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Restricted Diffusion of Pus in the Subarachnoid Space: MRSA Meningo-Vasculitis and Progressive Brainstem Ischemic Strokes - A Case Report.

Rose DZ, Parra-Herran C, Petito CK, Post MJ - Case Rep Neurol (2010)

Bottom Line: The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care.Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation.This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space - a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Fla., USA.

ABSTRACT
Extra-axial restriction on diffusion weighted imaging (DWI) is an unusual finding on brain magnetic resonance imaging (MRI). Intra-axial restriction on DWI, however, is common, and can represent brain parenchymal infarction, tumor, abscess, or toxic-metabolic process. The infrequency of extra-axial DWI restriction and the paucity of clinico-pathological correlation in the literature limit its differential diagnosis. Scant case reports suggest that extra-axial DWI restriction could be a lymphoma, neurenteric cyst, or, in one patient, subdural empyema [1,2,3]. We postulate that pus formation must be excluded first, because it can provoke an aggressive meningo-vasculitis with rapidly fatal, intra-axial infarctions. Our patient was a 45-year-old man, presenting to our hospital with left facial droop and right (contralateral) arm and leg weakness. Initial MRI revealed DWI restriction in the left lateral pons, consistent with a classic Millard-Gubler stroke. Also noted was a subtle, extra-axial area of curvilinear diffusion restriction in the left cerebellar-pontine angle's subarachnoid space. Days later, the patient had a headache, and repeat MRI revealed extension of the two DWI lesions - both the intra-axial pontine infarction and the extra-axial area of restricted diffusion in the subarachnoid space. The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care. Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation. This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space - a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions.

No MeSH data available.


Related in: MedlinePlus

Repeat MRI (top panel) revealed fourth ventricle effacement and infarct extension into the brainstem and cerebellum on FLAIR (left) and DWI (right). On this same MRI (bottom panel), the previously subtle cerebello-pontine angle signal has increased in size on FLAIR (upper left), T1 (upper right), DWI (lower left) and ADC (lower right).
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Figure 2: Repeat MRI (top panel) revealed fourth ventricle effacement and infarct extension into the brainstem and cerebellum on FLAIR (left) and DWI (right). On this same MRI (bottom panel), the previously subtle cerebello-pontine angle signal has increased in size on FLAIR (upper left), T1 (upper right), DWI (lower left) and ADC (lower right).

Mentions: A second MRI of his brain (fig. 2, top) showed extension of intra-axial FLAIR signal hyperintensities with diffusion restriction now seen in the bilateral pons and left cerebellum, indicating both new and exacerbating cerebral infarctions. The more caudal subarachnoid space DWI restriction (fig. 2, bottom) was no longer subtle – increasing in size and expanding more curvilinearly into the left posterior fossa. Communicating hydrocephalus developed, with effacement of the fourth ventricle, dilation of the lateral and third ventricles, and CSF trans-exudation. Another lumbar puncture was performed and it revealed 4 red blood cells, 112 white blood cells (74% neutrophils), glucose of 130, and protein of 2,126. High-dose, broad-spectrum antibiotics (vancomycin, ceftriaxone, and ampicillin) were utilized, along with aggressive intravenous fluids, pressor agents, ventriculostomy, and other supportive care measures. Nevertheless, the patient continued to deteriorate and became comatose. A third and final MRI of his brain was performed (fig. 3) which showed marked diffusion restriction and hyperintense FLAIR signals that had spread from the initial extra-axial area into the brainstem parenchyma, encompassing the entire pons, medulla, and left cerebellum. The repeat MRA revealed irregularity and narrowing of the entire vertebro-basilar circulation, including lack of flow-related enhancement in the left vertebral artery and portions of both posterior cerebral arteries (fig. 4b). The patient soon expired.


Restricted Diffusion of Pus in the Subarachnoid Space: MRSA Meningo-Vasculitis and Progressive Brainstem Ischemic Strokes - A Case Report.

Rose DZ, Parra-Herran C, Petito CK, Post MJ - Case Rep Neurol (2010)

Repeat MRI (top panel) revealed fourth ventricle effacement and infarct extension into the brainstem and cerebellum on FLAIR (left) and DWI (right). On this same MRI (bottom panel), the previously subtle cerebello-pontine angle signal has increased in size on FLAIR (upper left), T1 (upper right), DWI (lower left) and ADC (lower right).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC2968771&req=5

Figure 2: Repeat MRI (top panel) revealed fourth ventricle effacement and infarct extension into the brainstem and cerebellum on FLAIR (left) and DWI (right). On this same MRI (bottom panel), the previously subtle cerebello-pontine angle signal has increased in size on FLAIR (upper left), T1 (upper right), DWI (lower left) and ADC (lower right).
Mentions: A second MRI of his brain (fig. 2, top) showed extension of intra-axial FLAIR signal hyperintensities with diffusion restriction now seen in the bilateral pons and left cerebellum, indicating both new and exacerbating cerebral infarctions. The more caudal subarachnoid space DWI restriction (fig. 2, bottom) was no longer subtle – increasing in size and expanding more curvilinearly into the left posterior fossa. Communicating hydrocephalus developed, with effacement of the fourth ventricle, dilation of the lateral and third ventricles, and CSF trans-exudation. Another lumbar puncture was performed and it revealed 4 red blood cells, 112 white blood cells (74% neutrophils), glucose of 130, and protein of 2,126. High-dose, broad-spectrum antibiotics (vancomycin, ceftriaxone, and ampicillin) were utilized, along with aggressive intravenous fluids, pressor agents, ventriculostomy, and other supportive care measures. Nevertheless, the patient continued to deteriorate and became comatose. A third and final MRI of his brain was performed (fig. 3) which showed marked diffusion restriction and hyperintense FLAIR signals that had spread from the initial extra-axial area into the brainstem parenchyma, encompassing the entire pons, medulla, and left cerebellum. The repeat MRA revealed irregularity and narrowing of the entire vertebro-basilar circulation, including lack of flow-related enhancement in the left vertebral artery and portions of both posterior cerebral arteries (fig. 4b). The patient soon expired.

Bottom Line: The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care.Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation.This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space - a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Fla., USA.

ABSTRACT
Extra-axial restriction on diffusion weighted imaging (DWI) is an unusual finding on brain magnetic resonance imaging (MRI). Intra-axial restriction on DWI, however, is common, and can represent brain parenchymal infarction, tumor, abscess, or toxic-metabolic process. The infrequency of extra-axial DWI restriction and the paucity of clinico-pathological correlation in the literature limit its differential diagnosis. Scant case reports suggest that extra-axial DWI restriction could be a lymphoma, neurenteric cyst, or, in one patient, subdural empyema [1,2,3]. We postulate that pus formation must be excluded first, because it can provoke an aggressive meningo-vasculitis with rapidly fatal, intra-axial infarctions. Our patient was a 45-year-old man, presenting to our hospital with left facial droop and right (contralateral) arm and leg weakness. Initial MRI revealed DWI restriction in the left lateral pons, consistent with a classic Millard-Gubler stroke. Also noted was a subtle, extra-axial area of curvilinear diffusion restriction in the left cerebellar-pontine angle's subarachnoid space. Days later, the patient had a headache, and repeat MRI revealed extension of the two DWI lesions - both the intra-axial pontine infarction and the extra-axial area of restricted diffusion in the subarachnoid space. The patient became comatose, a third MRI revealed more extensive DWI restrictions, and he expired despite aggressive care. Autopsy revealed massive brainstem infarcts, a thick lymphoplasmacytic infiltrate, copious Gram-Positive cocci (likely MRSA) and arteries partially occluded with fibrointimal proliferation. This emphasizes the concept that extra-axial DWI restriction can represent pus development in the subarachnoid space - a radiographic marker to identify a patient at risk for demise due to septic, meningo-vasculitic infarctions.

No MeSH data available.


Related in: MedlinePlus