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Images in Neurology |

Meningococcal Meningitis With Brainstem Infarction

Diederik van de Beek, MD, PhD; Robin Patel, MD; Eelco F. M. Wijdicks, MD, PhD
Arch Neurol. 2007;64(9):1350-1351. doi:10.1001/archneur.64.9.1350.
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A 25-year-old woman was admitted with confusion, headache, and vomiting. Physical examination showed disorientation to time and place, difficulty following commands, and neck stiffness. Lumbar puncture revealed a cerebrospinal fluid (CSF) leukocyte count of 0.674/μL and a low CSF–blood glucose ratio. Ceftriaxone sodium administration was started empirically; CSF cultures grew Neisseria meningitidis. The second day, a sudden respiratory arrest occurred. No seizures were noted. Computed tomography revealed dilatation of the entire ventricular system, indicating communicating hydrocephalus (Figure). A right frontal external ventricular drain was placed for 5 days. The patient's confusion resolved after CSF drainage; however, a mild right hemiparesis and a right-sided Horner syndrome were noticed. Magnetic resonance imaging showed a focal zone of signal abnormality in the right dorsal aspect of the medulla oblongata, which had restricted diffusion, suggestive of cerebral infarction (Figure). Hemiparesis gradually improved over the course of hospitalization, but some numbness of the right hand remained.

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Brain computed tomography (A and B) reveals communicating hydrocephalus with enlargement of the entire ventricular system, including the fourth ventricle. Axial fluid-attenuated inversion recovery–weighted magnetic resonance imaging shows hyperintense signal in the right dorsal part of the medulla oblongata, indicating edema (C) (arrow), and a slightly enlarged ventricular system (external ventricular drain in situ) with infectious debris in the lateral ventricles, suggesting extensive purulence (D) (arrow), and enhancement with gadolinium of the ependymal surface, suggestive of ventriculitis.

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