Female, 67 years old, with ALL and altered mental status. Dense hemosiderin staining within the right occipital lobe is redemonstrated compatible with a prior parenchymal hemorrhage. Since the prior MRI, numerous additional foci of susceptibility have developed compatible with small hemorrhages in both cerebral hemispheres but particularly posteriorly and in the parietal and occipital regions. Sulcal hemosiderin staining is also seen in the left frontal and right parietal lobes. Several of these foci are T1 hyperintense indicating a subacute time course, and several correlate with the suspected petechial blood on recent prior CT.No evidence of restricted diffusion is seen. Extensive ill-defined white matter FLAIR hyperintensity is seen bilaterally in the cerebral hemispheres and in the thalami with scattered foci also noted in the brainstem and cerebellum. These findings have progressed compared to the prior examination. Nevertheless, no significant generalized mass effect is seen and the ventricles remain stable and normal in size. On postcontrast imaging, a curvilinear focus of enhancement along the prior right occipital hemorrhage is seen. Sulcal vascularity is prominent in the posterior cerebral hemispheres. However no clear evidence of any additional discretely enhancing lesions are seen. Mild mucosal inflammation is seen in the ethmoid air cells.
Multiple small foci of parenchymal and sulcal hemorrhage are identified, most of which are new when compared to the prior MRI, and several of which are likely subacute based on signal characteristics. A chronic right occipital hematoma shows no significant change apart from the possible development of some adjacent granulation tissue. These progressive small hemorrhages could reflect underlying thrombocytopenia/coagulopathy, treatment related vascular injury, or amyloid angiopathy. Certain intracranial infections including fungal etiologies can also present with multiple intracranial hemorrhages. Finally, intravascular leukemic aggregates could potentially induce leukostasis and vascular rupture resulting in small parenchymal hemorrhages.Since the prior MRI, there has also been a substantial increase in parenchymal signal abnormality unrelated to the hemorrhages and involving the cerebral white matter, thalamus, brainstem and cerebellum. This may be treatment related as well though the possibility of an atypical infection should be considered.