Presentation
Generalized weakness and bulbar symptoms.
Patient Data
T2 and FLAIR images of the brain revealed patchy hyperintense areas involving the cortico-spinal tracts extending from the precentral gyrus within the left posterior frontal lobe and along the internal capsule bilaterally and extending caudally along the midbrain and pons bilaterally. DWI shows T2-shine through with no evident true diffusion restriction.
Mild atrophic brain changes for the patient's age.
The MR spectroscopy (MRS) study revealed:
- reduction of the neuronal markers; namely the N-acetyl aspartate (NAA) and the creatine (Cr).
- relatively increased Choline (Cho) peak.
- elevated Cho/Cr and Cho/NAA ratios.
- decreased glutamate (Glx) peak.
- increased myoinositol (myo) peak.
Case Discussion
Diffuse T2 and FLAIR hyperintense signal along the corticospinal tracts extending from the precentral gyrus along with the internal capsules and down to the crus cerebri and the pons are characteristic of chronic small vessel ischemic disease with Wallerian degeneration.
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