Anti-NMDAR encephalitis with bilateral basal ganglia MRI lesions at a distance of time: a case report

Abstract

Background: Approximately half (55%) of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is known to show abnormal brain images, including high signal intensity in T2 or fluid attenuated inversion recovery (FLAIR) images. In a minority of anti-NMDAR encephalitis cases, high signal intensity on diffusion-weighted imaging (DWI) has been reported, a finding that is highly suggestive of a stroke.

Case presentation: We present the case of a 66-year-old man who experienced two separate focal seizure events, which involved first the right and then the left upper extremity in a short period of time. The patient showed focal clonic seizures involving right arm and hand, which sometimes evolved to bilateral tonic-clonic seizures on his first admission. Brain magnetic resonance imaging (MRI) showed high signal intensity on DWI and low signal intensity on the apparent diffusion coefficient (ADC) map of the left caudate nucleus and putamen. The patient was discharged symptom-free with anti-epileptic drugs for 2 weeks. The second admission occurred 4 days after the discharge. He exhibited a new symptom of focal clonic seizures involving left arm and hand while showing a brain lesion on the opposite side which is hyperintense on DWI image and hypointense on ADC map. The patient was eventually diagnosed with anti-NMDAR encephalitis according to the cerebrospinal fluid (CSF) antibody test.

Conclusions: This is the case of anti-NMDAR encephalitis patient whose DWI/ADC images revealed sequential involvement on the left and right basal ganglia with a short time interval. When stroke-like brain lesions on DWI are found in a patient with a focal seizure, a CSF study could help rule out autoimmune encephalitis. We also suggest that DWI/ADC map images may be useful for the early detection of anti-NMDAR encephalitis.

Keywords: Anti-N-methyl-D-aspartate receptor encephalitis; Basal ganglia; Magnetic resonance imaging; Seizure.

Fig. 1

Brain MRI findings at 1st (A-D) and 2nd admission (E-H). On the first admission, the left caudate nucleus and putamen showed high signal intensity on DWI (A) and low signal intensity on the ADC map (B). Hyperintense lesions on FLAIR were detected in the left caudate nucleus and putamen (C). Acute lesions on the contralateral side were detected on the second admission (E, F, G). A slightly high signal intensity (arrow) on FLAIR was detected in the left medial frontal lobe (D, H)