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Neuroradiology Case of the Week

Case 170

Loris Cedeno, MD, Ravinder Sidhu, MD, Sudhir Kathuria, MD,
and Per-Lennart Westesson, MD, PhD, DDS

Clinical Presentation: A 17-year-old male presented to the Emergency Department with a history of one week of headache, vertigo, ataxia, and fever. He also had 6th nerve cranial palsy bilaterally.

Radiological Findings: FLAIR and T2-weighted MR images demonstrate focal areas of hyperintensity. These are best appreciated on the coronal views in the superior right cerebellar folia, and a smaller area in the left inferior aspect of the cerebellum.

Diagnosis: Acute cerebellitis

Discussion: Acute cerebellitis is an uncommon syndrome characterized by acute onset of cerebellar dysfunction. Patients can present with headache, nausea vomiting, and ataxia. They can also present with abnormal eye movements and meningismus. Symptoms can last for weeks to months and usually resolve spontaneously.
     Laboratory data can show elevated protein and mononuclear pleocytosis in the CSF.
     It is considered by most to be a viral process. It can either be an infectious or a para- infectious process. However, it can have many causes such as lead intoxication, cyanide poisoning, demyelinating processes, and vasculitis.
     Imaging findings include low attenuation in the cerebellar hemispheres on CT as well as low signal intensity on T1 weighted images. T2 prolongation is also seen. Enhancement on the post gadolinium images, predominantly pial, can be seen in the subacute phase. Mass effect can result in hydrocephalus due to obstruction of the 4th ventricle. Atrophy can be seen as long-term sequelae of this process.

References:

1. Barkovich AJ. Pediatric Neuroimaging. Lippincott, Williams & Wilkins, 4th ed. 2005: 839-840.
2. Fischbein N, Dillon W, Barkovich AJ. Teaching Atlas of Brain Imaging. Thieme. 2000:149-152.