LAUSR

A 32-year-old Thai woman, who was previously healthy, was referred from a provincial hospital due to multiple recurrent episodes of hemorrhagic stroke within 3 months. In her first episode, she complained of severe thunderclap headache. Computer tomography (CT) of the brain revealed a subarachnoid hemorrhage in her left high frontal region. One month later, she had a sudden spastic dysarthria. Another CT was done showing a subarachnoid hemorrhage in her left parietal lobe and an ill-defined hypodensity lesion in her left posterior limb of the internal capsule. Plan for her referral was initiated but she later developed a new right hemiparesis and seizure within 2 weeks. A repeated CT showed intraparenchymal hemorrhage in the left temporal lobe. Therefore, she was referred to our facility. On examination, she was able to follow commands. Spastic dysarthria was prominent with right hemiparesis (Medical Research Council grade IV) and right facial weakness (upper motor neuron type). She had hyperreflexia on her right, both upper and lower limbs. Brain magnetic resonance imaging (MRI) showed T2-fluid-attenuated inversion recovery (FLAIR) imaging of a 4 cm hypersignal intensity lesion in the left basal ganglion and left insular lobe with vasogenic edema (Figure 1A). In a T1 with gadolinium sequence of the same region, it showed left leptomeningeal and gyral enhancement along the left cerebral cortex (Figure 1B). Susceptibility weighted imaging of the corona-radiata showed an abnormal hemosiderin line crossing the corpus callosum from the right lateral ventricle to the left lateral ventricle (Figure 1C), which is located beyond the normal vascular structure. In a coronal T2* gradient echo imaging, it showed an abnormal hemosiderin line crossing from the left basal ganglion down into left midbrain and penetrating into the right midbrain (Figure 1D). The hemosiderin line is suspected to be the migration track of the larvae. MRI scans of the arteries was unremarkable. Because the clinical manifestation of the patient did not give enough clues to differentiate the diagnosis, a thorough consideration of the neuroimaging should be elaborated to look for further clues, including specific locations and signs. Regarding the imaging findings, a unique pattern of hemorrhagic track-like appearance crossing the 2 hemispheres could narrow down the differential diagnosis. Intravascular lymphoma and primary central nervous system vasculitis were in the differential diagnosis because they could represent in multiple hemorrhage with hemosiderin stain in the corpus callosum. However, due to the hemorrhagic track-like appearance that was beyond the vascular structure, a larvae migration should be considered. Although, both Angiostrongylus cantonensis and Gnathostoma Spinigerum could cause hemorrhagic tracks, but the long hemorrhagic track-appearance with