Altered mental status, unspecified [R41.82], Reason for Study: ^Reason: ? CNS infection s/p DBS vs ischemia History: Fluid collection in head and chest There is fluid collection on the right frontal lobe middle frontal gyrus and right insular and internal capsule which show mass effects against surrounding structures. There is also high signal intensity on T2 weighted images on the right basal ganglia especially globus pallidus and posterior limb of internal capsule which surrounds DBS device.The signal intensity of the fluid collection is following the CSF signal intensity without showing any evidence of diffusion restriction. On contrast enhancement scan, the entry point of DBS device adjacent to the dura and proximal part show surrounding enhancement without evidence of peripheral enhancement. In addition, there is about 23.6mm x 17.1mm x 25.4mm sized peripherally enhancing subgaleal fluid collections on the site of the right frontal burr hole which may represent inflammatory/infectious nature. Diffuse right hemispheric meningeal enhancement was seen which could represent postoperative reactive changes. There is focal subtle susceptibility effects within the fluid collection especially inferior aspect of the right insular-external capsule lesion, but most of the lesion do not show any susceptibility effects.In summary, this most likely is the lesion of the CSF collection around the DBS device with evidence of contrast enhancement especially on both proximal part (intracranial portion) and entry point (extracranial portion) of the DBS device with mass effects, thus suggest possibility of inflammation or infection related nature. The possibility of acute ischemic lesion can be excluded. Although focal susceptibility effect was seen, the possibility of hemorrhagic lesion can also be excluded since it cannot explain the whole feature of the lesion. There is midline shift toward right side (about 3-4mm) but no evidence of uncal herniation.The cranial-cervical junction are normal. Normal flow voids are identified in the major intracranial vessels. The mastoid air cells are clear. Small retention cyst on the left maxillary sinus.
1. Possible inflammatory/infectious nature of both extra cranial and intracranial lesions including right frontal lobe and right insular-external capsule CSF collections with mass effects. 2. No evidence of acute ischemic or hemorrhagic lesion.