070904 MESENCEPHALIC CLEFT AND SUSPICIOUS MENINGITIS

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070904 MESENCEPHALIC CLEFT AND SUSPICIOUS MENINGITIS

Contributed by: pedrad CSH, Radiologist, Chung Shan Medical University Hospital, Taiwan.

Patient: 6 year old male

History: Seizure and persistent loss conscious
Leucocytopenia (WBC: 5050/mm3, Band:52%, Seg:30%, Lympho:12%)
Thrombocytopenia (56000/mm3)

Images:

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Fig. 1: short inversion time inversion recovery echo train spin echo (STIR)_axi


Fig. 2: short inversion time inversion recovery echo train spin echo (STIR)_axi


Fig. 3: Sagittal


Fig. 4: pre- and post- intravenous gadolinium-enhancement


Fig. 5: pre- and post- intravenous gadolinium-enhancement


Fig. 6: MR diffusion imaging (DWI)_1


Fig. 7: MR diffusion imaging (DWI)_2


Fig. 8: MR diffusion imaging (ADC)_1


Fig. 9: MR diffusion imaging (ADC)_2


Fig. 10: MR diffusion imaging (DWI and ADC)


Fig. 11: single voxel proton MR spectroscopy

Findings:

MRI of brain with T1 weighted echo train spin echo, T2 weighted
echo train spin echo, fluid-attenuated inversion recovery echo
train spin echo, short inversion time inversion recovery echo
train spin echo, MR diffusion imaging, single voxel proton MR
spectroscopy, and with intravenous gadolinium-enhancement:

1. A midline cleft in narrowed midbrain, extending from
   interpeduncular cistern to aqueduct (fig1 and arrows in fig2),
   and incomplete separation between midbrain and thalamus (fig3),
   in favor of mesencephalic cleft, possibly due to congenital
   abnormal development.
2. Mild but diffuse enhancement of leptomeninx around bilateral
   cerebral hemispheres, predominant over suprasellar cistern
   (fig5), interpeduncular cistern (fig4), and ambient cistern,
   infectious process such as tuberculous meningitis may be first
   considered.
3. Diffused gyriform distribution of restricted water diffusibility
   in gray-white matter interfaces of bilateral cerebral
   hemispheres (fig6-10) without contrast enhancement, and
   preservation of bilateral corpus striatum, suggesting diffused
   cytotoxic edema, possibly due to diffuse cerebritis, but toxic,
   metabolic brain disorder, or during/immediately after severe
   seizure can not be excluded.
   Presence of relative effacement of bilateral cortical sulci.
4. Reduced NAA [N-acetylaspartate (NAA)/total Creatine (Cr)= 0.92
   ], elevated choline [choline (Cho)/total Creatine (Cr)= 1.47],
   and presence of abnormal peak of lactate (fig11), sampling
   randomly from right posterior temporal lobe, suggesting neuronal
   damage and increased anaerobic glycolysis.

Impression:
1. Mesencephalic cleft, possibly due to congenital abnormality.
2. Leptomeningeal enhancement, suspicious meningitis.
3. Diffused cytotoxic edema, neuronal damage, and increased
anaerobic glycolysis in bilateral cerebral hemispheres,
nature to be determined.

Diagnosis: Mesencephalic cleft and suspicious meningitis.

Discussion: Poor prognosis of the patient with bilateral pupil dilatation until now

Comments:

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Additional Details:

Case Number: 10790002Last Updated: 09-10-2007
Anatomy: Cranium and Contents Pathology: Congenital
Modality: MRAccess Level: Readable by all users
Keywords: mesencephalic, cleft, meningitis, diffusion, spectroscopy, midbrain, leptomeninx, lactate, anaerobic, glycolysisACR: 146.1499

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