 BRAIN: There is abnormal enhancement in the left posterior nasopharynx soft tissues. There is abnormal enhancement along with innumerable foci of non-enhancement representing extensive infection with innumerable abscesses extending into the clivus. There is a low marrow T1 signal with enhancement in the left occipital condyle, inferior aspect of the left occipital bone (opisthion), left lateral mass of C1. There is epidural enhancement with small central abscess and the left cervical spinal epidural space at the foramen magnum extending inferiorly to the C1-2 level. There is extensive enhancement with multiple abscesses in the left prevertebral, paravertebral and the paraspinal left postero-lateral neck soft tissues. There is involvement of the sella surrounding the pituitary gland. There are erosive changes at the posterior cortex of the clivus with extension into the right prepontine cistern as noted previously. These findings are grossly unchanged from the prior examination.There is increased signal abnormality with somewhat bulky appearance and enhancement of the bilateral cavernous sinuses with multiple small abscesses, consistent with bilateral cavernous sinus thrombophlebitis, similar to prior examination. However, there remains no abnormal superior ophthalmic vein enlargement or proptosis. There is persistent enhancement of the walls of the cavernous carotid arteries bilaterally without significant narrowing of the internal carotid arteries.There is contiguous infection extension along the right temporal leaflet from the right cavernous sinus, with a thin subdural empyema in the right tentorial leaflet which is best appreciated on the 3-D postcontrast T1 coronal images. There is asymmetric signal abnormality with heterogeneous enhancement in the left jugular tubercle and left hypoglossal canal. The left proximal internal jugular vein appears occluded and infectious process surrounds the left jugular canal as on the prior examination. These findings are also grossly unchanged from the prior examination. The dural venous sinuses appear patent. There is no acute infarct, mass effect or midline shift. There is no evidence of infection involving the brain parenchyma, or suspicious brain parenchymal enhancement. The ventricles and sulci are normal for patient's age. The flow-voids of the skull base are patent. There are mucus retention cysts in the bilateral maxillary sinuses. There is inflammatory mucosal thickening involving the right sphenoid sinus.CERVICAL: Compared to the prior exam, there is overall slightly decreased infection involvement in the neck. Representative measurements are described below:1.Abscess in the left posterior lateral neck soft tissues previously measured 28 mm compared to 25 mm today on series 21 image 4.2.Soft tissue thickening and enhancement along the left lateral neck measured up to 47 mm previously in short axis, now measuring up to 41 mm in short axis on series 23 image 1. This process extends from the skull base inferiorly to C5-6 level, unchanged in overall extent.3.There is persistent left anterolateral epidural enhancement with foci of central non-enhancement measuring up to 7 mm at the foramen magnum extending to C1-2, compared to 9 mm previously. There is effacement of the ventral CSF space with the epidural component abutting the ventral medulla/cord at C1 level without stenosis.4.There is contiguous left anterolateral epidural infection spreading inferiorly to the C3 level measuring up to 7 mm in thickness with tiny central abscess, similar to prior examination.5.There is asymmetric enhancement in the left neural foramina down to C5-6 which may be reactive to adjacent soft tissue infection, similar to prior examination.There are postoperative findings in the left neck including scattered foci of susceptibility which appear new from prior examination.There is no cord signal abnormality or suspicious enhancement within the cord. There is no restricted diffusion in the cervical cord. Aside from the skull base and C1, there is no osseous signal abnormality or suspicious osseous enhancement in the cervical spine. There is no significant disk herniation, significant spinal canal or neural foraminal stenosis in the cervical spine.
1.No evidence of infection or abscess within the brain parenchyma.2.Extensive transspatial infection with innumerable abscesses centered in the skull base with extension into the sella with findings suggesting infectious involvement of the pituitary gland. There is thrombophlebitis of the bilateral cavernous sinuses, with contiguous extension of infection into the right tentorial leaflet resulting in a small subdural empyema. These findings are similar to prior outside MRI from January 2015.3.Extensive infectious involvement of the left sided deep neck/paraspinous and prevertebral soft tissue with multiple abscesses extending inferiorly to C5-6 level. Overall, infectious findings in the neck appears slightly decreased from the prior examination, although the overall extent of involvement appears similar to the prior examination. Please see details above.4.Left anterolateral epidural phlegmon/abscess extending from the foramen magnum to C3 level, slightly decreased from prior examination. Please see details above.5.Extensive erosive changes in the clivus with extension of infection into the pre-pontine cistern on the right, similar to prior study. Infectious marrow involvement of the left sphenoid and occipital bone as well as left lateral mass of C1, similar to prior study.6.Infectious process surrounding the left jugular and hypoglossal canals, similar to prior study.7.Left proximal internal jugular vein appears occluded, similar to prior study.Findings were discussed with Neurology resident Dr. Ali Mansour in person at the time of initial interpretation.