Fig. 16.4. Sagittal T1-weighted images without (left) and with (right) gadolinium enhancement in a patient with AIDS, demonstrating the typical heterogeneous rim enhancement seen with primary CNS lymphoma in this population of patients.

increased intracranial pressure in many patients. Definitive diagnosis usually requires tissue. Biopsy is more likely to yield diagnostic tissue if it is performed prior to the administration of corticosteroids, which, by lysing the malignant tumor cells, may obscure the diagnosis [16].

Once a diagnosis of CNS lymphoma is established, the need for investigations to exclude systemic lymphoma with secondary cerebral involvement is controversial. In immunocom-petent patients, spread of systemic lymphoma to the CNS is uncommon. When it does occur, it is usually late in the course of the disease and the leptomeninges are predominantly affected. In general, investigations should be limited to determining the extent of disease within the CNS [20]: cranial MRI with contrast, ophthalmologic examination, spinal MRI with contrast (for patients with neck or back pain or myelopathy) and lumbar puncture (if not contraindi-cated). For patients with AIDS, systemic lymphoma has a greater propensity to involve the CNS secondarily. In these patients, screening for systemic disease with bone marrow aspiration and chest, abdominal and pelvic imaging is advisable. Because of the association between PCNSL and AIDS, testing for HIV is also indicated for patients first found to have primary CNS lymphoma.

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