Perineural and subependymal spread of ALL

Case contributed by Dr Abdallah Alqudah


Known case of ALL with CNS involvement, complaining of severe headache. Lab exam showed low platelets of about 7000.

Patient Data

Age: 20 years old
Gender: Male

** Ring artifact degrading image quality.

Diffuse white matter hypoattenuation is seen. Maybe related to patient's history of chemotherapy/radiotherapy.
Multifocal partially defined hyperattenuation lesions seen in the subependymal region of the third ventricle as well as both CP angles near the origin of the trigeminal nerve bilaterally extending to both cavernous sinuses.
VP shunt is seen traversing the right frontal region.

There are heterogeneously enhancing partially defined lesions with signal void intensity on T2 and FLAIR and isointense on T1 WI's seen in the third ventricle posteriorly and in the prepontine cisterns bilaterally at the origin of the trigeminal nerves extending into both cavernous sinuses more on the left side exerting mass effect on the pons, respectively concerning for subependymal and perineural spread of ALL. The largest one is in the third ventricle, measuring about 1.2 cm in diameter.

Diffusely abnormal white matter donating high T2 and FLAIR signal intensity representing leukoencephalopathy related to patient's history of chemotherapy/radiotherapy

Case Discussion

The patient is  a known case of ALL, he was presented to the ER with acute headache and low platelets (7000). Brain hemorrhage was suspected. Although first look may mimic IVH, the well organized shape, site and the pattern of distribution of this hyper-attenuating lesion suggests an alternative diagnosis.

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Case information

rID: 49797
Published: 4th Dec 2016
Last edited: 15th Feb 2019
Inclusion in quiz mode: Included

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