Case Notes
History
38 yo male w/ Hx hypertension, diffuse rash, chrohn's dz, seizures, brain cysts (biopsied benign), who now presents with stairing spells and acute fatique. Years earlier the patient had surgical drainage of a parenchymal hemorrhage in the left frontal vertex area.Exam
MR susceptibility sequence
Prior Study
Noncontrast CT headThere are brain changes of chronic nature, which are likely the sequelae of a neonatal TORCH encephalopathy. No apparent hyperacute abnormality is evident
CT Perfusion
Possible focal left cortical stroke in the distal left lateral frontal artery territory but whether it is acute ischemia or reduced perfusion on a chronic basis is indeterminate.
CT perfusion changes, likely chronic, within both cerebral hemisphere matching the areas of chronic leukomalacia consistent with the sequelae of a perinatal TORCH infection.
CTA of the head
Focal left high convexity anterior frontal cortex with reduced size and beading of the pial arteries plus reduction in extent of venous egress veins. But, whether this is confirmation of angiitis is indeterminate.
Pre and post contrast T1-w sequences
This is a complex case, because underlying CNS abnormalities consistent with perinatal TORCH infection with significant brain injuries. However, the patient has had recent neurological changes. There is evidence of coagulative necrosis surrounding dilated Virchow Robin spaces in the deep frontal centrum semiovale on both sides. There is also enhancement in the same sites consistent with active inflammation. These changes in the Virchow-Robins spaces appear unrelated to prior TORCH encephalopathy, nor the prior left frontal hemorrhage drainage sites. They support the idea of a concurrent secondary CNS angiitis.
MR diffusion
Chronic changes of completed lacunar defects following the Virchow-Robin spaces bilaterally. Whether these represent sequelae of prior surgery or microhemorrhage versus angiitis with ischemic change is indeterminate. However, there is no positive diffusion to confirm a hyperacute or acute ischemic event.
MR flair and T2-w sequences
There is postive MR flair and T2-w signal change consistent with the diffuse parenchymal tissue injuries and the chronic leukomalacia. What proportion of the parenchymal injuries are related to the perinatal TORCH infection, what part is related to surgery for prior brain hemorrhage, and what proportion to possible secondary CNS angiitis is indeterminate.