case_images: PMC11097696_01
case_images: Multi-planar multi-sequential MRI Brain with and without contrast. Diffusion Weighted Image (DWI, A and C) and Apparent Diffusion Coefficient sequences (ADC, B and D) demonstrate multiple areas of restricted diffusion predominantly in the bilateral basal ganglia and thalami (arrows on A and B) and in the brainstem (arrows on C and D), consistent with acute infarcts. Prominent leptomeningeal enhancement in the basal cisterns on post-contrast T1WI (arrow E).
case_images: 10.1177_2329048X241227341-fig1.jpg
case_images: PMC11097696_01_10.1177_2329048X241227341-fig1.jpg
case_images: fig1-2329048X241227341
case_images: On the second day of hospitalization, brain MRI with and without contrast revealed multiple acute infarcts; with minimal enhancement in the bilateral basal ganglia, thalami, and brainstem; and prominent leptomeningeal enhancement in the basal cisterns, concerning for intracranial infection (Figure 1).
case_images: Follow up Fast T2 MRI Brain without contrast. DWI (A) and ADC (B) through basal ganglia demonstrate increased areas of restricted diffusion in the bilateral basal ganglia and thalami (arrows), consistent with increasing acute infarcts. There is corresponding edema on TWI (C). DWI (C) and ADC (D) through brainstem demonstrate Increasing infarcts in the brainstem (short arrows on D and E) and new right cerebellar infarct (long arrows on D and E).
case_images: 10.1177_2329048X241227341-fig2.jpg
case_images: PMC11097696_01_10.1177_2329048X241227341-fig2.jpg
case_images: fig2-2329048X241227341
case_images: Three days later, the patient was noted to have asymmetric pupils and an urgently performed fast T2 brain MRI demonstrated dilation of the lateral ventricles and increased acute infarcts in the bilateral cerebral hemispheres, gangliocapsular regions, thalami, upper brainstem, and cerebellar regions (Figure 2).
case_images: Follow up multi-planar, multi-sequence MRI Brain with and without contrast. DWI (A and B) and ADC images (C) demonstrate infarcts in the bilateral basal ganglia and thalami (A) and new large acute infarcts in the bilateral cerebellar hemispheres (arrows on B and C) with significant mass effect. Axial T1 WI post-contrast images through the basal ganglia (D) and through the basal cisterns (E) show extensive areas of parenchymal, leptomeningeal and pachymeningeal enhancement (arrows) and obstructive hydrocephalus (asterisks).
case_images: 10.1177_2329048X241227341-fig3.jpg
case_images: PMC11097696_01_10.1177_2329048X241227341-fig3.jpg
case_images: fig3-2329048X241227341
case_images: Additionally, progression of the meningitis was observed with extension of parenchymal, leptomeningeal, and pachymeningeal enhancement (Figure 3).