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Published: August 2010

Open Access Gateway

Restricted Diffusion of Pus in the Subarachnoid Space: MRSA Meningo-Vasculitis and Progressive Brainstem Ischemic Strokes – A Case Report

Rose D.Z.a · Parra-Herran C.b · Petito C.K.b · Post M.J.D.c

Author affiliations

Departments of aNeurology, bPathology, and cRadiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Fla., USA

Corresponding Author

David Z. Rose, MD

University of Pennsylvania3 West Gates Building, 3400 Spruce Street

Philadelphia, PA 19104 (USA)

Tel. +1 216 403 1522, Fax +1 215 614 1927, E-Mail dzr3s@aol.com

Related Articles for ""

Case Rep Neurol 2010;2:101–110

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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.

© 2010 S. Karger AG, Basel

Article / Publication Details

First-Page Preview
Abstract of Published: August 2010

Published online: August 07, 2010
Issue release date: May – August

Number of Print Pages: 10
Number of Figures: 6
Number of Tables: 0

eISSN: 1662-680X (Online)

For additional information: http://www.karger.com/CRN

Open Access License / Drug Dosage / Disclaimer

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
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