‘Face of giant panda’: a rare imaging sign in Wilson’s disease
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 cerulo-
plasmin (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
(i) ‘Face of giant panda’ in the midbrain on T2W
(Figure 1—high signal intensity in the teg-
mentum except the red nucleus forming ‘eyes’, pres-
ervation of signal intensity in lateral portion of pars
reticulata of substantia nigra forming ‘ears’ and
hypointensity in the superior colliculus forming
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, subthala-
mic tegmental region, red nucleus, substantia nigra
and dentate nucleus.
Atrophy of the head of the
caudate nucleus, brainstem, cerebral and cerebellar
hemispheres is also common.
The ‘Face of giant
panda’ sign was first described by Hitoshi et al. in
The ‘panda’ is not frequently reported,
though the sign is considered characteristic of
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.
Conflict of interest: None declared.
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.
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Q J Med 2014; 107:579
doi:10.1093/qjmed/hct217 Advance Access Publication 29 October 2013
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