Meningitis from mastoiditis resulting in death

Case contributed by Frank Gaillard


Altered conscious state requiring intubation.

Patient Data

Age: 25 years
Gender: Male

The patient is intubated with a nasogastric tube in situ. There is complete opacification of the middle ear and mastoid air cells on the right. Mucosal thickening in the right maxillary antrum.

Non-contrast CT of the brain demonstrates a thin subdural CSF density collection over the right hemisphere. The temporal horns are prominent for a 25-year-old. No other focal abnormality. 

Extensive cerebral swelling has developed. The temporal lobes appear low density, contributed by beam hardening through the base of skull.

The subdural collection is no longer visible but there appear to be hyperdense foci. Whether these represent areas of hemorrhage or perhaps prominent (potentially thrombosed) cortical veins is unclear.

There is extensive abnormal sulcal signal on FLAIR and multiple areas of high signal on DWI consistent with areas of infarction. Additionally, there is extensive extra-axial diffusion restriction, particularly over the convexity of the brain, as well as pooling in the occipital horns.

Uncal herniation is present.


The features are those of meningitis with cerebral edema and multifocal infarction.

The patient continued to deteriorate with clinical features of brain death developing. A catheter angiogram was requested to confirm this.

A four-vessel angiogram (bilateral common carotid and bilateral vertebral artery injections) demonstrates no cerebral parenchymal perfusion.

The vertebral arteries (left frontal, right lateral) before entering the dura, only giving off small radicular and muscular branches.

Similarly, common carotid artery injections only opacify external carotid artery branches. The internal carotid artery tapers to occlusion in the cervical portion with no contrast seen in the supraclinoid portion or any of the terminal branches.

Note, a retinal blush is seen late in the run. This is probably due to meningeal collaterals. However, even if this is from the internal carotid artery, as the orbit is extradural, this finding does not preclude the diagnosis of br

Case Discussion

The formal diagnosis of brain death is usually clinical, however, ancillary imaging tests can be requested. Catheter angiography is the gold standard.

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