Case Images
Case Notes
History
25 yo male with cystic fibrosis and new onset headache and systemic symptoms. Rx antibiotic. Symptoms worsened 10 days laterExam
Prior Study
MR flair1. There is evidence of extensive bilateral, subpial/cortical edema and intra-sulcal protein affecting the cerebrum more than the cerebellum. Findings are consistent with fulminant, acute, proinflammatory phase of a primary leptomeningitis, likely in the day 1-3 timeframe.
2. There is no evidence of complicating factors, such as ventriculitis, encephalitis, abscess or empyema.
3. There is a sequestered 3rd ventricle, likely under pressure, as above.
MR T1-w post contrast axial and/or sagittal planes
1. There is evidence of pial hyperemia and diffuse leak of contrast into cortical sulci in the supra and infratentorial compartments. These vascular changes are consistent with the acute inflammatory phase of fulminant leptomeningitis.
2. There is focal dilatation of the 3rd ventricle consistent with sequestered ventricular hydrocephalus. The lateral ventricles above and the fourth ventricle below are both compressed by mass effect of brain edema. This isolates the 3rd ventricle accounting for its' dilatation under pressure.
3. There is significantly downward tonsillar herniation consistent with raised intracranial pressure.
Dicom
Findings
| MR diffusion | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of a cortical/subcortical T2-shine through on diffusion consistent with leptomeningitis, or evidence of T2 shine through within brain parenchyma consistent with cerebritis/cerebellitis/rhombencephalitis. |
Yes | NA |
|
There is evidence of a parenchymal abscess or intraventricular infected sequestra with positive fluid restriction (i.e. positive DWI and positive ADC). |
No | NA |
|
There is evidence of an extraaxial empyema with T2 shine-through (positive DWI/negative ADC: both hyperintense). |
No | NA |
|
There is evidence of an extraaxial empyema with adjacent bone osteomyelitis having positive fluid restriction (positive DWI/positive ADC: DWI hyperintense/ADC hypointense) in both areas. |
No | NA |
|
There is evidence of secondary arterial ischemic event. |
No | NA |
|
No other significant imaging findings are present. |
No | NA |
Impression
Expert Answer
All of the above are correct
Your Answer
Recommendations & Acuity
Recommendations
Expert Answer
Proceed with additional MR imaging sequences.
Your Answer
Acuity
Expert Answer
Emergent (Action Necessary now)
