case_images: PMC11208823_01
case_images: MRI day 1. Vessel wall imaging (axial 3D T1 TSE SPACE Dante) after IV gadolinium administration. (a) There is diffuse supratentorial and infratentorial pathological leptomeningeal contrast enhancement compatible with meningitis. Also note the pathological contrast enhancement of the walls of the cerebral arteries, indicative of associated vasculitis. (b) The cavernous sinus appears thickened on the left side and enhances more heterogeneously, suggestive of inflammation. There is secondary narrowing of the left cavernous carotid artery.
case_images: CRIPE2024-6365796.001.jpg
case_images: PMC11208823_01_CRIPE2024-6365796.001.jpg
case_images: fig1
case_images: The MRI also showed vascular involvement of the left cavernous sinus and the circle of Willis, which resulted in ischemic infarcts most notably in the left middle cerebral artery territory (Figures 1-3).
case_images: MRI day 1. Axial postcontrast T1 TSE SPACE (a), b1000 diffusion-weighted image (b), and ADC map (c). There is a right-sided and an interhemispheric subdural empyema, characterized by pathological pachymeningeal and leptomeningeal contrast enhancement (short arrows), and increased diffusion restriction (long arrows). Also, note the mild hydrocephalus.
case_images: CRIPE2024-6365796.002.jpg
case_images: PMC11208823_01_CRIPE2024-6365796.002.jpg
case_images: fig2
case_images: The MRI also showed vascular involvement of the left cavernous sinus and the circle of Willis, which resulted in ischemic infarcts most notably in the left middle cerebral artery territory (Figures 1-3).
case_images: MRI day 1. Axial maximum intensity projection (MIP) of the 3D time of flight MR angiography (3D TOF MRA) (a) and ADC map at the level of the basal ganglia (b). The left internal carotid artery (long arrows) and proximal middle cerebral artery (short arrows) are narrowed on the 3D TOF MRA MIP reconstruction. There is a secondary ischemic infarct in the left basal ganglia, insular region, and temporal lobe, seen as low signal on the ADC map.
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case_images: PMC11208823_01_CRIPE2024-6365796.003.jpg
case_images: fig3
case_images: The MRI also showed vascular involvement of the left cavernous sinus and the circle of Willis, which resulted in ischemic infarcts most notably in the left middle cerebral artery territory (Figures 1-3).
case_images: Gram stain of the cerebrospinal fluid with multiple Gram-negative bacilli clearly visible.
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case_images: fig4
case_images: The Gram stain of the liquor revealed Gram-negative bacilli (Figure 4) and multiplex PCR meningitis/encephalitis panel that targets 14 of the most common bacterial, viral, and fungal causes were negative.
case_images: Follow-up MRI 18 months later. Vessel wall imaging (axial 3D T1 TSE SPACE Dante) after IV gadolinium administration. The diffuse leptomeningeal contrast enhancement and vessel wall contrast enhancement are no longer visible. There is limited residual contrast enhancement of the cerebellar tentorium (short arrow), and focal cystic encefalomalacia in the left mesial temporal lobe (long arrow) and basal ganglia (not shown) after ischemic infarction.
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case_images: fig5
case_images: Another MRI after 6.5 weeks treatment with intravenous ceftriaxone and metronidazole, showed a minimal right-sided residual empyema in the posterior fossa (Figure 5) and signs of petrous apicitis (mastoiditis of the apex of the os petrosum).