Findings
- Widespread cortical and leptomeningeal enhancement involving the left cerebral hemisphere extending along the left sylvian fissure and overlying mild dural thickening and enhancement
- Areas of mild cortical restricted diffusion in the left cerebral hemisphere, particularly involving the temporoparietal region
- Areas of encephalomalacia in the left middle cerebellar peduncle and left cerebellar hemisphere
- Confluent T2/FLAIR hyperintensity in the subcortical and periventricular white matter
- Age-advanced generalized cerebral and cerebellar volume loss
- No evidence of acute hemorrhage or hydrocephalus
- T2 hyperintense signal in the left middle ear and left mastoid air cells with extensive enhancement in the left mastoid temporal bone extending into the external auditory canal and anteromedially across the skull base
Diagnosis
Stroke-like migraine attacks after radiation therapy (SMART) syndrome
Sample Report
Widespread cortical and leptomeningeal enhancement involving the left cerebral hemisphere and extending along the left sylvian fissure with superimposed areas of cortical restricted diffusion in the left cerebral hemisphere. These findings may represent intracranial extension of infection from left otomastoiditis, though SMART syndrome is an additional consideration in this patient with history of whole brain radiation. No evidence of parenchymal abscess, extra-axial collection, acute hemorrhage, or hydrocephalus.
Findings consistent with otomastoiditis and possible adjacent skull base osteomyelitis. Recommend contrast-enhanced temporal bone CT and ENT consultation.
Areas of encephalomalacia in the left middle cerebellar peduncle and left cerebellar hemisphere likely correspond with previously treated lesions.
Background of age-advanced generalized cerebral and cerebellar volume loss and confluent T2/FLAIR hyperintensity in the subcortical and periventricular white matter, which though nonspecific likely represents a combination of posttreatment changes and chronic small vessel disease.
Discussion