Female, 36 years old, with extensive sinusitis and left-sided vision loss. Evidence of extensive pansinus infection/inflammation is seen with severe bilateral mucoperiosteal thickening. The sinus cavities are filled with very heterogeneous material which on MR sequences is particularly hypointense, a finding which suggests fungal elements. There is evidence of prior endoscopic sinus surgery.Sphenoid region inflammation extends superiorly, apparently eroding through the planum sphenoidale completely or nearly completely. As a result, this abnormal presumably infected tissue extends essentially to the margin of the gyri recti (see image 20 series 401 and image 16 series 901). No evidence of frank intracranial fluid collection or any brain parenchymal edema is seen. There may be other smaller areas of inflammatory penetration through the adjacent skull base. In addition, it appears that the floor of the sella is at least partially eroded by this process.The ethmoid air cell region is expanded bilaterally secondary to chronic inflammation. Abnormal enhancing tissue approaches very close to both optic nerves as they exit the optic nerve canals. The left optic nerve canal is significantly narrowed relative to the right, a finding which is better appreciated on the prior sinus CT, and which is secondary to sclerosis of the adjacent bone. The cisternal left optic nerve may even be somewhat smaller than the right suggesting a degree of atrophy. The intraorbital and cisternal segments of the optic nerves show no convincing evidence of enhancement or signal abnormality. Both nerves may potentially enhance mildly as they pass through the optic nerve canals but this could also be artifactual.The left pterygopalatine fossa is at least narrowed and possibly infiltrated by adjacent inflammation from the maxillary and sphenoid sinuses. No frank inflammatory extension is evident into the orbital apices.Limited intracranial views demonstrate multiple areas of periventricular and subcortical T2 hyperintensity. The hypothalamic region also seems to be affected by symmetric bilateral hyperintensity.
Findings are seen compatible with an aggressive, possibly fungal pansinus infection. This process has eroded through the anterior skull base at the level of the planum sphenoidale in at least one location but probably in several. The process extends as far as the margin of the gyri recti. No definite evidence of any intracranial abscess or parenchymal edema is seen at this point. The floor of the sella is also partially eroded and there are likely additional areas of more subtle anterior skull base erosion.The left optic nerve canal is significantly more narrowed than the right, a finding which is better seen on prior CT and secondary to sclerosis and chronic thickening of the adjacent bony structures. The cisternal left optic nerve appears slightly smaller than the right which may reflect a component of atrophy. The cisternal and orbital portions of the optic nerve show no clear evidence of pathologic enhancement or signal abnormality. As the optic nerves pass through the optic nerve canals, they approach very closely to the infectious/inflammatory process in the adjacent sinuses and there may be some mild nerve enhancement though this could be artifactual.