Findings
- Nodular enhancing soft tissue filling the suprasellar cistern and extending into the cavernous sinus, interpeduncular fossa, anterior interhemispheric fissure, and right greater than left ambient cisterns and sylvian fissures with areas of internal T2 signal hypointensity
- Peripherally enhancing components contiguously extend into the parenchyma of the inferior right frontal lobe, hypothalamus, and medial right temporal lobe with surrounding T2/FLAIR signal hyperintensity throughout a larger area of the right greater than left inferior frontal lobes, right temporal lobe, right greater than left basal ganglia and thalami, and right greater than left midbrain
- Small area of restricted diffusion in the approximate location of the anterior commissure on the right
- Mild generalized cerebral edema with FLAIR signal hyperintensity in multiple cerebral sulci and otherwise mild multifocal leptomeningeal enhancement
- Abnormal enhancement about the communicating segments of the right greater than left internal carotid arteries, M1 segment of the right MCA, right posterior communicating artery, P1 segment of the right PCA, and distal basilar artery with asymmetric narrowing of the communicating segment of the right ICA
- Left fetal-type PCA
- Abnormal hypoenhancement of the left transverse sinus, sigmoid sinus, jugular bulb, and proximal internal jugular vein, likely related to flow-related signal loss given the appearance on other sequences
- Left frontal approach ventricular drain with tip near the left Foramen of Monro
- Linear area of gliosis in the right frontal lobe related to a previously removed ventricular drain
- No acute hemorrhage, herniation, or hydrocephalus
- Bilateral mastoid and middle ear effusions
Diagnosis
Tuberculous meningitis
Sample Report
Extensive basal meningitis with differential considerations including tuberculosis as well as other bacterial and fungal pathogens. Recommend CSF sampling for further evaluation.
Peripherally enhancing components contiguously extend into the parenchyma of the inferior right frontal lobe, hypothalamus, and medial right temporal lobe concerning for small abscesses with surrounding larger areas of cerebritis.
Findings concerning for vasculitis involving the right greater than left internal carotid arteries, M1 segment of the right MCA, right posterior communicating artery, P1 segment of the right PCA, and distal basilar artery with asymmetric narrowing of the communicating segment of the right ICA. A small area of restricted diffusion in the approximate location of the anterior commissure on the right could represent a small perforator infarct vs infectious debris. No additional evidence for an acute infarct.
Left frontal approach ventricular drain with tip near the left Foramen of Monro. No evidence of hydrocephalus.
Bilateral mastoid and middle ear effusions, which can be seen with otomastoiditis.
Discussion
References