Reason: evaluate for etiology of L diplopia and EOM abnormalities in patient w/ history of ALL in remission. Relapsed disease vs. Infection History: L diplopia and EOM abnormalities There is mild prominence of the cortical sulci in proportion to the cerebral ventricles consistent with mild diffuse global volume loss. Extensive confluent T2/FLAIR hyperintensity is demonstrated in the periventricular and subcortical white matter as well as the infratentorial white matter, significantly increased since prior exam. There is no midline shift or mass effect appreciated. There is no diffusion restriction to suggest acute ischemia. No intracranial hemorrhage is identified. No abnormal parenchymal postcontrast enhancement is identified. Minimal mucosal thickening of the ethmoid air cells is seen. There is a nonspecific 7 mm area of nodular enhancement involving the anterior frontal scalp.There is a flattening deformity of the posterior globes, right greater than left, new since July 20, 2013. The bilateral optic nerves appeared tortuous with fluid distention of the optic nerve sheaths. Small area of enhancement is demonstrated involving the optic discs bilaterally, more conspicuous on the right. There is no definite associated diffusion restriction. There is no empty sella.Although the cranial nerves are suboptimally evaluated by this technique, there appears to be symmetric facial nerve enhancement along the distal canalicular segments within the fundus of the IACs, as well as asymmetric discontinuous enhancement involving the tympanic to mastoid segments, greater on the right side with perhaps mild nerve thickening distally on the right. There is also enhancement of the cisternal sixth cranial nerves. Additionally, there appears to be a small area of enhancement in the expected location of the left cranial nerve III origin, along the medial left cerebral peduncle. A persistent left trigeminal artery is incidentally noted.
1. Elevation of the optic nerve heads with associated punctate enhancement and tortuosity of the optic nerves with fluid distension of the sheaths, suggestive of papilledema and likely increased intracranial pressure. No definite empty sella, which can be seen with pseudotumor cerebri. Recommend correlation with ophthalmologic examination and lumbar puncture/opening pressure.2. There appears to be abnormal enhancement involving the bilateral sixth and seventh as well as possibly the origin of the left third cranial nerve. Further evaluation with cranial nerve protocol MRI of the brain/skull base, with and without contrast is recommended. No other leptomeningeal enhancement seen.3. Confluent T2/FLAIR hyperintensity involving the supratentorial and infratentorial white matter may be related to progressed leukoencephalopathy from prior reported prior treatment, including methotrexate.4. There is a nonspecific 7 mm nodular area of enhancement involving the anterior frontal scalp. Please correlate with physical exam.Findings were reported to Dr. Kelsey Reno on 10/1/2016 at 4:11 PM