Case Images
Case Notes
History
30 yo male presenting with fever and sinusitis initially then depressed level of consciousnessExam
Prior Study
MR flair1. Aggressive left ethmoid sinus resulting in a focal relative large empyema adjacent to the ethmoid bone dehiscence in the left basifrontal area.
2. Secondary, mainly left sided, acute phase leptomeningitis with multicentric bilateral smaller subdural empyemas.
MR post contrast T1-w axial and coronal planes
1. There are bilateral relative small (3-5 mm) in width subdural hematomas which are nearly pan hemispheric on the left and scattered on the right. Focal larger (12-14 mms) subdural empyemas are evident in the left basifrontal and left frontopolar areas.
2. There is diffuse venous hyperemia and actual pial/dural enhancement along the lateral surface of the left cerebrum indicating the leptomeningitis is likely >3 days in evolution.
3. Abnormal enhancement is evident in the left sphenoparietal sinus indicating there is underlying thrombophlebitis, which likely contributes to the spread of the subdural empyemas.
4. There is no evidence of ventriculitis, cerebritis, nor brain abscess at this time.
MR diffusion
1. MR diffusion evidence of subpial edema from leptomeningitis mainly on the left.
2. MR diffusion evidence of empyema formation in the subdural fluid collections to varying degrees, which indicates the empyemas are in an early state of formation.
3. The left hippocampal and splenial edema are likely the result of a recent seizure event.
Dicom
Findings
| MR T2-w turbo spin-echo | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of leptomeningitis. |
Yes | NA |
|
There is evidence of primary pachymeningitis. |
No | NA |
|
There is evidence of secondary pachymeningitis from extracranial infection site. |
Yes | 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). |
No | 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). |
No | NA |
|
No other significant imaging findings are present. |
Yes | NA |
Impression
Expert Answer
All of the above are correct
Your Answer
Recommendations & Acuity
Recommendations
Expert Answer
Proceed with additional imaging sequences.
Your Answer
Acuity
Expert Answer
Emergent (Action Necessary now)
