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Hydrocephalus secondary to meningitis and cerebellitis

Case Study
Truwit, Chip, MD, FACR Hennepin County Medical Center • USA

Patient history

A 21-year-old man with a history of seizures presented with headache and fevers. A prior study performed at 1.5T (at an outside institution) was unremarkable. At the time of presentation, he underwent MR imaging at Hennepin County Medical Center. A few months later, a follow-up exam was done.

MR examination

At the time of presentation, MR imaging was performed on an Ingenia 3.0T.
The follow-up exam a few months later was performed on an Achieva 1.5T system that was upgraded with SmartPath to dStream.

Images

Click on an image to enlarge.
T1W 5 months prior
T1W
5 months prior
TSE FLAIR pre-contrast Ingenia 3.0TT1W TFE post-contrast Ingenia 3.0T
TSE FLAIR pre-contrast
T1W TFE post-contrast
Ingenia 3.0T
Ingenia 3.0T
DWI Follow-up<br>
Achieva 1.5T dStreamT1W post contrast Follow-up<br>
Achieva 1.5T dStream
DWI
T1W post contrast
Follow-up
Achieva 1.5T dStream
Follow-up
Achieva 1.5T dStream

 

In the prior study the sagittal T1-weighted image reveals normal appearance of the posterior fossa and fourth ventricle. In particular, the cerebellar tonsils are in the normal location.

 

At the time of presentation, the sagittal reconstruction from 3D TSE FLAIR sequence shows dramatic signal and morphologic changes involving the posterior fossa and cervical spinal cord. The patient has already undergone ventriculostomy placement for acute hydrocephalus. The sagittal contrastenhanced T1-weighted gradient echo image shows avid leptomeningeal enhancement.

 

The follow-up exam on the Achieva 1.5T dStream system shows persistent diffusion restriction and meningeal enhancement. The sagittal contrast-enhanced T1-weighted gradient echo image shows avid leptomeningeal enhancement and tonsillar herniation. The axial diffusion weighted image shows persistent restricted diffusion of inferior cerebellar cortices, a consequence of meningitis and downward compressive forces secondary to acute hydrocephalus. While the continued contrast enhancement was not surprising, the MR images obtained in this patient revealed persistent findings on the DWI, presumably reflecting ongoing cerebellitis, either infectious, traumatic (compressive), or both.

Diagnosis

Diagnosis was acute hydrocephalus secondary to meningitis and cerebellitis.

 

Follow-up MR images obtained in this patient revealed persistent findings on the DWI, presumably reflecting ongoing cerebellitis, either infectious, traumatic (compressive), or both. In any event, recovery has been very slow, as patient continues to be encephalopathic. Cerebellar tonsils continue to show downward herniation through the foramen magnum.

Clinical impact

While 3.0T imaging is excellent, in reality these dStream 1.5T images are essentially comparable and clearly confirm the ongoing pathology.
 

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Jul 25, 2014

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Case Study
Achieva 1.5T dStream, Ingenia 3.0T
dStream, Head, hydrocephalus, meningitis, Neuro, SmartPath to dStream
 

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