Subcortical lesions due to cobalamin deficiency: an unusual MRI lesion pattern

ABSTRACT

We present a 44-year-old male patient with new onset of right focal epilepsy and bilateral hand hypesthesia. Cerebral MRI showed bilateral T2w/DWI hyperintense subcortical lesions in the cingulate gyrus, insula, and amygdala, whereas spinal MRI revealed a cervical posterior column lesion, corresponding to subacute combined degeneration. Laboratory workup revealed a cobalamin deficiency due to type A gastritis, and no evidence of antibodies associated with limbic encephalitis. After sufficient cobalamin substitution, the cerebral and spinal lesions gradually regressed. Our case represents a unique cerebral subcortical MRI lesion pattern in a patient with epilepsy and cobalamin deficiency. Thus, the latter represents an important differential diagnosis for autoimmune encephalitis.

KEYWORDS:

• Vitamin B12 deficiency
• cobalamin deficiency
• MRI
• focal epilepsy
• subcortical lesions

Acknowledgements

We would like to thank Katie Göttlinger for copy-editing the manuscript. O. Kremmyda, J. Heinrich and A. Straube contributed to the conception and design of the research; R. Forbrig and T. Winkler contributed to the acquisition and analysis of the data; O. Kremmyda, J. Heinrich and A. Straube contributed the interpretation of the data; and O. Kremmyda and A. Straube drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Olympia Kremmyda

Olympia Kremmyda is a consultant in the Department of Neurology of the Ludwig-Maximilians-University Hospital in Munich. She completed her medical training and her Ph.D. in the National Capodistrian University of Athens and her neurological residency at the Department of Neurology of the Ludwig-Maximilians-University Hospital in Munich.

Robert Forbrig

Robert Forbrig is senior physician at the Institute of Neuroradiology of the Ludwig-Maximilians-University Munich.

Johanna Heinrich

Johanna Heinrich is a resident at the Department of Neurology of the Ludwig-Maximilians University in Munich. She completed her medical studies at the Ludwig-Maximilians University in Munich, the Miguel Hernández University of Elche (Spain) and the Medical University of Vienna (Austria).

Tobias Winkler

Tobias Winkler is head of the neurological department at the kbo-Inn-Salzach Clinic in Wasserburg am Inn. He completed his neurological residency at the Department of Neurology of the Ludwig-Maximilians-University Hospital in Munich.

Andreas Straube

Andreas Straube is Professor of Neurology at the Ludwig-Maximilians-University Hospital in Munich and head of the Bavarian Headache Centre. He studied at the University of Bochum and Essen in Germany and completed his medical training in the Departments of Neurology of the Krupp-Hospital in Essen and of the Ludwig-Maximilians University in Munich. His scientific interests include oculomotor testing, cerebellar functions and headache.