Interest of multi-modal imaging in bilateral lesions of basal ganglia: A case report of a post-anoxic dystonia

Objectives: We report the case of a 16-year-old patient with progressive generalized choreo-dystonia that appeared two months after a suicide attempt by hanging associated with a cardiorespiratory arrest. An initial magnetic resonance imaging (MRI) brain scan was judged normal by radiologists. Discordance between clinical presentation and morphological imaging led to the hypothesis of a psychogenic dystonia but striatal lesions were suspected by neurologists.Methods: A second MRI high field was performed and the patient also underwent 123I-fluopane single photon emission computed tomography (SPECT). MRI and SPECT fusion images were analysed.Results: The second MRI failed to reveal any lesions involving the basal ganglia. 123I-fluopane-SPECT, however, highlighted bilateral posterior putaminal presynaptic dopaminergic denervation. Post hoc analysis of MRI and SPECT fusion images confirmed bilateral posterior putamen lesions, with low signal intensity on DWI, confirming the diagnosis of postanoxic generalized dystonia.Conclusions: We report this case to highlight the utility of multimodal imaging in diagnosis of bilateral lesions in difficult neurologic disorders where there is discordance between the clinical presentation and morphological brain imaging.