52-year-old female s/p OLT now with altered mental status status There is patchy restricted diffusion in the pons with questionable mildly restricted diffusion involving the caudate nuclei and bilateral thalami. Corresponding T2 hyperintensity is seen involving the caudate and putamina bilaterally and possibly the medial temporal lobes and hypothalami. The ventricles are not frankly enlarged though they do appear to be 2 to 3 mm larger in caliber when compared to previous CT. There is a thin rim of ependymal T2 hyperintensity along the lateral ventricular margins.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified.
Restricted diffusion is evident in the pons, thalami and questionably the basal ganglia. Abnormal T2 signal intensity is seen in these areas, and also in the hypothalami and medial temporal lobes. Although the ventricles are not frankly dilated, they have increased in caliber by 2 to 3 mm and there is a thin rim of ependymal signal abnormality along the lateral ventricular margins. Some of the above findings could be accounted for by a metabolic derangement, perhaps osmotic demyelination related to osmotic stress, although other metabolic abnormalities are not excluded. On the basis of this examination, a nonspecific encephalitis (infectious, autoimmune or drug related) could also be considered. Findings are not typical for either an ischemic process or classic hepatic encephalopathy. Imaging follow-up with contrast enhanced MRI should be considered if symptoms fail to improve.