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 [1-3]. 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.
| Original language | English |
|---|---|
| Pages (from-to) | 101-110 |
| Number of pages | 10 |
| Journal | Case Reports in Neurology |
| Volume | 2 |
| Issue number | 2 |
| DOIs | |
| State | Published - May 1 2010 |
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Keywords
- Brainstem stroke
- Diffusion weighted imaging
- Extra-axial
- Magnetic resonance imaging
- Meningitis
- MRSA
- Vasculitis
ASJC Scopus subject areas
- Clinical Neurology
Cite this
Restricted diffusion of pus in the subarachnoid space : MRSA meningo-vasculitis and progressive brainstem ischemic strokes - A case report. / Rose, David Z.; Parra-Herran, Carlos; Petito, Carol; Judith Post, M.
In: Case Reports in Neurology, Vol. 2, No. 2, 01.05.2010, p. 101-110.Research output: Contribution to journal › Article
}
TY - JOUR
T1 - Restricted diffusion of pus in the subarachnoid space
T2 - MRSA meningo-vasculitis and progressive brainstem ischemic strokes - A case report
AU - Rose, David Z.
AU - Parra-Herran, Carlos
AU - Petito, Carol
AU - Judith Post, M.
PY - 2010/5/1
Y1 - 2010/5/1
N2 - 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 [1-3]. 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.
AB - 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 [1-3]. 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.
KW - Brainstem stroke
KW - Diffusion weighted imaging
KW - Extra-axial
KW - Magnetic resonance imaging
KW - Meningitis
KW - MRSA
KW - Vasculitis
UR - http://www.scopus.com/inward/record.url?scp=78650633332&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=78650633332&partnerID=8YFLogxK
U2 - 10.1159/000319691
DO - 10.1159/000319691
M3 - Article
AN - SCOPUS:78650633332
VL - 2
SP - 101
EP - 110
JO - Case Reports in Neurology
JF - Case Reports in Neurology
SN - 1662-680X
IS - 2
ER -