Clinical and Imaging Patterns of Neurological Involvement in Intravascular Large B-Cell Lymphoma: A Single-Center Retrospective Study

Objective: Neurological involvement in intravascular large B-cell lymphoma (IVLBCL) is heterogeneous, prompting us to characterize its diverse manifestations through an integrated clinical and neuroimaging framework. Methods: This single-center retrospective study included 55 patients with pathologically confirmed IVLBCL diagnosed at Peking Union Medical College Hospital between January 2015 and June 2023. Pretreatment neurological involvement was identified in 29 patients based on attributable clinical and/or imaging findings after exclusion of more plausible alternative causes. Patterns were assigned primarily by clinical manifestations, supported by available imaging. Results: Six potentially overlapping clinicoradiologic patterns were identified. The stroke-like pattern (n= 5) comprised acute focal deficits with corresponding infarct-like or ischemic lesions. The encephalopathy pattern (n= 11) included cognitive decline, behavioral changes, impaired consciousness, and/or seizures, with or without infarct-like lesions or white matter hyperintensities. Three patients developed encephalopathic features following stroke-like presentations, including one with concomitant myelopathy. The mass-like pattern (n= 1) presented with headache and vomiting associated with enhancing lesions and surrounding edema. Myelopathy (n= 3) was characterized by lower-limb weakness with spinal cord-localizing signs, whereas radiculoneuropathy (n= 5) manifested as bilateral lumbosacral nerve-root involvement with weakness, sensory abnormalities, and reduced reflexes. Corresponding MRI abnormalities were absent in two patients with encephalopathy and one with myelopathy. The asymptomatic pattern (n= 8) comprised patients with imaging abnormalities but no neurological symptoms or signs. A total of 19 of 22 patients evaluable for treatment response achieved complete remission. Conclusions: Neurological involvement in IVLBCL comprises overlapping and evolving clinicoradiologic presentations, with variable correspondence between symptoms and imaging findings. This descriptive framework may help clinicians recognize its diverse manifestations and consider IVLBCL when the clinical course or imaging findings remain insufficiently explained.