Case Notes
History
55 yo female with diabetes who presented with headache and fever and sinusitis (diagnosed on prior outside maxface CT). For the last several hours later had worsening symptoms and altered mental status changes.Exam
MR T2-w turbo spin-echo
Prior Study
MR flair1. There is evidence of diffuse leptomeningitis with findings on MR flair mostly in the hyperacute humeral immune phase of infection.
2. There is prominent mucosal edema in the paranasal sinuses and within the sella and within the retroglobal orbital soft tissue plus inflammation in the nasopharyngeal soft tissues. It is possible that the leptomeningitis is related to nasopharyngeal infection spreading into the sella and secondarily into the CSF.
MR T1-w post contrast
1. There is evidence of the contrast enhancement of the dura and pial surfaces consistent with the proinflammatory phase of the leptomeningeal infection.
2. There is pachymeningitic basilar meningitis, plus epidural venous engorgement in the upper cervical spine, plus mucosal enhancement of the nasopharyngeal mucosa, and enhancement of a persistent nasopharyngeal canal into the sella. The combination of findings from the contrast enhanced sequences plus the MR flair sequence are consistent with post infectious changes of differing ages. Likely the nasopharyngeal infections came first. It spread to the sella via the persistent nasopharyngeal canal causing basilar pachymeningitis and later spread to the CSF causing the more hyperacute leptomeningitis.
MR diffusion
1. The DWI demonstrates the subpial edema is a similar manner and distribution as evident on the MR flair. There is no cerebritis.
2. The ADC map demonstrates restriction in the right anterior temporal fossa, possibly an early subdural empyema, despite not being evident on the T1-w post contrast sequence.
MR susceptibility (SWI)
1. Developmental right transmantle parietal venous anomaly.
2. The cortical pial vessels are not as well seen as expected raising the possibility of early arterial vasospasm.