Bilateral thalamic and cerebellar hypodensity

These are the CT Brain images of a young male patient, who had h/o fever & Status Epilepticus 

(? for 1 hour),became unresponsive and was intubated.

Left Centrum Semi Ovale showed two calcific foci.

Left frontal lobe showed a round, relatively well defined hypodensity - ? Focal Infarct. Smaller scattered hypodensities were also present bilaterally.

Bilateral symmetrical parieto-occipital, basal ganglia and thalamic hypodensities were noted. See following images.

Thalami are sort of expanded ? Edematous.

Temporal horns and sulci show effeacement -( brain edema)

The patient unfortunately expired after 2 days of the CT.

Hypodensities due to severe Ischemia or Hypoxia usually spares the Cerebellum and the Central structures - which is called as the White Cerebellum Sign or the Dense Cerebellum Sign or Reversal Sign.

See Radiopaedia Article  http://radiopaedia.org/articles/white-cerebellum-sign

But in this case there is Symmetrical involvement of bilateral thalami and cerebellar white matter ! - point against Hypoxic etiology.

Symmetrical cerebellar involvement also !

So this case would be Atypical for Hypoxia/Ischemia alone. One thing here to be noted is, majority of the cerebral parenchyma is not showing much decreased attenuation and the grey-white differentiation is preserved.

These findings 1. Diffuse brain edema +/- Thalamic +/- Cerebellar hypodensities , infarcts has been described in Cerebral Malaria !!

For further data on Imaging in Cerebral Malaria : 

1. Adult Cerebral Malaria: Prognostic Importance of Imaging Findings and Correlation with Postmortem Findings - Radiology 2002, September by Patankar et al.
Cerebral Malaria Imaging @ Radiology RSNA, Patankar et al.

2. http://radiopaedia.org/articles/cerebral-malarial-infection

Patankar et al describes 4 patterns in cases of Cerebral Malaria
1. Normal Imaging 2. Diffuse brain edema 3. Diffuse brain edema with bilateral thalamic hypoattenuation and 4. Diffuse cerebral edema with thalamic and cerebellar hypoattenuation.

"These areas of hypoattenuation represent infarction in the territories supplied by the thalamoperforating and cerebellar vessels as a result of microvascular occlusion.  "

4th pattern is the most severe and survival is rare, as in our case. 

Normal imaging is the most common pattern. (2nd pattern was the MC in Patankar et al Study). 


"Focal hemorrhagic or nonhemorrhagic infarcts in the cortex, basal ganglia, thalamus, pons, and cerebellum in patients with cerebral malaria occasionally have been described in isolated case reports." The left frontal lesion may represent a focal infarct.


"Bilateral, symmetric infarction of the thalami has been seen in internal cerebral vein thrombosis, Japanese encephalitis, and occlusion of both paramedian thalamic and mesencephalic arteries caused by atherosclerosis or tuberculous meningitis."

"Hypoglycemia, which occurs in 8%–32% of patients with cerebral malaria , may also cause serious cerebral damage. The cortex, hippocampus, basal ganglia, and the substantia nigra (but not the thalamus or cerebellum) are particularly vulnerable to this."


So our possible diagnosis for this case would be CEREBRAL MALARIA.


Whats your opinion on this case?