Nontraumatic subdural hemorrhage. 4-month-old with macrocephaly, hydrocephalus and hypertonia. Evaluate for stroke, infection and hemorrhage. There is again marked enlargement of the lateral, third and fourth ventricles, with layering oblique collections within the occipital horns of the lateral ventricles and the fourth ventricle which restrict diffusion, with obliquity probably related to prior head position given plagiocephaly along the right occiput. There is no hemosiderin deposition within these collections on susceptibility weighted imaging to suggest hemorrhage. There is also diffuse ependymal enhancement.An extra-axial lentiform collection is identified along the left parietal convexity that causes mass effect on the brain parenchyma. The collection measures 12 mm in maximum thickness x approximately 3.5 cm AP, and restricts diffusion. There is a small rim of susceptibility posteromedially, which likely represents displaced and compressed vessels, rather than a small amount of blood products. There is associated localized mass effect without midline shift. There is also a trace right paramedian frontal subdural collection which restricts diffusion.There are scattered foci of susceptibility most conspicuous within the region of bilateral caudothalamic grooves and right cerebellum, that may represent microhemorrhage and/or mineralization. There is abnormal T2 hyperintensity involving the bilateral frontal, left greater than right temporal and right parietal white matter, which is difficult to evaluate due to brain compression by ventriculomegaly. No conspicuous associated volume loss is appreciated in these areas.There is abnormal T2 hyperintensity within the right cerebellum, with associated probable minimal leptomeningeal enhancement along the right cerebellar folia. This is best appreciated on the sagittal postcontrast images of the cervical spine. There is thick leptomeningeal enhancement involving the basal cisterns and along the brainstem, with prominent prepontine cistern collection. A rim enhancing collection measures approximately 25 x 10 mm, restricts diffusion and is contiguous with the dilated fourth ventricle. This collection arises just distal to the foramina of Luschka/Magendie, displaces the compressed brainstem ventrally and displaces the cerebellum superiorly. The major cerebral flow voids are intact. There is bilateral enophthalmos. There is no evidence of fracture.There is thick diffuse leptomeningeal enhancement along the entire visualized spinal cord down to at least T6, with visible extension the dorsal nerve roots especially on the upper thoracic levels. The spinal cord appears mildly expanded with abnormal diffuse central T2 hyperintense signal extending from the craniocervical junction to C5. There is heterogeneous signal throughout the subarachnoid space diffusely along the visualized spinal canal. There is focal prominence of the epidural space at C2-3 with abnormal T2 hypointense signal, although this is favored to represent engorged venous structures rather than a true epidural collection.Normal alignment of the cervical spine is maintained. The airway remains patent. The major cervical vessels are patent. There is no suspicious osseous lesion.
1.Diffuse ependymal enhancement. Thick leptomeningeal enhancement along the basal cisterns, brainstem, possibly the right cerebellar folia and along the entire visualized spinal cord down to the C6 level. Findings are most consistent with diffuse likely chronic meningitis and ventriculitis, palpable with gram-negative rods resulting from lumbar puncture. If clinically indicated, additional MR imaging of the remaining thoracic and lumbar spine may be helpful.2.Left lateral parietal epidural abscess/empyema with localized mass effect.3.Additional non-diffusion restricting peripherally enhancing collections emanating from the fourth ventricular outflow, contributing to compression of the upper cervical spinal cord and brainstem. 4.T2 hyperintense signal within a mildly expanded cord at C2-C5. Differential diagnosis includes infection/inflammation, versus less likely ischemic or demyelinating etiologies.5.Severe ventriculomegaly with layering debris demonstrating associated restricted diffusion, compatible with pus. Findings may represent a combination of obstructive and nonobstructive chronic hydrocephalus, as there is no significant transependymal edema.6.Scattered foci of susceptibility, most conspicuous in the region of the bilateral caudothalamic grooves and right cerebellum, may represent mineralization versus microhemorrhage.7.Areas of vasogenic pattern of T2 hyperintensity involving scattered cerebral white matter, which may represent a combination of gliosis and/or edema. More focal abnormal signal and the right cerebellum may represent additional parenchymal infection/inflammation associated given associated mild leptomeningeal enhancement.8.Probable enophthalmos, correlate clinically.Findings discussed with Dr. Lander at 8:30 AM on 10/18/2016.