Findings
- Extensive restricted diffusion involving the entire left cerebral hemisphere, most of the left cerebellum, the left dorsolateral midbrain, the corpus callosum, the anterior commissure, and geographic regions in the right frontal lobe including the precentral gyrus
- Affected areas show associated T2/FLAIR hyperintensity and swelling with generalized sulcal effacement and 4 mm left to right midline shift with crowding of the fourth ventricle. No hydrocephalus
- Likely multifocal narrowing of the cavernous, ophthalmic, and communicating segments of the left greater than right internal carotid arteries with bilateral MCA and ACA branches remaining patent
- Diffuse narrowing of the left PCA
- Hypoenhancement involving the cavernous sinus bilaterally and of the superior ophthalmic veins with engorged veins, enhancement, and areas of restricted diffusion in the bilateral orbits
- Hypoenhancement and susceptibility artifact associated with the bilateral sphenoparietal sinuses, petrosal veins/sinuses, left transverse sinus, bilateral sigmoid sinuses, and bilateral internal jugular veins
- Widespread leptomeningeal enhancement involving the brainstem, cerebellar folia, and left greater than right cerebral hemispheres
- Dural thickening and enhancement along the left cerebral convexity without extraaxial collection
- Susceptibility artifact in the left ambient cistern
- Small fluid-fluid level in the occipital horn of the right lateral ventricle without associated restricted diffusion or susceptibility artifact
Diagnosis
Meningitis with infarct, arteritis, and venous thrombosis
Sample Report
Findings concerning for meningitis complicated by arteritis involving the internal carotid arteries and left PCA with resultant large areas of infarct involving the entire left cerebral hemisphere, most of the left cerebellum, the left dorsolateral midbrain, the corpus callosum, the anterior commissure, and geographic regions in the right frontal lobe including the precentral gyrus. Some of this signal abnormality (particularly in the corpus callosum) could relate instead to seizure activity.
Associated edema with generalized sulcal effacement and 4 mm left to right midline shift with crowding of the fourth ventricle. No evidence of hydrocephalus at this time, though the patient is at risk for developing hydrocephalus.
Bilateral cavernous sinus and widespread dural venous sinus thrombosis with bilateral orbital venous congestion and possible areas of intraorbital tissue infarct versus phlegmon.
Small volume subarachnoid hemorrhage in the left ambient cistern. No additional extraaxial collection.
Small fluid-fluid level in the occipital horn of the right lateral ventricle without associated restricted diffusion or susceptibility artifact, likely representing layering proteinaceous material.
Discussion