astrocytes and neurons which manifests macroscopically as cytotoxic edema 12.
It appears that the reason the splenium of the corpus callosum is preferentially affected is the presence of a high density of oligodendrocytes expressing large numbers of glutamate affected receptors 12.
Cytotoxic lesions of the corpus callosum are seen in a wide variety of clinical settings, although exactly which conditions are listed in any one publication varies. Classically CLOCCs are seen in patients with seizures or metabolic disturbances, although many other etiologies are recognized. Reported etiologies include 1-5,12:
- complex relationship – CLOCCs seen in a variety of settings:
- antiepileptic medications (with or without seizures)
- sudden cessation of antiepileptic drugs (classic)
- seizures with or without antiepileptic medications
- complex relationship – CLOCCs seen in a variety of settings:
- metabolic disturbance
- CNS malignancy
- many are associated with chemotherapy and/or seizures
- drugs and toxins
- antidepressants (e.g amitriptyline)
- antiepileptics (e.g. carbamazepine, lamotrigine, phenytoin)
- antipsychotics (e.g. clozapine)
- chemotherapy (e.g. cyclosporin, fluorouracil)
- pesticide (e.g. methyl bromide)
- especially if large volume
- not the result of vasospasm
Transient lesions of the splenium are only really appreciable on MRI where they have three distinct patterns 4,12:
- well-circumscribed, small, oval lesions in the midline within the substance of the splenium (most common)
- more extensive less well-defined irregular lesions extending throughout the splenium and into the adjacent hemispheres (boomerang sign)
- more extensive extension anteriorly into the body of the corpus callosum
The smaller well-circumscribed lesions are the typical lesion seen in the setting of seizures/cessation of antiepileptic medication, whereas the larger lesion is more typical of other etiologies.
These lesions demonstrate the expected features of cytotoxic edema 4,12:
- T1: hypointense
- T2: hyperintense
- DWI/ADC: restricted diffusion (ADC typically 300–500 x 10-6 mm2/s)
- T1 C+ (Gd): no enhancement
Some studies have shown that patients generally recover completely on MRI studies within 1 month, mostly within 1 week following the neurological recovery 7.
Treatment and prognosis
The prognosis generally depends on the underlying cause, but in the setting of epilepsy or antiepileptic drug-related lesions, it is very good.
Depending on the publication, some of the differentials to contemplate are included in the list of etiologies of CLOCCs. In any case, when confronted with a splenial lesion consider:
- 1. Takanashi J, Barkovich AJ, Shiihara T et-al. Widening spectrum of a reversible splenial lesion with transiently reduced diffusion. AJNR Am J Neuroradiol. 2006;27 (4): 836-8. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 2. Bulakbasi N, Kocaoglu M, Tayfun C et-al. Transient splenial lesion of the corpus callosum in clinically mild influenza-associated encephalitis/encephalopathy. AJNR Am J Neuroradiol. 2006;27 (9): 1983-6. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 3. Singh P, Gogoi D, Vyas S et-al. Transient splenial lesion: Further experience with two cases. Indian J Radiol Imaging. 2010;20 (4): 254-7. doi:10.4103/0971-3026.73531 - Free text at pubmed - Pubmed citation
- 4. Malhotra HS, Garg RK, Vidhate MR et-al. Boomerang sign: Clinical significance of transient lesion in splenium of corpus callosum. Ann Indian Acad Neurol. 2012;15 (2): 151-7. doi:10.4103/0972-2327.95005 - Free text at pubmed - Pubmed citation
- 5. Cho JS, Ha SW, Han YS et-al. Mild encephalopathy with reversible lesion in the splenium of the corpus callosum and bilateral frontal white matter. J Clin Neurol. 2007;3 (1): 53-6. doi:10.3988/jcn.2007.3.1.53 - Free text at pubmed - Pubmed citation
- 6. Kimura. International Journal of Clinical Pediatrics. 2012; . doi:10.4021/ijcp51w
- 7. Tada H, Takanashi J, Barkovich A et-al. Neurology. 2004;63 (10): . doi:10.1212/01.WNL.0000144274.12174.CB
- 8. Loh Y, Watson WD, Verma A, Krapiva P. Restricted diffusion of the splenium in acute Wernicke's encephalopathy. J Neuroimaging. 2005 Oct;15(4):373-5. https://www.ncbi.nlm.nih.gov/pubmed/16254404
- 9. Maeda M, Shiroyama T, Tsukahara H, Shimono T, Aoki S, Takeda K. Transient splenial lesion of the corpus callosum associated with antiepileptic drugs: evaluation by diffusion-weighted MR imaging. European radiology. 13 (8): 1902-6. doi:10.1007/s00330-002-1679-5 - Pubmed
- 10. Biller, Jose, Hornik, Alejandro, Rodriguez-Porcel, Federico, Agha, Caroline, Flaster, Murray, Morales Vidal, Sarkis Gibran, Schneck, Michael J, Lee, John. Central and Extrapontine Myelinolysis Affecting the Brain and Spinal Cord. An Unusual Presentation of Pancreatic Encephalopathy. (2018) Frontiers in Neurology. 3: 135. doi:10.3389/fneur.2012.00135 - Pubmed
- 11. Aralikatte O Saroja, Karkal R Naik, Rajendra V Mali, Sanjeeva R Kunam. 'Wine Glass' sign in recurrent postpartum hypernatremic osmotic cerebral demyelination. (2013) Annals of Indian Academy of Neurology. 16 (1): 106. doi:10.4103/0972-2327.107719 - Pubmed
- 12. Starkey J, Kobayashi N, Numaguchi Y, Moritani T. Cytotoxic Lesions of the Corpus Callosum That Show Restricted Diffusion: Mechanisms, Causes, and Manifestations. (2017) Radiographics : a review publication of the Radiological Society of North America, Inc. 37 (2): 562-576. doi:10.1148/rg.2017160085 - Pubmed
- 13. Omar Abdel-Mannan, Michael Eyre, Ulrike Löbel, Alasdair Bamford, Christin Eltze, Biju Hameed, Cheryl Hemingway, Yael Hacohen. Neurologic and Radiographic Findings Associated With COVID-19 Infection in Children. (2020) JAMA Neurology. doi:10.1001/jamaneurol.2020.2687 - Pubmed