Case 41 - Invasive Fungal Sinusitis

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

EXAM: MRI skull base protocol; MRV head with and without intravenous contrast

INDICATION: 64-year-old male with history of diabetes mellitus, hypertension, end-stage liver disease, an angioinvasive fungal osteomyelitis of the skull, who presents with severe hypertension and headache. Evaluate for progression of disease and thrombosis.

TECHNIQUE: Multiplanar multisequence magnetic resonance imaging of the brain was performed (via skull base protocol) with and without intravenous contrast on a 3 Tesla magnet and with injection of 4 cc Gadavist.

COMPARISON: MRI brain 8/10/2020; MRI skull base and MRV head 7/28/2020

FINDINGS:

MRI BRAIN/SKULL BASE:

Postoperative changes related to prior midline partial clivus resection with sinonasal debridement and partial left mastoidectomy.

Stable retroclival dural-based enhancement, as well as soft tissue fullness within the retropharyngeal, paraspinal, and prevertebral soft tissues. Dural based enhancement extends into the left internal auditory canal, axial slice 26-55 for example.

There is also enhancement inferiorly into the prepontine cistern. Asymmetric enhancing tissue within the left hypoglossal canal, axial slice 26-30. Stable anterior extension of enhancement along the left middle cranial fossa and paracavernous region, axial slice 26-61 for example.

There is similar stranding of the retrobulbar fat centered about the optic nerve sheath complex bilaterally without organized fluid collection within either orbit. No intervally developed proptosis.

No areas of restricted diffusion to suggest acute infarct. No acute intracranial hemorrhage or extra-axial fluid collection.

Multiple periventricular and subcortical T2 FLAIR hyperintensities, nonspecific, likely related to chronic microvascular ischemic disease. Additionally, there is stable size and appearance of a T1 and T2 hyperintense, nonenhancing focus within the right globus pallidus, with associated susceptibility artifact, in comparison to prior imaging, likely reflecting mineralization. Gray-white matter differentiation is otherwise preserved.

Age-related global parenchymal volume loss with ventricular and sulci prominence.

Ventricular system appears otherwise unremarkable. Major intracranial flow voids intact.

Mild mucosal thickening of the maxillary sinuses, minimal mucosal thickening within the frontal sinuses, mild to moderate mucosal thickening within the sphenoid sinuses, and mild mucosal thickening of multiple ethmoid air cells.

Complete opacification of the left mastoid air cells; the right mastoid air cells are clear. Redemonstrated dilation of the right greater than left superior ophthalmic vein, slightly more pronounced since 7/28/2020 with similar to 8/10/2020.

Partially visualized cervical spine demonstrates congenital spinal canal stenosis to 9 mm at the level of C2 with mild spinal canal stenosis C2-5.

MRV HEAD:

Stable occlusion of the left mid to distal sigmoid sinus and partially visualized left internal jugular vein. As before, both superior ophthalmic veins appear enlarged right more so than left, and there is similar patchy enhancement within the right cavernous sinus with associated drainage into the right petrosal sinuses. However there remains no convincing enhancement within the left cavernous sinus and left-sided petrosal sinuses, similar to prior MRA 7/28/2020.

The superior sagittal sinus, transverse sinuses, right sigmoid sinus, and proximal right internal jugular vein are patent. Notably, initial MRV series 14 demonstrates mixing artifact within the mid aspect of the right internal jugular vein, which resolves on subsequent series 19.

The internal cerebral veins, basal veins of Rosenthal, vein of Galen, and straight sinus are patent.

IMPRESSION:

1. Extensive soft tissue and dural based enhancement at the level of the skull base, as described above, reflecting sequelae of known osteomyelitis, unchanged in extent in comparison to recent prior imaging.

2. Stable occlusion of the left mid to distal sigmoid sinus and partially visualized left internal jugular vein. There remains no convincing venous enhancement within the left cavernous sinus and left-sided petrosal sinuses, similar to prior MRA

7/28/2020. The major venous structures of the head are otherwise patent without evidence of new thrombus.

3. No acute abnormality of the brain. No acute infarct, new mass, or acute hemorrhage.

4. Similar prominence of the superior ophthalmic veins bilaterally, right more so than left, and probably similar retrobulbar stranding about the optic nerve sheath complex since 7/28/2020, nonspecific in nature, perhaps on the basis of chronic venous congestion centered at the cavernous sinuses.

ADDENDUM:

There is moderate circumferential mucosal thickening involving the left sphenoid sinus as detailed, with opacification of the pneumatized left pterygoid plate. Osteitis of the left sphenoid sinus walls reflective of chronic inflammation. No air-fluid level. There is also osseous thinning and dehiscence of the lateral wall of the left sphenoid sinus which may relate to recurrent, possibly aggressive infection. Appearance is stable dating back to CT from 7/17/2018. No evidence of intracranial extension of infection on this noncontrast MRI, however if clinical concern for this, contrast MRI of the brain could be performed.

######## ORIGINAL REPORT ########

* Outside film interpretation **

MRI BRAIN WO CONTRAST, CT HEAD/BRAIN WO CONTRAST

INDICATION: Migraine without status migrainosus, not intractable, unspecified migraine type. History of prostate cancer, liver disease, and status post kidney transplant.

OUTSIDE FILMS PRESENTED FOR SECOND OPINION INTERPRETATION -

TECHNIQUE: MRI of the brain was performed without intravenous contrast. CT head was performed without intravenous contrast.

COMPARISON: MRI brain of 7/20/2018.

FINDINGS:

MRI brain of 9/7/2018:

Again seen are periventricular and subcortical white matter T2/FLAIR hyperintensities, which are nonspecific; however, most commonly related to chronic microvascular ischemia, and also could be related to migraines. There is mild global parenchymal brain volume loss.

There is no restricted diffusion to suggest acute ischemia. There is no extra-axial fluid collection or hydrocephalus. Major vascular voids are intact.

The temporal lobes and hippocampi are normal and symmetric in appearance. No space occupying mass is identified.

Again seen is mucosal thickening involving the bilateral ethmoid air cells, left sphenoid sinus, and bilateral maxillary sinuses. Opacification of the lateral pterygoid recess is redemonstrated. The mastoid air cells are clear. The orbits are normal.

No aggressive osseous lesion is seen.

CT head of 9/5/2018:

There is no intracranial hemorrhage, extra-axial collection, hydrocephalus, or acute territorial ischemic infarct. There are arteriosclerotic calcifications in bilateral cavernous and supraclinoid segments of internal carotid arteries. There are also atherosclerotic calcifications in bilateral intradural vertebral arteries.

Opacification of the left pterygoid recess is again noted

######## ADDENDUM #1 ########

IMPRESSION:

No acute intracranial abnormality on the MRI brain or CT head. Global volume loss and chronic small vessel ischemic changes, unchanged from the prior 7/20/2018 MRI.