Wk 10, Case 4 - Review

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Report

Patient History
67 year old man with history of CAD (status post-CABG), PAD, HTN, HLD, alcoholic liver disease, referred for TEE with a 1.6 cm mobile echogenic mass on the atrial aspect of the posterior mitral annulus, presents with fever and confusion.

Findings
These images demonstrate a small focus of restricted diffusion along the prefrontal cortex on the right side measuring approximately 6 mm.

Additional foci of restricted diffusion are present in the medial aspect of the frontal lobes bilaterally as well as the prefrontal cortex of the left frontal lobe. Additional punctate areas of restricted diffusion are present in the left caudate, periinsular region and occipital lobes. There is high signal intensity material also layering in the lateral ventricles and fourth ventricle, likely purulent material. Small punctate areas of restricted diffusion are also found in the cerebellum.

The FLAIR scans show periventricular white matter high signal intensity as well as ventricular enlargement. There are subinsular high signal intensity as well. Punctate areas of high signal intensity are present in the pons.

Both vertebral arteries, the basilar artery and both carotid arteries are patent.

No abnormal parenchymal or meningeal enhancement on the followup images from the next day.

Impressions
Multifocal punctate areas of restricted diffusion in multiple vascular distributions likely a manifestation of the patient's known endocarditis with embolic infarctions.

The high signal intensity on the diffusion-weighted scans of the ventricles suggesting purulent material likely from meningitis.

Case Discussion

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Joshua P Nickerson, MD

Associate Professor of Neuroradiology

Oregon Health & Science University

Francis Deng, MD

Assistant Professor of Radiology and Radiological Science

Johns Hopkins University School of Medicine

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Wk 10, Case 4 - Review