Neuro_MR_Orbits: 85 M, left cranial nerve II and VI palsies.

MRI ORBITS WITH AND WITHOUT CONTRAST:

CLINICAL HISTORY: 85 years of age, Male, with left cranial nerve III, VI palsy, recently treated with azithromycin. Concern for aseptic thrombus.

FINDINGS: 

Orbits and soft tissues: There is marked enhancement and inflammatory changes within the left orbit as well as the superficial periorbital soft tissues, including thick enhancement about the left globe, extending along the left optic nerve sheath to the orbital apex and superior orbital fissure. Asymmetric enhancement of the left extraocular muscles. No associated restricted diffusion. Enhancement extends towards the anterior aspect of the cavernous sinus, left cavernous sinus slightly asymmetrically prominent relative to the right. Mildly increased CSF signal surrounding the left optic nerve, without demonstrable enhancement. No drainable fluid collection. 

Normal right globe, extraocular muscles, and optic nerve and apparatus. Questionable hazy foci of enhancement in the left retrobulbar fat (series 16 image 16 and series 17 image 20), difficult to distinguish active inflammation vasculature given extent of active process within the left orbit. 

The superior ophthalmic vein is patent on postcontrast BRAVO images. 

Soft tissues: Normal cavernous sinuses and visualized extracranial soft tissues. 

Visualized skull base foramina: Normal. 

Visualized paranasal sinuses: Mucous retention cyst or polyp within the right maxillary sinus. Minimal pansinus mucosal thickening. 

Mastoid air cells: Trace right mastoid effusion. 

Bones: Degenerative changes of the cervical spine. 

Brain parenchyma: Moderate global volume loss with commensurate enlargement of the sulci and ventricles. No acute hemorrhage, infarction, mass, or abnormal enhancement.

Ventricles and extra-axial spaces: Appropriate for age. 

Additional comment: None. 

Perfusion: Increased perfusion to the left orbit. 

IMPRESSION:

1.  Extensive inflammatory process in the left orbit notably with thick enhancement about the globe, optic sheath, tracking to the optic apex and superior orbital fissure, with enhancement of the left oculomotor nerve within the left cavernous sinus. Questionable foci of abnormal enhancement in the right retrobulbar fat. Constellation of findings is most suggestive for orbital inflammatory disorder including IgG4 related diseases given areas of masslike thickening, and possible bilateral involvement. Infection is an additional consideration though would expect clinical infectious signs and symptoms given extensive inflammation, no drainable fluid collection or abscess. Infiltrative neoplasm difficult to exclude but considered less likely given absence of significant restricted diffusion. No evidence of cavernous sinus or superior ophthalmic vein thrombosis as questioned clinically.