Wk 7, Case 3 - Review

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Report

Patient History
45-year-old male with a history of alcohol abuse who presents with dizziness, unsteadiness, left facial numbness, fever and diplopia.

Findings
MRI brain:

There is markedly abnormal FLAIR hyperintensity throughout the pons involving principally the lateral ventral and dorsal pons as well as the lateral pons sparing the extreme dorsal aspect of the pons and extending minimally into the left middle cerebellar peduncle and rostrally into the caudal aspect of the central midbrain. There is subtle enhancement within this region particularly on post contrast coronal imaging (which is not as well visualized on axial postcontrast imaging performed immediately previously which could be on the basis of enhancement kinetics and/or minimal difference in technique). There is a suggestion of subtle leptomeningeal enhancement over the ventral aspect of the medulla for instance on image 10 series 45.

No evidence of enhancement within the mammillary bodies or thalami and findings would be atypical for Wernicke Encephalopathy in the setting of alcohol usage. The region of involvement is not entirely typical of osmotic demyelination, there is no significant restricted diffusion and enhancement would also be atypical. Findings would not be typical for neoplasia.

Orbits normal in appearance. Large right maxillary sinus mucous retention cyst. Trace mucosal thickening of the left maxillary sinus and ethmoid air cells. Remaining paranasal sinuses are clear. Mastoid air cells clear.

Impressions
1. Findings are most suggestive of infectious inflammatory processes with rhombencephalitis, favor Listeria. CSF sampling may be instructive if not already performed.

2. Scattered foci of T2/FLAIR signal hyperintensities in the periventricular and subcortical white matter, which is nonspecific and may be related to prior infectious/inflammatory processes, microvascular ischemic disease, or migraines.

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 7, Case 3 - Review