MRI - Day 8
Extensive white matter FLAIR hyperintensities involving the centrum semiovale, extreme capsule and periventricular white matter. Further FLAIR signal abnormality surrounding the cerebral aqueduct and fourth ventricle, as well as in the imaged upper cervical cord. Scattered foci of susceptibility artifact consistent with microhaemorrhages, in the brainstem and corona radiata. Cortical increased diffusion restriction in the right precentral gyrus, bilateral occipital lobes and left parietal lobe. Further foci of punctate diffusion restriction in both cerebellar hemispheres. On post-contrast imaging, there is no abnormal focus of contrast enhancement. Normal ventricular size. Small bilateral mastoid effusions.
Conclusion:
Extensive white matter changes in this clinical context are consistent with immune effector cell-associated neurotoxicity syndrome (ICANS) - ASTCT grade 4.
Microhemorrhages and small cortical restricted diffusion are also present and have also described in ICANS.