Q J Med 2014; 107:579 doi:10.1093/qjmed/hct217
Advance Access Publication 29 October 2013
Clinical picture ‘Face of giant panda’: a rare imaging sign in Wilson’s disease
(i) ‘Face of giant panda’ in the midbrain on T2W images1 (Figure 1—high signal intensity in the tegmentum except the red nucleus forming ‘eyes’, preservation of signal intensity in lateral portion of pars reticulata of substantia nigra forming ‘ears’ and hypointensity in the superior colliculus forming ‘mouth’).
The most common radiological abnormalities described in Wilson’s disease are changes in signal intensity of grey and white matter especially T2W hyperintensities in putamen (particularly lateral side), globus pallidus, thalamus, caudate, subthalamic tegmental region, red nucleus, substantia nigra and dentate nucleus.2 Atrophy of the head of the caudate nucleus, brainstem, cerebral and cerebellar hemispheres is also common.2 The ‘Face of giant panda’ sign was first described by Hitoshi et al. in 1991.1 The ‘panda’ is not frequently reported, though the sign is considered characteristic of Wilson’s disease.2
Acknowledgements A.G. drafted the manuscript. All authors reviewed and edited the manuscript. Photographs and text from: A. Gupta, S. Chakravarthi and M.K. Goyal, Department of Neurology, PGIMER, Chandigarh 160012, India. email: [email protected] Conflict of interest: None declared.
References 1. Hitoshi S, Iwata M, Yoshikawa K. Mid-brain pathology of Wilson’s disease: MRI analysis of three cases. J Neurol Neurosurg Psychiatry 1991; 54:624–6. 2. van Wassenaer-van Hall HN. Neuroimaging in Wilson disease. Metab Brain Dis 1997; 12:1–19.
Figure 1. T2-weighted axial MRI demonstrates the ‘face of the giant panda’ in the midbrain (arrow).
! The Author 2013. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 17, 2015
A 26-year-old girl presented with fever and jaundice at 17 years of age followed by generalized tonic clonic seizures, right hand postural tremor, reduced school performance, inappropriate laughter and slowness of activities 2 years later. She also reported dystonic posturing of the right upper and lower limb with drooling of saliva. She had a positive Kayser– Fleischer ring bilaterally on ocular examination. Neurologic examination revealed dystonia of the right arm and leg, bradykinesia and rigidity of limbs. Laboratory tests revealed low serum ceruloplasmin (0.1 g/l, normal range 0.2–0.6 g/l) and copper (247.3 mg/l, normal range 510–1610 mg/l) and high 24-hr urinary copper (38.6 mg/l, normal range 2–30 mg/l). MRI Brain revealed
Advance Access Publication 29 October 2013
Clinical picture ‘Face of giant panda’: a rare imaging sign in Wilson’s disease
(i) ‘Face of giant panda’ in the midbrain on T2W images1 (Figure 1—high signal intensity in the tegmentum except the red nucleus forming ‘eyes’, preservation of signal intensity in lateral portion of pars reticulata of substantia nigra forming ‘ears’ and hypointensity in the superior colliculus forming ‘mouth’).
The most common radiological abnormalities described in Wilson’s disease are changes in signal intensity of grey and white matter especially T2W hyperintensities in putamen (particularly lateral side), globus pallidus, thalamus, caudate, subthalamic tegmental region, red nucleus, substantia nigra and dentate nucleus.2 Atrophy of the head of the caudate nucleus, brainstem, cerebral and cerebellar hemispheres is also common.2 The ‘Face of giant panda’ sign was first described by Hitoshi et al. in 1991.1 The ‘panda’ is not frequently reported, though the sign is considered characteristic of Wilson’s disease.2
Acknowledgements A.G. drafted the manuscript. All authors reviewed and edited the manuscript. Photographs and text from: A. Gupta, S. Chakravarthi and M.K. Goyal, Department of Neurology, PGIMER, Chandigarh 160012, India. email: [email protected] Conflict of interest: None declared.
References 1. Hitoshi S, Iwata M, Yoshikawa K. Mid-brain pathology of Wilson’s disease: MRI analysis of three cases. J Neurol Neurosurg Psychiatry 1991; 54:624–6. 2. van Wassenaer-van Hall HN. Neuroimaging in Wilson disease. Metab Brain Dis 1997; 12:1–19.
Figure 1. T2-weighted axial MRI demonstrates the ‘face of the giant panda’ in the midbrain (arrow).
! The Author 2013. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 17, 2015
A 26-year-old girl presented with fever and jaundice at 17 years of age followed by generalized tonic clonic seizures, right hand postural tremor, reduced school performance, inappropriate laughter and slowness of activities 2 years later. She also reported dystonic posturing of the right upper and lower limb with drooling of saliva. She had a positive Kayser– Fleischer ring bilaterally on ocular examination. Neurologic examination revealed dystonia of the right arm and leg, bradykinesia and rigidity of limbs. Laboratory tests revealed low serum ceruloplasmin (0.1 g/l, normal range 0.2–0.6 g/l) and copper (247.3 mg/l, normal range 510–1610 mg/l) and high 24-hr urinary copper (38.6 mg/l, normal range 2–30 mg/l). MRI Brain revealed
