Wallerian degeneration (WD) is the anterograde degeneration of axons following a proximal neuronal injury [1]. In the brain, WD has been described as commonly affecting the corticospinal tract after various insults [2, 3]. Diffusion-weighted imaging (DWI) and diffusion tensor imaging sequences on magnetic resonance imaging (MRI) can precisely detect WD from the altered water content of affected tracts days to months after the initial insult [4,5,6]. Its behavior on apparent diffusion coefficient (ADC) is variable [7]. We describe the unique case of WD of corticobulbar fibers in the brain visualized as a restrictive lesion on MRI-DWI sequences 13 months after an intracerebral hemorrhage (ICH).
A middle-aged patient with history of acute myeloid leukemia developed disseminated intravascular coagulation associated with acute myeloid leukemia relapse, resulting in a left frontal ICH, diffuse alveolar hemorrhage, and hemoperitoneum. A 3.0 Tesla brain MRI 10 days after emergent craniotomy and evacuation of the ICH demonstrated postoperative changes with brain edema and mass effect. The patient had a long hospital course involving chemotherapy and management of Staphylococcus aureus bacteremia, deep vein thromboses, and seizures. Repeat brain MRI after 4 months showed resolution of the hematoma with a small faint area of diffusion restriction in the subcortical tissue adjacent to the left frontal encephalomalacia. The patient received total body irradiation and haploidentical peripheral stem cell transplantation. The post-transplant course was complicated by graft-versus-host-disease, which was treated with steroids, tacrolimus, and mycophenolate. The patient recovered and was discharged home with home health care services.
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