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NEUROIMAGES
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 270-272

Multiple cranial nerve enhancement as a rare presentation of secondary brain lymphoma


1 Department of Radiology, Mashhad University of Medical Sciences, Mashhad, Iran
2 Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Web Publication11-Jan-2018

Correspondence Address:
Dr. Bita Abbasi
Department of Radiology, Imam-Reza Hospital, Razi Square, Mashhad
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.222884

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How to cite this article:
Seilanian-Toosi F, Shams M, Akhavan R, Abbasi B. Multiple cranial nerve enhancement as a rare presentation of secondary brain lymphoma. Neurol India 2018;66:270-2

How to cite this URL:
Seilanian-Toosi F, Shams M, Akhavan R, Abbasi B. Multiple cranial nerve enhancement as a rare presentation of secondary brain lymphoma. Neurol India [serial online] 2018 [cited 2019 Jul 17];66:270-2. Available from: http://www.neurologyindia.com/text.asp?2018/66/1/270/222884




Central nervous system (CNS) involvement can be an isolated recurrence or as a part of the progressive systemic disease in secondary CNS lymphoma (SCNSL). SCNL is typically a non-Hodgkin's type of lymphoma, and unlike primary CNS lymphoma, more commonly involves the leptomeninges.[1] In this report, we present the rare case of secondary CNS involvement from thyroid lymphoma in the form of multiple cranial nerve involvement.

A 26-year old lady presented to the emergency department with acute onset of right facial weakness, blurred vision, dysphagia and bilateral ptosis. She had noticed a gradually enlarging neck mass and upper limb weakness for the past five months.

On the initial examination, she was pale with a huge anterior neck mass. Neurologic examination demonstrated bilateral ptosis, sluggish response of the pupils to light, right facial paralysis, and paralysis of multiple extra-ocular muscles. The gag reflex was also impaired. There were no signs of meningeal irritation.

Cervical magnetic resonance imaging (MRI) examination revealed a huge thyroid mass and an epidural mass in the cervical spinal canal with cord compression [Figure 1]. On brain MRI examination, homogenous enhancement of multiple hypertrophic cranial nerves was noted [Figure 2]. Cytological examination of the cerebrospinal fluid (CSF) revealed lymphoma cells in the CSF specimen. The thyroid mass was resected and the cervical thecal sac was decompressed. The histopathological analysis confirmed the diagnosis of large B-cell lymphoma. Chemotherapy was administered after debulking the tumor; however, the patient succumbed to her illness.
Figure 1: Sagittal contrast enhanced T1-weighted (a) and coronal contrast enhanced T1-weighted MRI (b) of the cervical spine shows a bulky heterogeneous mass in the thyroid gland with mild heterogeneous enhancement (arrows in a and b). There is also a mild enhancing epidural mass in the spinal canal (arrowhead in a)

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Figure 2: There is contrast enhancement in the labyrinthine part of the facial and vestibulocochlear nerves (arrows in a) and bilateral abducens nerves (arrowheads in a). Contrast enhancement is also seen in bilateral trigeminal nerves (arrows in b) and bilateral oculomotor nerves in the interpeduncular cistern (arrowheads in c), and bilateral trigeminal nerves at the Meckel's caves (arrowheads in d). Contrast enhancement is seen of the cisternal part of the oculomotor nerve (arrows in e), of bilateral Meckel's caves (arrowheads in e) and of the pontine segments of trigeminal nerves (arrows in f)

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The clinical presentations of SCNSL include new onset headache, cranial nerve palsy, mental alteration, coma and seizure.[2] Assuming a neoplastic source for the CNS symptoms in our patient, we ordered contrast enhanced MRI. Although the most common imaging presentations of SCNSL include superficial or periventricular enhancing masses or meningeal enhancement,[3],[4],[5] our patient presented with multiple cranial nerve enhancement, which is not a common imaging finding. This uncommon radiological presentation can be seen in infectious or neoplastic causes (in metastasis or lymphoma), or in association with a demyelination process.[6],[7] Hypertrophy of cranial nerves is an important clue that favors the neoplastic nature of the disease.[8] Isolated enhancement of multiple cranial nerves without meningeal enhancement is an extremely unusual finding in CNS lymphoma and its exact etiology is yet to be elucidated. We could only find two other cases of isolated cranial nerve enhancement secondary to CNS lymphoma in the literature.[8],[9] Although the patient did not consent for nerve biopsy, the presence of primary thyroid lymphoma and the presence of lymphoma cells in the CSF supported the diagnosis of secondary brain lymphoma as the cause of multiple cranial nerve enhancement in this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Manoj N, Arivazhagan A, Mahadevan A, Bhat DI, Arvinda HR, Devi BI, et al. Central nervous system lymphoma: Patterns of incidence in Indian population and effect of steroids on stereotactic biopsy yield. Neurol India 2014;62:19-25.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
MacKintosh FR, Colby TV, Podolsky WJ, Burke JS, Hoppe RT, Rosenfelt FP, et al. Central nervous system involvement in non-Hodgkin's lymphoma: An analysis of 105 cases. Cancer 1982;49:586-95.  Back to cited text no. 2
    
3.
DeRosa P, Cappuzzo JM, Sherman JH. Isolated recurrence of secondary CNS lymphoma: Case report and literature review. J Neurol Surg Rep 2014;75:e154-9.  Back to cited text no. 3
    
4.
Kaku MV, Savardekar AR, Muthane Y, Arivazhagan A, Rao MB. Primary central nervous system dural-based anaplastic large cell lymphoma: Diagnostic considerations, prognostic factors, and treatment modalities. Neurol India 2017;65:402-5.  Back to cited text no. 4
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5.
Patel B, Chacko G, Nair S, Anandan J, Chacko AG, Rajshekhar V, Turel M. Clinicopathological correlates of primary central nervous system lymphoma: Experience from a tertiary care center in South India. Neurol India 2015;63:77-82.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Sakai K, Hamaguchi T, Yamada M. Multiple cranial nerve enhancement on MRI in primary Sjogren's syndrome. Intern Med 2010;49:857-9.  Back to cited text no. 6
    
7.
Salunke P, Gupta K, Singla N, Singh H, Singh P, Mukherjee KK. Meningeal tuberculoma mimicking chloroma in a patient with chronic myeloid leukemia on imatinib. Neurol India 2011;59:628-30.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Khadilkar SV, Bhutada AG, Chaudhari CR, Velho V, Domkundwar S, Muzumdar G. Hypertrophic multiple cranial neuropathies: An unusual presentation of primary CNS lymphoma. Ann Indian Acad Neurol. 2015;18:74-6.  Back to cited text no. 8
    
9.
Tajima Y, Tashiro J, Miyagishi R, Matsumoto A. A case of malignant lymphoma exhibiting multiple cranial nerve enhancement: Leptomeningeal metastasis? Or another lymphoma associated event? J Neurol Neurosurg Psychiatry 2001;70:565-6.  Back to cited text no. 9
    


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