Figure 1
Axial T2- weighted MRI
Signal intensity changes at the level of midbrain resemble Face of the Giant Panda.
Face of the giant panda
SectionNeuroradiology
Case TypeClinical Cases
Authors
Arora A, Puri SK, Upreti L, Kapoor A
Department of Radiodiagnosis, G.B. Pant Hospital and associated Maulana Azad Medical College, New Delhi, India.
Connected authors
24 years, male
Clinical History
A 24-year-old male patient presented for MR imaging of the brain in lieu of gradually progressive behavioural changes.
Imaging Findings
MR imaging of the brain revealed bilateral symmetrical hyperintensity involving the putamen, thalami, and brainstem on T2-weighted images. Signal intensity changes at the level of midbrain resembled 'Face of the Giant Panda'. Patient was subsequently worked up and was found to have low serum ceruloplasmin and an increased 24-hour urinary copper excretion consistent with Wilson's disease.
Discussion
Wilson’s disease is an inherited (autosomal recessive) disorder of inborn error of copper metabolism characterised by abnormal copper deposition in multiple organs such as liver, eyes and the brain. Accordingly these patients may present with either hepatic or neuropsychiatric symptoms such as tremors, rigidity, altered behaviour, seizures, ataxia etc. MR imaging plays a vital role in evaluation of these patients and may show diverse findings ranging from a normal scan to hyperintense basal ganglia, thalami, brainstem and white matter on T2-weighted images. At times, T1-w hyperintensity within the basal ganglia may be encountered.
Characteristic signal alteration in the brainstem in Wilson's disease simulating 'Face of the Giant Panda' was first described by Hitoshi et al in 1991. This appearance is caused by a combination of signal intensity changes at the level of midbrain on T2-weighted MR images. These include: high signal intensity in the tegmentum, normal signals in the red nuclei and lateral portion of the pars reticulata of the substantia nigra, and hypointensity of the superior colliculus. The exact pathogenesis of this constellation of MR findings is not known, but it is postulated that the paramagnetic effects of the deposition of heavy metals, such as iron and copper, may be responsible. It is believed that iron is assumed to play a more important role than copper in reducing the signal intensity of the superior colliculi on the T2-weighted scan. At times, signal alteration may also be encountered within the dorsal pons which has been popularly called as 'Giant panda cubs'.
Characteristic signal alteration in the brainstem in Wilson's disease simulating 'Face of the Giant Panda' was first described by Hitoshi et al in 1991. This appearance is caused by a combination of signal intensity changes at the level of midbrain on T2-weighted MR images. These include: high signal intensity in the tegmentum, normal signals in the red nuclei and lateral portion of the pars reticulata of the substantia nigra, and hypointensity of the superior colliculus. The exact pathogenesis of this constellation of MR findings is not known, but it is postulated that the paramagnetic effects of the deposition of heavy metals, such as iron and copper, may be responsible. It is believed that iron is assumed to play a more important role than copper in reducing the signal intensity of the superior colliculi on the T2-weighted scan. At times, signal alteration may also be encountered within the dorsal pons which has been popularly called as 'Giant panda cubs'.
Differential Diagnosis List
MR brain findings in Wilson disease
Final Diagnosis
MR brain findings in Wilson disease
References
[1] Shivakumar R, Thomas SV (2009) Teaching NeuroImages: face of the giant panda and her cub: MRI correlates of Wilson disease. Neurology 72:e50 (PMID: 19289731)
[2] Thapa R, Ghosh A (2008) \'Face of the giant panda\' sign in Wilson disease. Pediatr Radiol 38:1355 (PMID: 18839167)
[3] Sinha S, Taly AB, Ravishankar S, Prashanth LK, Venugopal KS, Arunodaya GR, Vasudev MK, Swamy HS (2006) Wilson\'s disease: cranial MRI observations and clinical correlation. Neuroradiology 48:613-21 (PMID: 16752136)
[4] Liebeskind DS, Wong S, Hamilton RH (2003) Faces of the giant panda and her cub: MRI correlates of Wilson’s disease. J Neurol Neurosurg Psychiatry 74:682 (PMID: 12700322)
Case information
| URL: | https://eurorad.org/case/8798 |
| DOI: | 10.1594/EURORAD/CASE.8798 |
| ISSN: | 1563-4086 |
Figure 2
Coronal FLAIR image
Coronal FLAIR image confirms bilateral symmetrical hyperintensity of the basal ganglia and thalami.
Figure 3
Axial T2- weighted MRI
Symmetrical T2-weighted hyperintensity of the bilateral basal ganglia and thalami is noted.
Figure 4
Axial T1- weighted MRI
A combination of high signal intensity in the tegmentum, normal signals in the red nuclei and pars reticulata of the substantia nigra, and hypointensity of the superior colliculi is responsible for the characteristic FACE OF THE GIANT PANDA appearance.
Axial T2- weighted MRI
Signal intensity changes at the level of midbrain resemble Face of the Giant Panda.
Coronal FLAIR image
Coronal FLAIR image confirms bilateral symmetrical hyperintensity of the basal ganglia and thalami.
Axial T2- weighted MRI
Symmetrical T2-weighted hyperintensity of the bilateral basal ganglia and thalami is noted.
Axial T1- weighted MRI
A combination of high signal intensity in the tegmentum, normal signals in the red nuclei and pars reticulata of the substantia nigra, and hypointensity of the superior colliculi is responsible for the characteristic FACE OF THE GIANT PANDA appearance.