Age: 46
Sex: Female
Indication: Headache, fever
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Case #2
Findings
- Heterogenous T1/T2 signal in the clivus, occipital condyles, and C1 and C2 vertebral bodies with patchy enhancement and osseous erosions
- Circumferential epidural enhancement from the skull base through C2 with mild pial enhancement along the surface of the brainstem
- Fluid signal and enhancement in the bilateral atlantooccipital and right atlantoaxial joints
- Right lateral subluxation of the C1 on C2 with the odontoid process indenting the left ventral aspect of the thecal sac
- Material layering in the occipital horns of the lateral ventricles and in the fourth ventricle which restricts diffusion and is T2 hypointense relative to CSF
- Diffuse ventriculomegaly with periventricular T2/FLAIR hyperintensity
- Hypoenhancement and abnormal flow-related signal loss in the left transverse and sigmoid sinuses extending into the left internal jugular vein
- Left mastoid effusion
Diagnosis
- Ventriculitis
- Skull base osteomyelitis
- Dural venous sinus thrombosis
- Hydrocephalus
Sample Report
Findings concerning for skull base osteomyelitis involving the clivus, occipital condyles, and C1 and C2 vertebral bodies complicated by meningitis, ventriculitis, and thrombosis of the left transverse and sigmoid sinuses and left internal jugular vein. Cervical spine MRI with and without contrast is recommended for further assessment.
Communicating hydrocephalus with transependymal edema. No evidence of acute infarct, hemorrhage, or herniation.
Fluid signal and enhancement in the bilateral atlantooccipital and right atlantoaxial joints concerning for septic arthritis. As a likely complication of this infectious process, there is right lateral subluxation of the C1 on C2 with the odontoid process indenting the left ventral aspect of the thecal sac, concerning for instability.
Left mastoid effusion. While this may be reactive, infectious mastoiditis could have a similar appearance.
Discussion
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References
- Fukui MB, Williams RL, Mudigonda S. CT and MR imaging features of pyogenic ventriculitis. AJNR Am J Neuroradiol 2001; 22(8): 1510-1516.
- Leach JM, Fortuna RB, Jones BV, Gaskill-Shipley MF. Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. Radiographics 2006; 26: S19-S43.
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