Female, 68 years old, with facial numbness and tremor. Nearly symmetric ill-defined T2 hyperintensity is seen in the bilateral thalami, best visualized on axial T2-weighted images (image 20 series 8). In addition, on spin-echo T1-weighted images, the basal ganglia appear somewhat T1 hyperintense such that they are nearly indistinguishable from the cerebral white matter (see series 10). The basal ganglia are not particularly hyperintense on T2/FLAIR, so the T1 findings could potentially be artifactual.No evidence of edema or mass effect is seen. No restricted diffusion is noted. No pathologic parenchymal or extra-axial enhancement is observed. Scattered small foci of FLAIR hyperintensity are seen within the white matter of the cerebral hemispheres. No evidence of intracranial hemorrhage or any abnormal extra axial fluid collections are seen. The ventricles are normal in size and morphology. Brain parenchymal volume is grossly preserved.
Ill-defined but nearly symmetric T2 hyperintensity is seen within the thalami. There may, in addition, be some T1 hyperintensity of the basal ganglia, though this could be artifactual. Numerous small scattered foci of T2 hyperintensity are evident in the cerebral hemispheres.The differential diagnosis for these findings is extremely broad and would include prior demyelination including ADEM, prior hypoxic ischemic injury, small vessel ischemic disease, a metabolic derangement or toxic exposure. The findings are somewhat suggestive of Wilson disease, though the patient age would be atypical. However, hepatic dysfunction in general could produce some of the findings noted above.