# Case Report: Cerebellar microhemorrhages: an underrecognized feature of MMA-HC revealed by high-field 7.0 T MRI

## TL;DR

A rare metabolic disorder called MMA-HC was found to cause cerebellar microhemorrhages, detectable with high-field MRI, in an adult patient.

## Contribution

This is the first report of cerebellar microhemorrhages in MMA-HC detected via high-field 7.0 T MRI susceptibility-weighted imaging.

## Key findings

- Cerebellar microhemorrhages were identified in a patient with MMA-HC using 7.0 T MRI SWI.
- The patient showed an unusual adult-onset presentation of MMA-HC with acute neurological symptoms.
- Vitamin-based therapy resolved symptoms, but microhemorrhages were a previously unreported feature.

## Abstract

Cerebellar microhemorrhages have not been previously documented in methylmalonic acidemia with homocystinuria (MMA-HC), a rare inherited metabolic disorder. Herein, we reported an 18-year-old female presented with acute gait instability and dysarthria post-febrile illness. Biochemical testing revealed severe hyperhomocysteinemia. Brain MRI demonstrated bilateral cerebellar DWI/FLAIR hyperintensities. Whole-exome sequencing confirmed compound heterozygous MMACHC mutations, establishing cblC-type MMA-HC diagnosis. Symptoms resolved after one month of vitamin-based therapy. Follow-up 3.0 T MRI and 7.0 T MRI susceptibility-weighted imaging (SWI) uncovered multiple punctate cerebellar vermian microhemorrhages—a previously unreported finding. This case highlights an unusual adult-onset presentation of MMA-HC and represents the first report of SWI-detectable cerebellar vermis microhemorrhages with this condition, visualized. This finding suggests that cerebellar microhemorrhages may be an under-recognized feature in MMA-HC, particularly detectable using high-field SWI during acute exacerbations, and contributes to a more comprehensive understanding of the neurological complications in this metabolic disorder.