Case Notes
History
53 year old female who presented with confusion, depressed level of consciousnes, fever, and right ear pain. On admission patient had right coalescent otomastoiditis. Her lumbar puncture grew out strep pneumococcus.Exam
MR flair sequence
Prior Study
CT headThere is evidence of aggressive right otomastoiditis with sigmoid plate dehiscence (coalescent otomastoiditis) producing a small volume, epidural abscess, which partiall compresses the adjacent dural sinus. Focal deformity of the sigmoid sinus is evident at the site of epidural abscess, however, the remaining lumen of the right sigmoid sinus and the internal jugular vein are patent. Intraluminal thrombus is present in the torcular herophile, the left transverse/sigmoid sinuses, extending into the high cervical left IJ.
CT perfusion NO CT perfusion is available
CTA of the neck
Thrombosis of the high cervical left internal jugular vein with collateral drainage into the other left neck veins. The right IJ is patent. No soft tissue abnormality is evident within the cervical soft tissues.
MRV of the head obtained 4 days after the CTA
Segmental thromboses are evident in multiple dural sinuses, especially in the posterior superior sagittal sinus (SSS), the torcular herophile, and the left transverse/sigmoid sinuses. The extent of dural CVT has increased since the prior initial post contrast temporal bone CT. There is evidence of venous re-routing utilizing pial/dural anastomotic connections (the venous lacunae over the vertex, and the lateral tentorial confluence on the left) draining into the expanded dural wall venous plexus. Persistent right sigmoid deformity remains because of the persistent small epidural abscess adjacent to the right sigmoid plate.
Delayed post contrast CT for analysis of the venocapillary pool
There are known multiple dural sinus thromboses that are underestimated on the delayed post contrast CT. There is no evidence of reduced CT density within the venocapillary pool in either the cerebrum or cerebellum.
There is evidence of both optic hydrops and early hydrocephalus related to venous hypertension caused by the dural sinus egress block. It is concievable that the hydrocephalus could be in part related to meningitis associated with the right coalsecent otomasoiditis.
Post contrast T1-w MR
There is partial improvement In the extent of dural sinus thromboses likely related to improved venous collateral egress and/or progressive recanalization with improved antegrade blood flow. There is persistent right otomastoiditis and epidural abscess; the size of the abscess has gotten smaller with treatment. There is some reduction in the degree of ventriculomegaly likely related to improved venous egress with reduction in CSF pressure.
MR diffusion
There is evidence of positive MR diffuson in the site of coalscent mastoiditis with epidural abscess on the right plus evidence of a very small recent embolic arterial stroke in the left superior vermis.