Clinical and radiological aspects of bilateral temporal abnormalities: pictorial essay

Bisinotto, Heloisa Sisconeto; Jarry, Vinicius Menezes; Reis, Fabiano

doi:10.1590/0100-3984.2019.0134

Heloisa Sisconeto Bisinotto Correspondence: Heloisa Sisconeto Bisinotto. Universidade Estadual de Campinas - Radiologia e Diagnóstico por Imagem. Rua Vital Brasil, 241, Cidade Universitária. Campinas, SP, Brazil, 13083-872. Email: hsbisinotto@gmail.com.

Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil.

http://orcid.org/0000-0003-1191-4396

Vinicius Menezes Jarry

Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil.

http://orcid.org/0000-0002-7391-1193

Fabiano Reis

Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil.

http://orcid.org/0000-0003-2256-4379

Correspondence: Heloisa Sisconeto Bisinotto. Universidade Estadual de Campinas - Radiologia e Diagnóstico por Imagem. Rua Vital Brasil, 241, Cidade Universitária. Campinas, SP, Brazil, 13083-872. Email: hsbisinotto@gmail.com.

Figures (12)
Tables (1)

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Figure 1
Coronal T1-weighted MRI sequence showing the normal anatomy of the temporal lobe. 1, transverse temporal gyrus; 2, superior temporal gyrus; 3, middle temporal gyrus; 4, inferior temporal gyrus; 5, lateral occipitotemporal gyrus; 6, medial occipitotemporal/parahippocampal gyrus; 7, hippocampus. Red arrow, superior temporal sulcus; yellow arrow, inferior temporal sulcus; blue arrow, occipitotemporal sulcus; green arrow, collateral sulcus.

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Figure 2
A 46-year-old male patient with headache, fever, and mental confusion. A: Axial FLAIR MRI sequence showing a hyperintense signal in both temporal lobes (arrow), more pronounced on the right. B: DWI with bilateral restricted diffusion (arrow). Positivity for human herpesvirus 1 on polymerase chain reaction of the cerebrospinal fluid.

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Figure 3
A 35-year-old, HIV-positive female patient who presented with a one-week history of fever and left frontoparietal headache. Cerebrospinal fluid analysis showed high protein levels, lymphocytic leukocytosis, reduced glucose, and increased adenosine deaminase, favoring a diagnosis of neurotuberculosis. Axial FLAIR-weighted and contrast-enhanced axial T1-weighted MRI sequences (A and B, respectively) showing thickening of the dura mater (arrows), which was more pronounced in the right temporal region, where the FLAIR-weighted shows a change in the signal. The patient showed symptom improvement, the follow-up examinations performed one year after the onset of symptoms showing resolution of the radiological aspects (images not shown).

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Figure 4
A 9-year-old female patient with behavioral changes, inversion of the sleep-wake cycle, and seizures. Tests for infectious and metabolic causes were negative. The cerebrospinal fluid tested positive for anti-GAD antibodies. Positron emission tomography/CT with 18F-fluorodeoxyglucose with no hypermetabolic changes suggestive of neoplastic involvement. Axial FLAIR-weighted MRI sequence and DWI (A and B, respectively) showing hyperintense signals in the mesial temporal regions with foci of restricted diffusion (arrows). A follow-up examination one year later showed a marked reduction in the volume of the hippocampal formations (image not shown).

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Figure 5
A 77-year-old female patient who presented with short-term memory loss and attention deficit. Coronal T1-weighted MRI sequence showing enlargement of the temporal horns and a reduction in the volume of the hippocampi.

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Figure 6
A 37-year-old male patient with progressive neurological deterioration. Axial T2-weighted and coronal T1-weighted MRI sequences (A and B, respectively) showing bilateral reduction in the volume of the encephalon beyond what would be expected for the age bracket, predominantly in the frontotemporal region, and preservation of the posterior cortical regions (A).

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Figure 7
A 62-year-old male patient with refractory seizures. Coronal T2-weighted MRI sequence showing a reduction in the volume of both hippocampi, with a hyperintense signal and a loss of rugosity on the upper surface (cytoarchitectural alteration). Note the blurring of the transition between the gray and white matter in the right temporal pole (arrow).

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Figure 8
A 67-year-old male patient who presented with sudden-onset headache, blurred vision, and a reduced level of consciousness. Axial CT scan showing hypoattenuation of the cortical and subcortical regions, involving the medial temporal and occipital lobes, as well as the mesencephalon and cerebellum. Note the hyperdense artery sign, consistent with acute thrombosis, in the basilar artery (arrow).

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Figure 9
A 4-year-old female patient with a history of neonatal hyperbilirubinemia. Coronal T2-weighted MRI sequence showing a hyperintense signal in the globus pallidus, as well as, to a lesser extent, in the subthalamic, mesencephalic, and hippocampal regions (with reduced hippocampal volume).

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Figure 10
A 9-year-old male patient with macrocrania (since 5 months of age) and delayed neuropsychomotor development. Axial T2-weighted MRI sequence showing cysts in the left temporal pole (arrow). Note also the hyperintense signal in the subcortical and deep regions of the temporal lobes, as well as in the subcortical regions of the occipital lobe.

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Figure 11
A 31-year-old female patient with a history of headaches and seizures. A: Axial FLAIR-weighted MRI showing a hyperintense signal in both temporal lobes and in the frontal lobes (more pronounced on the right), together with involvement of the mesencephalic parenchyma. In contrast-enhanced sequences, no enhancement was identified, nor was there any increased perfusion (images not shown). B: Multivoxel spectroscopy with an echo time of 144 ms, showing a choline/creatine ratio ≤ 1.23 and a trend toward a reduction in N-acetylaspartate. The patient underwent a temporal lobectomy and a right amygdalohippocampectomy, and the histopathology study showed a low-grade (grade II) diffuse fibrillary astrocytoma.

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Figure 12
A 47-year-old male patient, diagnosed with high-grade B-cell non-Hodgkin lymphoma, who presented with sudden-onset diplopia, ataxia, and loss of balance. An initial analysis of the cerebrospinal fluid showed no relevant changes. A: Axial contrast-enhanced T1-weighted MRI sequence showing lesions with diffuse, intense enhancement in the anterior aspect of the temporal lobes, hippocampi, mesencephalic tegmentum and in the cerebellum. B: Point resolved spectroscopy with a short echo time (31 ms), showing a significant lipid/lactate peak in the lesions, with a solid aspect and homogeneous enhancement (which can be due to microscopic necrosis, suggestive of lymphoma, given that gliomas and metastases usually present such a peak in areas of low contrast enhancement). There was also an increase in choline levels, suggesting increased membrane turnover.

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Table 1
Summary of diseases with bilateral involvement of the temporal lobes.

Disease	Main anatomical changes	Accompanying changes	Perfusion	Spectroscopy
Herpes simplex encephalitis	Bilateral, asymmetric T2/FLAIR hyperintensity in the temporal lobes	Cortical hemorrhage, gyriform enhancement, and restricted diffusion on DWI	Hypoperfusion	Reduced NAA/Cr ratio and increased Cho/Cr ratio. There can be Lip and Lac⁽²2 Hitosugi M, Ichijo M, Matsouka Y, et al. Proton MR spectroscopy findings in herpes simplex encephalitis. Rinsho Shinkeigaku. 1996;36:839-43.^,³3 Demaerel P, Wilms G, Robberecht W, et al. MRI of herpes simplex encephalitis. Neuroradiology. 1992;34:490-3.⁾
Neurotuberculosis	Enhancement of leptomeninges and dura mater, tuberculomas	Hydrocephalus, ventriculitis, vasculitis, infarction, venous thrombosis, neuropathies	Variable	Lip and Lac peak⁽⁴4 Khatri GD, Krishnan V, Antil N, et al. Magnetic resonance imaging spectrum of intracranial tuberculous lesions: one disease, many faces. Pol J Radiol. 2018;83:e524-e535.^,⁵5 Mader I, Rauer S, Gall P, et al. (1)H MR spectroscopy of inflammation, infection and ischemia of the brain. Eur J Radiol. 2008;67:250-7.⁾
Limbic encephalitis	Bilateral, asymmetric T2/FLAIR hyperintensity in mesial temporal structures	Involvement of basal ganglia, enhancement, and restricted diffusion on DWI	Hypoperfusion	Reduced NAA. Increased Cho, Lac, and MI⁽⁶6 Isik N, Candan F, Dincer A, et al. Serial cranial MR imaging and single voxel proton MR spectroscopy in paraneoplastic limbic encephalitis. Eur J Radiol Extra. 2004;50:1-7.⁾
Alzheimer's disease	Reduction in the volume of the mesial temporal structures (especially the hippocampus) disproportional to the atrophy in the remaining parenchyma	Atrophy of the superior parietal lobule	Hypoperfusion	Reduced NAA and NAA/Cr ratio in the cingulate gyrus and hippocampi. Increased MI/Cr ratio in the cingulate gyrus and parietal cortex⁽⁷7 Kantarci K. Magnetic resonance spectroscopy in common dementias. Neuroimaging Clin N Am. 2013;23:393-406.⁾
Frontotemporal dementia	Selective atrophy of the frontal or temporal lobes	Atrophy predominantly on the left in primary progressive aphasia	Hypoperfusion	Reduced NAA/Cr ratio and increased MI/ Cr ratio in the frontal cortex⁽⁷7 Kantarci K. Magnetic resonance spectroscopy in common dementias. Neuroimaging Clin N Am. 2013;23:393-406.⁾
Mesial temporal sclerosis	T2/FLAIR hyperintensity in the hippocampus with loss of volume and dilatation of the temporal horn (bilateral in 10% of cases)	Atrophy of the amygdala, fornix, mammillary body and entorhinal cortex. Loss of cortical/subcortical differentiation in the temporal pole	Hypoperfusion	Reduced NAA in the affected temporal lobe and in the hippocampus⁽⁸8 Capizzano AA, Vermathen P, Laxer KD, et al. Multisection proton MR spectroscopy for mesial temporal lobe epilepsy. AJNR Am J Neuroradiol. 2002;23:1359-68.⁾
Cerebrovascular disease	Loss of cortical/subcortical differentiation in the involved vascular territory. T2/FLAIR hyperintensity. Early restricted diffusion on DWI	Hyperdense artery sign, gyriform enhancement	Hypoperfusion	In the acute phase, there is increased Cho, Lip, and Lac, with reduced NAA⁽⁵5 Mader I, Rauer S, Gall P, et al. (1)H MR spectroscopy of inflammation, infection and ischemia of the brain. Eur J Radiol. 2008;67:250-7.^,⁹9 Faria AV, Reis F, Zanardi VA, et al. The pattern of proton magnetic resonance spectroscopy in non-neoplastic encephalic lesions. Arq Neuropsiquiatr. 2004;62:429-36.⁾
Kernicterus	T2/FLAIR hyperintensity with hippocampal atrophy in the chronic phase	Change in the signal of the globus pallidus and subthalamic nuclei	Hypoperfusion	Increased Tau, Glx, and MI, with reduced Cho⁽¹⁰10 Oakden WK, Moore AM, Blaser S, et al. 1H MR spectroscopic characteristics of kernicterus: a possible metabolic signature. AJNR Am J Neuroradiol. 2005;26:1571-4.⁾
Megalencephalic leukoencephalopathy with subcortical cysts	Diffuse hyperintense signal of deep white matter sparing basal ganglia and cerebellum	Subcortical cysts evident initially in the temporal lobes and later in the frontal and parietal lobes	Hypoperfusion	Increased Cho and MI, with reduced NAA, in the early stage. Increased Lac in the advanced stage⁽¹¹11 Reis F, Kido RYZ, Mesquita JA, et al. Megalencephalic leukoencephalopathy with subcortical cysts (MLC) - a case with clinical and magnetic resonance imaging (MRI) dissociation. Arq Neuropsiquiatr. 2015;73:171-2.⁾
Lowgrade diffuse astrocytoma	T1 hypointensity and T2/FLAIR hyperintensity, infiltration of the cortex, no enhancement, and no restricted diffusion on DWI	No evidence of necrosis or hemorrhagic components	Hypoperfusion (rCBV < 1.75). Hyperperfusion if anaplastic/ high grade	Increased MI, slightly increased Cho (Cho/Cr ratio < 2), reduced NAA, and absence of Lac⁽³3 Demaerel P, Wilms G, Robberecht W, et al. MRI of herpes simplex encephalitis. Neuroradiology. 1992;34:490-3.⁾
Lymphoma	T2/FLAIR hypointensity with restricted diffusion on DWI. Intense, homogeneous enhancement	In immunocompetent patients, a necrotic component is rarely seen	Hypoperfusion	Increased Cho, Lip, and Lac. Reduced NAA⁽¹²12 Reis F, Schwingel R, Nascimento FBP. Central nervous system lymphoma: iconographic essay. Radiol Bras. 2013;46:110-6.⁾

[1] Correspondence: Heloisa Sisconeto Bisinotto. Universidade Estadual de Campinas - Radiologia e Diagnóstico por Imagem. Rua Vital Brasil, 241, Cidade Universitária. Campinas, SP, Brazil, 13083-872. Email: hsbisinotto@gmail.com.

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Clinical and radiological aspects of bilateral temporal abnormalities: pictorial essay

Abstract