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
| Pre and or post head CT | Correct Answer | Your Answer |
|---|---|---|
|
There is evidence of acute leptomeningitis. |
No | NA |
|
There is evidence of active primary pachymeningitis. |
No | NA |
|
There is evidence of secondary pachymeningitis associated with extension of extra cranial infections (i.e. otomastoiditis, sinusitis, parapharyngeal/skull base infections, calvarial infections, thrombophlebitis). |
No | NA |
|
There is evidence of complications of meningitis (subperiosteal, epidural, subdural empyema's). |
No | NA |
|
There is evidence of acute cerebritis. |
No | NA |
|
There is evidence of brain abscess(es). |
No | NA |
|
There is evidence of septic emboli with multicentric abscesses or micro abscesses. |
No | NA |
|
There may be contrast enhancement once viral infections undergo tissue necrosis. |
No | NA |
|
There is evidence of calvarial osteomyelitis and possible subperiosteal empyema. |
Yes | 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 imaging sequences.
Your Answer
Acuity
Expert Answer
Emergent (Action Necessary now)
