Streptococcus pneumoniae meningitis. Intermittent right-sided ptosis, concerning for abducens nerve palsy, static on the right intermittent on the left, versus abscess. BRAIN MRI:Brain demonstrates no abnormal diffusion restriction or susceptibility effect. There is no contrast-enhancing or other space-occupying brain lesion. The CSF-containing spaces, including the ventricles, are normal in size and there is no abnormal extra-axial fluid collection. On FLAIR sequences, there is incomplete attenuation of the signal from the sulci and interfolial spaces. This is not associated with abnormal contrast enhancement and while this may relate to the known meningitis, it may also in part relate to the patient being sedated and on mechanical ventilation. While this study is not dedicated for cranial nerve assessment, there is suggestion of mild asymmetric fullness and increased T2 signal in the left Meckel's cave, which is associated with mildly increased peripheral contrast enhancement, most prominent on the delayed orbital postcontrast coronal image #10 (of series #2801). However, the cisternal segment of the trigeminal nerves show no abnormal signal/enhancement or thickening. Additionally, there is subtle apparent asymmetric contrast enhancement in the fundus of the right internal auditory canal. This, however, may relate to the increased slice thickness and patient obliquity. These equivocal findings are probably better assessed with follow-up dedicated cranial nerve MRI with contrast.The above-described left Meckel's cave asymmetry is also associated with focal noncontrast enhancement in the left cavernous sinus medial to the internal carotid artery, best seen on the coronal postcontrast fat-saturated T1 sequence of the orbits (series number 2801, image #11). The cavernous segment of the left internal carotid artery is slightly smaller than the right but this is due to developmental variation. Superior ophthalmic veins demonstrate normal flow-voids.Minimal linear contrast enhancement in the right prepontine cistern in expected level of cranial nerve VI is probably related to a vessel, again incompletely assessed.There is fluid signal and peripheral contrast enhancement involving the left mastoid air cells and middle ear cavity. The inferior portion of the opacification is associated with mild diffusion restriction. There is diminutive flow-void associated with the left transverse and sigmoid sinuses. However, this is probably related to a congenital variation of either very small or absent left transverse sinus and subsequently small left sigmoid sinus there are rather than thrombosis. The remainder of the dural venous sinuses demonstrate well visualized flow voids. The major intracranial arterial flow voids are also preserved.The right mastoid air cells are clear. There is mucosal thickening in the paranasal sinuses.ORBITS MRI:There is minimal asymmetric STIR hyperintense edema and contrast enhancement involving the medial right preseptal soft tissues without abscess. This may represent cellulitis but is better assessed clinically. The lateral left preorbital/preseptal soft tissues as well as the left lateral facial soft tissues show mild swelling and contrast enhancement, which can be dependent. There is no intraorbital abnormality or fat stranding. There is no subperiosteal abscess.CERVICAL SPINE MRI:Minimal reversal of the normal cervical lordosis probably related to position. Alignment is otherwise anatomic. Vertebral bodies and intervening discs show normal signal and morphology. There is no spinal canal stenosis. The cervical and included upper thoracic spinal cord shows normal signal and shape.Small lymph nodes are symmetric along both sides of the neck.
1.There is no intracranial abscess. Subtle but apparent asymmetric contrast enhancement and fullness in the left Meckel's cave and questioned in the fundus of the right internal auditory canal are equivocal and incompletely assessed due to lack of thin section dedicated cranial nerve imaging. This could be obtained on follow-up exam as clinically indicated. No overt leptomeningeal enhancement to suggest meningitis, with at most subtle FLAIR hyperintensity within the sulci and along the cerebellar folia which may in part relate to artifact. 2.Mild cavernous sinus asymmetry and focal decreased contrast enhancement in the left cavernous sinus medial to the internal carotid artery is nonspecific, and could represent focal heterogeneity, although clinical correlation is recommended to exclude the possibility of early thrombosis. Superior ophthalmic veins appear within normal limits.3.There is minimal asymmetric swelling and contrast enhancement involving the medial right preorbital/preseptal soft tissue without abscess, most likely representing cellulitis. The lateral left preorbital/preseptal soft tissues as well as the left lateral facial soft tissues show mild swelling and contrast enhancement which could be dependent in nature.4.Severe left mastoid and middle ear opacification with nonspecific enhancement in very minimal diffusion restriction. This is not associated with subperiosteal abscess. Please correlate clinically. Attenuated flow in the left transverse and sigmoid sinuses is almost certainly congenital, rather than from thrombosis related to the presumed mastoiditis.5.There is no cervical spine abnormality.Dr. Monther Qandeel discussed the above findings and recommendations with Dr. Reem Nubani over the phone on January 2, 2016 at 1030 hours. The radiology on-call resident also discussed the findings with the care team at the time of the examination on the day prior.