 BRAIN: Compared to 2/19/2015, there is minimal progression in appearance of the extensive skull base osteomyelitis. Again seen is abnormal enhancement of the bilateral nasopharyngeal soft tissues slightly worse on the right in the interval. 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 involving the sphenoid bone at the level of the left pterygoid process, the clivus including the basisphenoid and basiocciput, the left occipital condyle, the left lateral mass of C1 as well as the visualized odontoid process.Again seen is abnormal enhancement and fluid collection involving the cervical epidural space. Left sided epidural collection at the left C2 level measures 8 x 22 mm in the AP and craniocaudal dimensions (sag postgad image 13/25), previously of 6 x 21 mm. There is extensive enhancement with multiple abscesses in the left prevertebral, paravertebral and the paraspinal left postero-lateral neck soft tissues. There is a fluid collection in the visualized left upper paraspinous soft tissues which appears slightly larger than 2/19/2015 but better evaluated on recent CT neck study.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 similar 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 from the right cavernous sinus, with a thin subdural empyema along the right tentorial leaflet again seen. 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 foramen as on the prior examination. These findings are also grossly unchanged from the prior examination. 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. There are mucus retention cysts in the bilateral maxillary sinuses. Polypoid inflammatory mucosal thickening involving the sphenoid sinuses is slightly increased since 2/19/2015.MR VENOGRAM BRAIN: MR venogram demonstrates absent flow within the distal aspect of the left sigmoid sinus and left upper internal jugular vein. Asymmetrically diminished flow is seen within the left transverse sinus and proximal sigmoid sinus without evidence of thrombosis. Remainder of the visualized superficial and deep venous systems appear patent. Thrombus is noted within the left sigmoid sinus and internal jugular vein on recent CT neck from 4/2/2015. Thin enhancing fluid collection is noted at the left sigmoid sinus and internal jugular vein junction which may be compressing the left-sided venous system.
1.Interpretation of outside MRI brain dated 4/5/2015. There is no MRI evidence of meningoencephalitis or intracranial abscess.2.Compared to 2/19/2015 there is minimal progression in the appearance of the trans-spatial neck/skull base infection with innumerable abscesses centered in the skull base with extension into the sella, thrombophlebitis of the bilateral cavernous sinuses, and contiguous extension of infection into the right tentorial leaflet resulting in a small subdural empyema. The tiny subdural empyema is not significantly changed.3.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 greater than right sphenoid and occipital bones as well as left lateral mass of C1 appear similar to prior study. Infectious process surrounding the left jugular foramen and hypoglossal canals, similar to prior study.4.Visualized cervical epidural collection at the C2 level appears minimally larger than 2/19/2015.5.Extensive infectious involvement of the left sided deep neck/paraspinous and prevertebral soft tissue with multiple abscesses are again seen and better imaged on recent CT neck study.6.MR venogram demonstrates occlusion of the left internal jugular vein and distal aspect of the left sigmoid sinus. This finding is grossly similar when compared to prior brain and cervical spine MRI from 2/19/2015 allowing for differences in technique. Thin enhancing fluid collection is noted at the left sigmoid sinus and internal jugular vein junction which may be compressing the left-sided venous system. Remainder of the intracranial venous system appears patent.