Presentation
New onset of vertigo. Currently receiving R-CHOP for B-cell lymphoma diagnosed on splenic histology 8 months prior.
Patient Data
Diffuse, smooth, high T2 signal abnormality in subependymal regions and particularly around the 4th ventricle. There is also diffuse subependymal contrast enhancement.
Although the subtle hyperintensities seen on T2 imaging may appear non-specific and appear similar to changes associated with chronic small vessel disease; with patient's background history and clinical setting, secondary CNS lymphoma or ventriculitis required consideration.
CSF Microscopy: The mildly cellular fluid contains mild numbers of large atypical mononuclear cells. These have enlarged vesicular nuclei and mild to moderate delicate cytoplasm. Occasional macrophages are noted. There is also a moderate amount of blood.
Conclusion: Malignant. Scanty atypical mononuclear cells are identified, consistent with this patients history of known diffuse large B-cell lymphoma.
The changes centered around the fourth ventricle in the form of a periventricular FLAIR and T2 signal hyperintensity as well as some vague enhancement have progressed dramatically, now apparent across the entire ventricular system. The most readily appreciable interval change is adjacent to the anterior horns of the lateral ventricles.
Case Discussion
Secondary central nervous system lymphoma, which is also referred to as metastatic lymphoma, is an aggressive disease. It is rare, and nearly always fatal occurring in <1% of indolent systemic lymphomas, and in <5% of aggressive systemic lymphomas1.
It tends to occurs between 5-12 months after the primary lymphoma diagnosis, and most lesions occur in periventricular or central hemispheric white matter2. It has been shown that CNS lymphoma relapses occur earlier in patients receiving R-CHOP as compared to those receiving CHOP chemotherapy regimes3.
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