Reason: 39 y/o male with a PMHx of melanoma, coming in with severe right sided headache and c/f bell's palsy vs. Other autoimmune etiology vs. Clot vs. vasculitis. Need to eval History: headache, bell's palsy. MRIThere are prominent linear branching pattern enhancement on bilateral centrum semiovale, periventricular white matter and basal ganglia indicating enhancement of vascular structures such as medullary veins. These findings suggest possible generalized inflammatory process. However, there is no nodular or mass like enhancement on brain parenchyme, nor dural enhancement.The right side internal auditory canal especially right facial nerve shows enhancement. Bilateral oculomotor nerves and trigeminal nerves also show diffuse enlargement and enhancement. The left cerebellar hemisphere especially anterior superior folia shows linear and gyral pattern enhancement.There are several hyperintense foci seen on FLAIR images, which are nonspecific. There is no evidence of acute ischemic or hemorrhagic lesion on this scan.There is well marginated, smooth and confined enhancing pineal gland lesion which likely represent pineal cyst.Ventricles and sulci are normal in size. The cerebellar tonsils are in normal position. The pituitary gland is normal in size. There is no evidence for intracranial hemorrhage or acute cerebral, brainstem or cerebellar infarction. No diffusion-weighted abnormalities are identified. There are no extraaxial fluid collections or subdural hematomas. Flow voids are present within the major vessels indicating patency. The paranasal sinuses and mastoid air cells are clear. MRVSuperficial and deep venous drainage system appear to be normal. In particular, the superior sagittal sinus, inferior sagittal sinus, transverse sinuses, sigmoid sinuses, straight sinus, vein of Galen, internal cerebral veins, and several visualized cortical veins are patent. There is no evidence of venous thrombosis.IACThere is abnormal asymmetric enhancement of the right proximal cranial nerve VII especially meatal segment. In addition, the right facial nerve's labyrinthine segment including the right geniculate ganglion, and mastoid segment show asymmetric enhancement. There is also bilateral enhancement of cranial nerve III and the V2 segments of the trigeminal nerves. Especially for bilateral extending into the foramen ovale and an additional enhancing focus within the left cerebellar folia. The trigeminal nerves are abnormally thickened bilaterally.Lower cranial nerves also show subtle enhancement but did not show evidence of thickening. The brainstem, cerebellum, vermis and tonsils are normal. The inner ear structures, cochlea, vestibule, semicircular labyrinth are normal. This constellation of findings including prominent small vascular enhancement on bilateral deep white matter (possible medullary veins enhancements), leptomeningeal enhancement (cerebellar folia enhancement) and multifocal cranial nerve enhancements are non specific thus differential diagnosis include neoplastic process such as leptomeningeal metastasis from the patient's known melanoma, inflammatory or immunologic responses due to immuno/chemotherapeutic agents such as Ipilimumab usage, other granulomatous lesions such as sarcoidosis or tuberculosis or combined neoplastic (leptomeningeal carcinomatosis) and associated meningitis.
1. No evidence of acute ischemia, hemorrhage, mass effect, or edema.2. Multifocal cranial nerves and leptomeningeal enhancements, differential diagnosis include leptomeningeal carcinomatosis, inflammatory or immune response due to immuno/chemotherapy such as Ipilimumab use, granulomatous disease such as sarcoidosis or combined leptomeningeal carcinomatosis and leptomeningitis. 3. Normal brain MR venogram.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.