Presentation
Out-patient head CT scan was performed as a 6 month screening follow-up after left anterior cerebral artery aneurysm surgical clipping. Patient has a past medical history of coccidioidal meningitis, three cerebrovascular accidents within the past year, and hydrocephalus status post craniotomy and VP shunt placement. Patient did not present with any acute symptoms.
Patient Data
Extensive hyperdense subarachnoid material consistent with granulomatous meningitis. Associated remote bilateral basal ganglia and left thalamic infarcts. With post-surgical changes related to A1/A2 aneurysm clipping. Stable right parietal approach ventricular shunt catheter with stable mild ventricular prominence.
Diffuse leptomeningeal disease suggestive of granulomatous/fungal meningitis. Redemonstration of right posterolateral basal ganglia infarct, left basal ganglia infarct, left thalamus and right caudate head infarcts, and small left anterior cerebral artery aneurysm clipp.
In addition to the MRI study taken six months prior that showed the classic finding of leptomeningeal enhancement consistent with granulomatous meningitis, the patient had elevated CSF protein, and the patient underwent a broncho-alveolar lavage that demonstrated spherules and filamentous material consistent with a coccidioidal infection.
Case Discussion
In the context of a recent anterior cerebral aneurysm surgical clipping, the hyperdense material occupying the basal cisterns and sylvian fissures were concerning for subarachnoid hemorrhage. However, upon further investigation the hazy appearance of the borders of enhancement were not consistent with subarachnoid hemorrhage and raised suspicion for persistent changes due to known coccidioidal meningitis. In addition to the stable presentation of the patient, MRI taken six months prior showing leptomeningeal enhancement, and positive broncho-alveolar lavage for spherules consistent with coccidioidal infection, the hyper-dense material was concluded to be consistent with granulomatous meningitis.
Coccidioidal meningitis is a rare complication of coccidioidal infection resulting in hematogenous spread from a primary pulmonary infection1. 30-50% of cases will be complicated by hydrocephalus. Other complications include cerebrovascular accidents due to vasculitis, and subarachnoid hemorrhage2-4.
Nonspecific imaging findings that can appear on CT or MRI include hydrocephalus, basilar enhancement, and cerebral infarcts. However, MRI is the preferred modality. The classic finding on MRI is leptomeningeal enhancement that can be either diffuse or localized to the basal cisterns2-4.
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