Acute on chronic liver failure and respiratory failure requiring mechanical ventilation with progressive development of ARDS in setting of parainfluenza infection with likely secondary Aspergillus and MSSA pneumonia and probable cystic fibrosis. There appear to be two contiguous lesions in the right occipital lobe with peripheral T1 hyperintensity and extensive susceptibility effect and central restricted diffusion, the largest of which measures up to approximately 25 mm. There is surrounding vasogenic edema and overlying sulcal T2 hyperintensity and enhancement. In addition, there are punctate (1 to 3 mm diameter) enhancing lesions in the left frontal lobe periventricular white matter and in the grey-white matter junctions of the left postcentral gyrus, left inferior parietal lobule, and right middle frontal gyrus. There are punctate foci of susceptibility effect in the left cerebellar hemisphere. There is no evidence of acute infarct. There is no midline shift or herniation. The ventricles are unchanged in size and configuration. The major cerebral flow voids are intact. There is fluid signal in the bilateral mastoid air cells. There is diffuse mucosal thickening and enhancement, as well as secretions within the pneumatized portions of the paranasal sinuses. There is a partially-imaged right nasoenteric tube. The orbits, skull, and scalp soft tissues are grossly unremarkable.
1. The lesions in the right occipital lobe may represent abscess, either pyogenic or fungal, with superimposed hemorrhage and regional cerebritis and meningitis and/or superimposed subarachnoid hemorrhage. Metastatic disease is nevertheless an imaging differential consideration.2. A few scattered punctate enhancing lesions in the bilateral cerebral hemispheres may represent septic emboli. Similarly, punctate foci of susceptibility effect in the left cerebellar hemisphere may represent hemorrhagic microabscesses or chronic aseptic microhemorrhages related to the underlying coagulopathy. Metastatic disease is nevertheless an imaging differential consideration.3. Apparent inflammatory changes in the paranasal sinuses are suggestive of acute sinusitis, perhaps related to cystic fibrosis.4. Effusions within the bilateral mastoid air cells may represent mastoiditis or may be related to intubation.