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.
MR diffusion
1. DWI evidence of subpial, cortical or the cerebrum and cerebellum. The cerebellar changes are more apparent on the diffusion imaging than on the MR flair.
MR susceptibility (SWI)
1. Negative MR susceptibility for intra or extraaxial hemorrhage.
Dicom
Findings
| MR T2-w turbo spin-echo | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of leptomeningitis. |
No | NA |
|
There is evidence of primary pachymeningitis. |
No | NA |
|
There is evidence of secondary pachymeningitis from extracranial infection site. |
No | NA |
|
There is evidence of cerebritis. |
No | NA |
|
There is evidence of brain abscess(es). |
No | NA |
|
There is evidence of hydrocephalus (ventriculomegaly plus signs of elevated CSF pressure). |
Yes | NA |
|
There is evidence of ventriculitis and intraventricular infected sequestra. |
No | NA |
|
There are characteristic features for certain infections (i.e. HSV1 & 2, tuberculosis, etc.). |
No | NA |
|
Recognize the features of infection in the immuno-incompetent host (i.e. HIV, AIDS, steroid therapy, transplant patients, chemotherapy). |
No | NA |
|
There is evidence of raised intracranial pressure (i.e. optic hydrops, partially empty sella, and/or downward tonsillar displacement). |
Yes | NA |
|
No other significant imaging findings are present. |
No | NA |
Impression
Expert Answer
All of the above are true.
Your Answer
Recommendations & Acuity
Recommendations
Expert Answer
Proceed with additional MR imaging sequences.
Your Answer
Acuity
Expert Answer
Emergent (Action Necessary now)
