Neuro_MR_Brain: 6 mo, AMS and right ear infection.

MRI BRAIN, MRA HEAD AND NECK, MRV HEAD WITH AND WITHOUT CONTRAST:

CLINICAL HISTORY: 6 months of age, Female, occlusion of the right jugular vein on CT with right frontal infarct.

FINDINGS:

BRAIN MRI:

There is reduced diffusion in the cerebrum along bilateral ACA territories, left MCA territory, including bilateral basal ganglia, concerning for acute infarction.  There is also reduced diffusion of the splenium of the corpus callosum, as well as scattered additional punctate foci of restricted diffusion bilaterally in the cortical and subcortical regions. 

There is right mastoid fluid collection with peripheral enhancement and associated reduced diffusion suggesting abscess.  There is also abnormal diffusion of the right petrous apex.  There is thrombosis of the right transverse sinus, sigmoid sinus, and jugular vein. There is bilateral cavernous sinus thrombosis, right greater than left, with a 2 x 3 mm lateral outpouching of the right cavernous internal carotid artery concerning for pseudoaneurysm. There is also reduced diffusion in bilateral cavernous sinus, basilar cistern, and bilateral foramen rotundum, concerning for abscess/phlegmonous collection.

There is abnormal enhancement of all of the visualized cranial nerves (optic nerve, III, V, VI, VII, VIII), as well as enhancement along the brainstem surface consistent with leptomeningeal process. 

There is intraventricular hemorrhage, and hemorrhage in the prepontine cistern adjacent to the basilar artery tip.

IMPRESSION:

1.  Acute cerebral infarcts in bilateral ACA and left MCA distribution.  Scattered foci of abnormal diffusion throughout the brain may represent a combination of septic thrombotic-embolic components and pial/leptomeningeal process.

2.  Abnormal signal in right mastoid and petrous apex consistent with petro-mastoiditis/osteomyelitis with intracranial complications, including thrombosis of the right transverse sinus, sigmoid and jugular vein. There is also bilateral cavernous sinus thrombosis/thrombophlebitis, right greater than left, with pseudoaneurysm of the right cavernous internal carotid artery.

3.  Hemorrhage and phlegmonous enhancement within the basilar cisterns, concerning for basilar meningitis. There is also abnormal enhancement of the cranial nerves consistent with leptomeningeal process.   No definite basilar tip aneurysm; however, either diagnostic angiogram or CT angiography will be helpful for further delineation.

4.  Multifocal intracranial arterial stenoses, which may be seen with vasculitis and vasospasm.

5.  Mild ventriculomegaly and intraventricular hemorrhage.

(Severe complicated otomastoiditis/skull base osteomyelitis)