Hemorrhagic Presentation in Primary Central Nervous System Lymphoma: A Case Study

Abstract

BACKGROUND Primary central nervous system diffuse large B-cell lymphoma (DLBCL) is an extremely aggressive brain disease that rarely affects immunocompetent non-elderly patients, particularly with hemorrhagic presentation. Brain magnetic resonance imaging (MRI) plays an important role in the diagnosis of this entity, which typically demonstrates restricted diffusion and a T2 hypointense appearance, suggesting hypercellularity. CASE REPORT A 44-year-old man came to the emergency department with a persistent and treatment-resistant bilateral frontal headache that had been bothering him for the past 3 weeks. Upon conducting a neurological assessment, the patient displayed temporal disorientation and incoherent speech, but without any observable motor deficits. A non-contrast enhanced brain computed tomography scan was carried out, revealing a hyperattenuating, space-occupying lesion and hemorrhage in the left hemisphere of the brain. Subsequently, brain MRI demonstrated hypointense signal on T2-weighted images, restricted diffusion, and homogeneous lesional contrast enhancement, suggesting a very cellular expansive lesion with hemorrhage. To establish a definitive diagnosis, a brain biopsy was undertaken, confirming the presence of DLBCL of the primary central nervous system (germinal center phenotype). CONCLUSIONS Hemorrhagic presentation of primary central nervous system DLBCL occurs very rarely, particularly in non-elderly immunocompetent patients. Brain MRI plays an important role in the diagnosis of this entity, which allows differentiation from high-grade glial or other lesions that present more frequently with hemorrhage. Therefore, it is crucial to suspect lymphoma before surgical intervention for appropriate patient management.

Figure 1.

Non-contrast 64-slice computed tomography revealing an expansive hyperdense lesion (thin arrow) located on the left basal ganglia with surrounding edema, in association with an adjacent hyperdense collection (thick arrow) suggestive of parenchymatous and intraventricular hemorrhage.

Figure 2.

1.5 T MRI. A–C: Axial MRI T2-weighted images (A) and FLAIR images (B) showing a low-signal mass on the left basal ganglia (arrows), with associated isointensity (C) on T1-weighted images. D: This lesion revealed high signal on DWI (D1) with a corresponding low signal on the ADC map (D2), consistent with restricted diffusion (arrows). E–G: On post-contrast T1-weighted images (E), there was a homogenous enhancement of the lesion (arrow). Axial T2* images (F) depicted the hemorrhagic component, represented by marked hyposignal (arrow). No significant rCBV alterations were noted (G). Altogether, these findings were suggestive of lymphoma with associated hemorrhage. MRI – magnetic resonance imaging; FLAIR – fluid-attenuated inversion recovery; DWI – diffusion-weighted imaging; ADC – apparent diffusion coefficient; rCBV – relative cerebral blood volume.