Cryptococcal Meningitis

Findings:

The ventricular system is dilated. Abnormal FLAIR hyperintensity involves the subarachnoid spaces, with patchy areas of leptomeningeal enhancement. A small focus of superimposed hemorrhagic change is present in the left frontal lobe with abnormal enhancement. Confluent FLAIR signal alteration extends in both frontal lobes and periatrial regions. The subarachnoid spaces along the sylvian fissures demonstrate a lobulated loculated appearance.

Differential Diagnosis/Discussion:

The differential diagnosis for leptomeningeal disease is fairly broad, but in the absence of subarachnoid hemorrhage is likely due to infectious/inflammatory process or neoplasm. Grapelike loculations of CSF space may be seen with cryptococcal meningitis, not necessarily specific for this diagnosis. It is also important to know your scanner since symmetric hyperintensity in the subarachnoid spaces may be seen in normal patients and/or those being examined under anesthesia, more accentuated in some types of MRI scanners than others. Asymmetric leptomeningeal FLAIR hyperintensity as in this case is nearly always abnormal.

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