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Suggest treatment for right-sided pain in head, neck and spine

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Posted on Thu, 14 May 2015
Question: History:
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The patient presented with pain in the right side of his head, neck, shoulder, and spine, increasing in intensity for six weeks. He sought care on discovering a 2 cm (0.8 in) abscess behind his right ear the previous day in one of the most painful areas, of typical mastoiditus appearance, of unknown duration since the area was non-visible and never before examined. Was put on antibiotics APO-AMOXI CLAV 875/125 two a day for ten days.

Patient experienced “increase in energy” two days after start of antibiotics and substantial clearing of abscess within four days. However, he then reported a return of pain, and “clunking” sounds of “the bone settling” in the back right of his head. An MRI was performed, summary results provided below. The Patient is currently at home, stable, however reports feeling “not well”. Question: do the results of the MRI below indicate a need for urgent care?

Procedure:
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Sagittal T1, axial T1, T2, FLAIR, gradient sequence and diffusion weighted imaging was performed of the brain. Sagittal T1, T2 and STIR as well as axial 2D and 3D MEDIC sequences were performed of the cervical spine.

Findings 1:
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The gradient sequence demonstrates a total of 6 small areas of blooming artifact on the axial gradient sequence. The largest is in the grey-white junction at the level of the medial left occipital lobe, with the second largest at the level of the genu of the right internal capsule.

Smaller hypointense areas are identified in the superior left cerebellar hemisphere as well as in the right frontal and right parietal lobes medially.

The findings are in keeping with hemorrhagic axonal injury.

Findings 2:
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There are a small number of scattered hyperintense T2 foci within the white matter of both cerebral hemispheres which would be in keeping with either chronic microvascular changes or non—axonal hemorrhagic injury.

There is a moderate amount of increased T2 signal in the pens which would be in keeping with chronic microvascular changes.

doctor
Answered by Dr. Dariush Saghafi (2 hours later)
Brief Answer:
I would definitely consider an urgent evaluation- something's afoot

Detailed Answer:
Good evening. My name is Dr. Saghafi and I am a neurologist from the XXXXXXX OH area of the world. I see you are from Toronto. When I was a child we lived in Montreal...I got lost in La Ronde in Expo '67 and got the whoopin' of my life when my mother finally found me happily playing at the kids lost and found! I had no clue why she was so mad....I was having a great time playing there! LOL.

Now, a couple of questions. Can you explain what you mean by "Findings 1 and Findings 2". Are these on separate dates or were both sets of findings read out on the same date? Secondly, please specify more what you mean to say that "the patient doesn't feel well"...are we talking about feeling very tired, sleepy, nauseous, slurring words, saying things that don't make sense?

Did the patient have neurological symptoms of any sort such as numbness/tingling of one side of his body, weakness of an arm or leg? Did the patient suffer some type of traumatic head injury?

The reason I ask is because the reports are discussing something to do with hemorrhagic axonal injury and this is mainly seen with injuries of a traumatic nature such as acceleration/deceleration injuries, blows to the head as occur in a fight, car accident, fall to the ground. Did he suffer from any of these types of traumatic injuries recently?

Was the thought that he could be suffering from some type of venous thrombosis due to the abscess having been there so long that it could've broken through into the brain and thereby result in these areas of hemorrhagic insult and is it possible that these areas of "hemorrhagic axonal injury?" are actually areas of septic emboli that could be forming?

The MRI revealed items of artifact referred to as BLOOMING artifacts which is a type of false image generated on an MRI (or any radiograph) demonstrating an increased size or diameter of a structure in a region due to increased paramagnetic susceptibility of the area. That usually means that these artifacts make actual areas of aberration or defect to look bigger than they really are. In the first set of findings, it would seem that the most obvious and out front findings were called in 6 different regions of the brain and on both sides of the brain.

In the 2nd set of findings there is a typo...where it says "PENS" should be PONS...that's the part of the brainstem I always refer to as having the 'GUT'...OR THE PROTRUDING BELLY compared to the medulla and the midbrain! LOL. Changes there essentially talk about chronic changes of microvascular ischemia in all likelihood and these are not entirely unexpected in a 52 year old's brain and again do not represent either anything acute going on or related even to the abscess or infection. If for instance the patient is a smoker, or exposed to second hand smoke, or has hypertension, or high cholesterol, or has diabetes then, microvascular changes that are reported would be considered expected findings.

Furthermore, it is stated that the areas of signal intensity in the pons are related to NON-AXONAL HEMORRHAGIC INJURY.

Bottom line is this: If the patient has not suffered from any form of traumatic brain injury in the recent past then, the abnormal areas identified as hemorrhagic axonal injuries may be due to septic emboli traveling through the brain to different locations. I don't know if this is secondary to venous sinus thromboses or something else but with the abscess being located where it was and even though it seemed to be resolving nicely the fact is he doesn't feel "well."

To me this is a potentially ominous sign of something afoot and so time to act becomes critical. I believe he should get an MRI with contrast and also as importantly an MRV should be done as well (Magnetic Resonance Venography) to look for sinus venous thrombosis. I believe that there is a chance that the patient could develop complications and quickly and decompensate if not seen soon. Then, he's going to be behind the 8 ball and even the most aggressive treatments may not be able to catch up with what's going on in the head.

If this answer satisfactorily addresses your question then, I'd appreciate the favor of a HIGH STAR RATING with some written feedback.

Also, CLOSING THE QUERY on your end (if there are no further comments) will be most helpful and appreciated so that this question can be transacted and archived for further reference by colleagues as necessary.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best.

The query has required a total of 87 minutes of physician specific time to read, research, and compile a return envoy to the patient.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi (9 hours later)
Both findings were on 21 April 2015.

He has an X-Ray from 1993 of an unexplained break in C1, and recollection of "the most pain" of his life with a neck injury while pressing a bar over his head in 1987 that was not treated, and greatly restricted movement and "months" to get back to normal life."

For "the patient doesn't feel well" his greatest complaints are ongoing fluctuation of hearing, especially right side, like "plugging in an airplane descent". The ear is clear of any infection visual inspection. He also feels "pressure", "heat", and "movement" in the lower right back of his head. He has had long time numbing along his right neck, however this symptom has not noticeably worsened recently.

In the past two days he has not had periods of significant confusion. However, over 19, 20, 21 April he says he frequently found he had moved things in the bathroom to the wrong place, and had to "fix" what he had done, and found he was carrying objects around without noticing - tools from looking at a tap in the basement all in his hands when goes upstairs.

His next greatest concern is long time pain he has had along his spine and right shoulder. On 9 April, two days after discovering the abscess, one day into antibiotics before any relief, and after seven Tylenol 3's (32 MG codeine), the pain on his spine was so severe he left large bruises, still visible a week later, with a walking cane to "try and numb the pain". This pain has decreased greatly, to what he calls "usual" levels of only 2 out of 10. However, the great worsening of the symptom in such close time proximity to the abscess, the cervical break likely in the 1987 injury, and the signs of hemorrrhagic axonal injory in the MRI, cause him to ask if there could be any special relevance.

Bottom line: how can we know if the six artifacts of hemorrhagic axonal injury are (a) more likely not urgent, the result of the 1987 injury and unlikely to be worsening at the moment, or (b) merit urgent investigation (i.e. today).

Unfortunately, calling on additional resources in this city requires special convincing, and without a good reason it is justified will likely be contested as the injury is 28 years old, the vital signs are stable, and the hemorrhagic areas are likely not worsening. Does the data support a different view that one would be confident providing to the specialist?

Thanks,
XXXX

Fwiw, the patient also reports today an increase in "itchiness" in the back of his head, from the base of the skull around to top of head. The right side is "half" as itchy, from the back forward to the location of the ear abscess.

These started at the same time as the original bone movement sensations, although he says that when those were at peak a week ago, the itchiness was more like "stitches" or a series of very small stabs running quickly from the top to the bottom.

Now that it is just itchiness, he reports it as his only not unpleasant symptom, like "feeling coming back into a numb area". His concern is minor, and more about relevance in the context of the rest of the case and timeline.

The appearance of the abscess was nearly identifical to mastoiditis in the literature, even though the ear is now clear. Given the large increase in spine pain at the same time, are the following relevant, or have they already been ruled out by the MRI done after antibiotics started?
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Epidural abscess as a complication of acute mastoiditis in a 7-year-old child
Otolaryngol Pol. 2010 Sep-Oct;64(5):320-3. doi: 10.1016/S0030-6657(10)70615-6.
XXXX

Epidural abscess is the commonest intracranial complication of acute mastoiditis. In some cases this entity may pose a diagnostic problem.

http://www.ncbi.YYYY.gov/pubYYYY/0000
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Subperiosteal abscess (mastoid)
Dr Ayush Goel and Dr XXXXXXX Gaillard et al.

Subperiosteal abscess is one of the more frequent complications of acute otomastoiditis, and results in coalescent mastoiditis extending through the external cortex of the mastoid sinus. This can occur in any direction.

http://YYYY.org/articles/YYYY-abscess-YYYY
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doctor
Answered by Dr. Dariush Saghafi (21 hours later)
Brief Answer:
Thank you for the updated information- No change in my posture

Detailed Answer:
May I ask if the person writing these notes and the patient are one in the same? It is confusing to read some of what is going and to imagine that a caregiver is the one relaying all this and not the patient since at some points in the discussion we seem to be going from one status shift to another. Not that's it's critical to the overall question being asked but I believe it would help me follow the storyline if it were crystal clear to me who is telling it and how that person is related to the patient.

The other issue is that whoever is writing these notes is injecting a lot of what I refer to as "out loud thinking" which raises questions, answers them, and then, at times loses coherency and consistency....again, a very distracting way to follow a story.

From the first question it was obvious that many important details were likely missing which is why when I read the radiology report I didn't get the same sense of urgency as I may have imparted simply I tend to be very cynical when I'm told that a patient "is not feeling well." Now, that you've explained what that exactly means I feel that the acuity of the situation seems to have belayed somewhat.

Having said that, your specific question that I wish to focus on is:

Bottom line: how can we know if the six artifacts of hemorrhagic axonal injury are (a) more likely not urgent, the result of the 1987 injury and unlikely to be worsening at the moment, or (b) merit urgent investigation (i.e. today).

And more importantly I need you to understand that:

1. I am keenly sensitive and aware of the difference in medical management systems between Canada and the U.S....for that matter, Anywhere else in the world practically and the U.S. when it comes to obtaining timely testing, medications, hospitalizations, procedures, etc. etc.

2. Notwithstanding the above statement as a doctor I cannot (and will not) make any equation of financial gravity or importance a part of my calculation when I state what I believe is in the best medical interest of the patient. That is for others to worry about. My job and my oath as a doctor is to make my best recommendations for the patient to have the best quality of life under the assumption that what I recommend be done WILL BE DONE or at least CAN BE DONE expeditiously. I realize that is Wish List Thinking.....I know because I have international patients who are waiting months just to change medications for which they've been having side effects.

With that clearly in mind the answer to your question of with the MRI data of April 21, 2015 taking into account the clinical description of a person who suffers from both chronic as well as what APPEAR to be acute or subacute symptoms of pain, cognitive dysfunction, and the history of a recently treated cervical abscess which has largely but incompletely resolved at this time:

Bottom line: how can we know if the six artifacts of hemorrhagic axonal injury are (a) more likely not urgent, the result of the 1987 injury and unlikely to be worsening at the moment, or (b) merit urgent investigation (i.e. today).


Is--- I CANNOT know or give any guarantees that what is being seen on the scans is not something that is new in development and potentially represents an insidious spread of an infection recently treated by oral antibiotics (appears to be incompletely resolved at this time).

Also, and most importantly, I do not see any scan reports which have even looked at the cervical spine or spinal cord region in order to RULE OUT an epidural abscess. I just don't see the reports that clears him of that problem therefore, I think there is still a chance he may have that issue as an active one and this needs to be treated aggressively if it exists.

What is of course, in favor of this not being an emergency situation is that despite all this time which has passed...his overall condition and neurological situation have not appreciably changed... (i.e. he hasn't crashed during all this rhetoric being exchanged) which you would expect to have suffered some acute transformation at least over the past 48 hrs. though nothing's happened.

Still, I always think of the question...if this patient were my mother, my father, a close friend or other relative and there were these doubts and questions as to whether something was or was not worthy of elevation to an emergency/more aggressive posture.....when it comes to protecting the brain and spinal cord....I always vote for OVERCALLING A SITUATION and getting whatever tests or procedures that need to be done in order to FIRMLY AND DEFINITIVELY RULE OUT POTENTIAL CATATROPHES....and if within a period of 7-10 days under watchful eyes of others whoc can make changes instantly as necessary nothing really happens then, I may instruct services to "stand down."

Does that make sense?

And so, I would recommend that the patient be submitted for more specific testing and evaluation in the event that we are on the front end of a majorly disseminating infection of some sort that if left unchecked could spell disaster and make it nearly impossible to come back out of the woods and then, go back in.....

If after all is said and done things come out clean and this was all to do about nothing...my answer would be, "So what?" Again, I'm a doctor and my responsibility is to the patient and their family...not to a managed healthcare plan, company, or country's government who places more of a premium on the monetary aspects of healthy living and convenient dying compared to the rights, needs, and desires of the individual to receive the very best care available for any and all infirmities that fellow countrymen contract, suffer with or otherwise, find themselves battling without want and who are just as deserving of the best workups and treatments as anybody else would be in similar circumstances in any other part of the world.

"Onward Christian Soldiers!" LOL....and that is by all means intended to be stated in its most secular connotation possible.

If this answer satisfactorily addresses your questions then, I'd appreciate the favor of a HIGH STAR RATING with some written feedback.

Also, CLOSING THE QUERY on your end (if there are no further comments) will be most helpful and appreciated so that this encounter may be transacted and archived for further reference by colleagues as necessary.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best.

The query has required a total of 123 minutes of physician specific time to read, research, and compile a return envoy to the patient.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi (2 hours later)
Your feedback clearly communicates both your intelligence, and your compassion. If there is a way for me to pay you back, or pay it forward, in a more meaninfgul way when this is behind me, I will do so.

I am the patient. My problem is I was first seen by an unsupervised medical student. He misdiagnosed the abscess as surface, since mastoiditus is rare in the developed world. Despite an emergency doctor documenting the abscess later that night, my family doctor in the same clinic is going with the person she knows, the student, and maintains it was surface.

And since that symtom is denied, that has led her to say that bruising on my spine was something I must have done to myself, presumably for psychological reasons, not due to huge increase in pain at the same time as the abscess.

I also had a huge increase in energy, a restoration of vision in the bottom of my right eye, and a complete release of a hip muscle for the first time in decades, several days after antibiotics. The once in a life-time improvements are so dramatic, it strongly increases my (amateur Dr. of Computer Science) suspician that a long-time infection dramatically improved.

If it is gone, my life should continue to get better, all is good. If there is any chance it remains, I want to leverage the advantage that seems to have been obtained.

Can you tell me specifically what MRI to obtain, and I will pay for it privately? Any other antibiotics besides the and length of treatment recommended?

(If ever in Ottawa, my wife and I would be pleased to make you dinner in our simple heritage home downtown. I recognize a happy, fun mind when I see it! I will communicate my personal website when this is concluded.)
doctor
Answered by Dr. Dariush Saghafi (24 hours later)
Brief Answer:
Thank you for your kind comments

Detailed Answer:
I appreciate the kindness of your comments. I feel badly that you may end up having to pay out of pocket for any testing that could be in the spirit of practicing simply good preventive medicine in a situation such as you've described which would be commonplace and virtually considered standard of care. However, so is the world we live in today. If your symptoms of pain and cognitive issues either stabilized or improving over the past 24 hrs. since last I responded then, again I think the likelihood of a repeat scan or that different tests would be positive for anything particularly noxious or dangerous is lower than when I first responded.

Again, the limitations of a network such as this when answering questions drives me toward "overcalling" potentially harmful situations rather than undercalling and then, risking a major complication if the person were to take no action at all.

Therefore, with all that being said my order (if you were before me in a hospital or outpatient setting) would be to obtain an MRI of the cervical spine with contrast enhancement just to be sure that no osteomyelitis had possibly developed from the abscess. It doesn't sound likely but again, an ounce of prevention.

As far as discovering whether or not the Bloom artifacts were of any consequence I may order an MRV (Magnetic resonance venography) study which would measure the possibility of a low flow venous state that could result in congestion without venous sinuses if not clots that could cause infarcts elsewhere....again, less likely a scenario if your mental faculties and other neurological function have remained stable throughout the past 24 hrs.

I don't know how much they would charge for a cervical MRI study with contrast and an MRV in Canada. Just for comparison sake I can tell you that there are diagnostic centers here in my area which will charge around $300-400 for such studies if they knew the patient were paying fully out of pocket. Would it possibly behoove you to take a jaunt across the border to get such a study performed if in Canada they were to charge upwards of $1500 or $2000 for something like that? And by across the border I don't necessarily mean to XXXXXXX although you are certainly welcome to our fair town but I'm sure similar facilities with accessible imaging prices can be found in XXXXXXX NYC, and other US locations that would be probably closer to Toronto. It would simply be a matter of your deciding which port of entry you wished to use and then, call facilities in those areas to ask for prices.

There'd be one more hurdle to overcome though and that would be a doctor's order that they can follow. They would likely follow a Canadian doctor's order or one from whatever State the facility were located in but I don't think they will do a study based upon what a patient relays to them.

Ahead of those tests those I would consider doing some blood work looking for evidence of an infectious process that could be brewing either subclinically or even clinically if your symptoms are correlative to what infectious process is present. Blood cultures x 3 are the usual way we handle such things and again, my index suspicion comes into play and says that the yield of finding something significant is lower if the patient does not have fevers, general malaise, or other clinical symptoms of a bacteremic or septic process. You could be bacteremic. I highly doubt that you are septic.

Antibiotic choice would be guided by blood culture results. If the blood cultures were negative then, I would conclude that another round of antibiotics for the abscess would be likely unnecessary and overkill.

GO MAPLE LEAFS!

If this answer satisfactorily addresses your questions then, I'd appreciate the favor of a HIGH STAR RATING with some written feedback.

Also, CLOSING THE QUERY on your end (if there are no further comments) will be most helpful and appreciated so that this encounter may be transacted and archived for further reference by colleagues as necessary.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best.

The query has required a total of 141 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi (1 hour later)
I had so much confidence in you, and then you cheered for the Maple Leafs. *Now* we have hard evidence someone is delusional ;-)

I'm actually in Ottawa, and the Senators last night won their second in a row, to the revered and h*ted Canadiens first three wins. They are teaching my 11 year old son great things about keeping faith even when behind and against great odds.

I'll do a final review and see if I have any more questions. I really don't want to take your valuable time unnecessarily, however if I am going to chase this down I want to do it right, and close it definitely and put it behind me one way or another.

One of your comments hit it on the head (no pun intended). In my project management language Risk = Probability x Impact. I still feel the popping ears today, both sides now, never on the left before. And the pressure and heat in the areas described. All the literature I had read, even before your input, indicated Impact could be high. And there is enough evidence Probability is significant.

Finally seeing physical evidence at the site of my pain, a dead grey-white wedge so much more disturbing than if it had just been red, got my attention as a huge spike in quantifiable information. And the improvement on antibiotics was so large, and although not complete or total has been enduring, it is difficult, even after trying hard to fairly look at the skeptical view, to dismiss the association as coincidence. So I need to chase this down. I will get back with any hopefully final interaction soon.

Much thanks again.

One last question. I will upload graphics in a minute annotated showing my pain and other issues, head and back. I am trying to document information, to get out of the explaining to every new Physician situation.

Can I ask you to take a look for any useful additional information? For example, do the lines where I am having pain in my head correspond to anything anatomically that jumps out at you as relevant? Or does the swelling areas on my back (not previously mentioned to reduce overload, however visually apparent to my family doctor friend, who is actually my wife) trigger any important observations?

I am bothering my wife with this very little, for many reasons, as I'm sure you can appreciate.

Thanks so much again. (Senators will even series tonight!)
doctor
Answered by Dr. Dariush Saghafi (37 hours later)
Brief Answer:
Senators forgot to bring their sticks with them tonight! LOL!

Detailed Answer:
I did view the pictures you sent and appreciate the degree of confidence you have in me for asking for an opinion. However, if I'm reading your question correctly I'm afraid I wouldn't be the best specialist to ask about the co-relations between those pain points or regions to one another. I can tell you that they do not represent dermatomal regions subserved by specific spinal nerve roots...that would've been easy. Instead I believe the specialists best suited to analyzing these pictures in the way you've labeled them would be a rheumatologist, pain management specialist, or acupuncturist, or PM&R doc (Physical Medicine and Rehabilitation doctor).

I will make the following barely worthwhile comments on the pictures:

1. Curvature of the back (i.e. scoliosis) is best assessed using radiography as opposed to visual inspection. Sometimes a person in pain can unknowingly cock themselves in a way that automatically gives them a curvature without anybody really being aware that's what's happening.

2. Places that are "indented" vs. "swollen" are best visualized in different positions and under different circumstances other than when in pain in order to get the most unbiased points of view. My wager is that if we were able to find you in a position of least compromise (i.e. when you were asleep) and then, retake some of these photos looking at the areas of both indentation and swelling...that we would see big differences to the current pics. Try and see if your wife doesn't even agree.

I hope these answers satisfactorily addresses your questions as a whole though my apologies for the final photos but as a neurologist such detailed drawings and specific indicators of pain and discomfort that are very difficult to ascribe to either a peripheral or central system disorder would be much better answered by others more expert than I. Therefore, I hope that despite blurting out my favor for a team named after one of my primary schools before (The Maple Leafs!), I may still be in your good graces for a HIGH STAR RATING with some written feedback on what I've documented for you to this point.

Also, may I ask that with this final question we CLOSE THE QUERY on this set of questions so that the responses can be transacted and archived for further reference by colleagues as necessary? We can always open a new set of questions if you'd like to continue the thread of conversation.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best.

The query has required a total of 170 minutes of physician specific time to read, research, and compile a return envoy to the patient.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Dariush Saghafi

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Suggest treatment for right-sided pain in head, neck and spine

Brief Answer: I would definitely consider an urgent evaluation- something's afoot Detailed Answer: Good evening. My name is Dr. Saghafi and I am a neurologist from the XXXXXXX OH area of the world. I see you are from Toronto. When I was a child we lived in Montreal...I got lost in La Ronde in Expo '67 and got the whoopin' of my life when my mother finally found me happily playing at the kids lost and found! I had no clue why she was so mad....I was having a great time playing there! LOL. Now, a couple of questions. Can you explain what you mean by "Findings 1 and Findings 2". Are these on separate dates or were both sets of findings read out on the same date? Secondly, please specify more what you mean to say that "the patient doesn't feel well"...are we talking about feeling very tired, sleepy, nauseous, slurring words, saying things that don't make sense? Did the patient have neurological symptoms of any sort such as numbness/tingling of one side of his body, weakness of an arm or leg? Did the patient suffer some type of traumatic head injury? The reason I ask is because the reports are discussing something to do with hemorrhagic axonal injury and this is mainly seen with injuries of a traumatic nature such as acceleration/deceleration injuries, blows to the head as occur in a fight, car accident, fall to the ground. Did he suffer from any of these types of traumatic injuries recently? Was the thought that he could be suffering from some type of venous thrombosis due to the abscess having been there so long that it could've broken through into the brain and thereby result in these areas of hemorrhagic insult and is it possible that these areas of "hemorrhagic axonal injury?" are actually areas of septic emboli that could be forming? The MRI revealed items of artifact referred to as BLOOMING artifacts which is a type of false image generated on an MRI (or any radiograph) demonstrating an increased size or diameter of a structure in a region due to increased paramagnetic susceptibility of the area. That usually means that these artifacts make actual areas of aberration or defect to look bigger than they really are. In the first set of findings, it would seem that the most obvious and out front findings were called in 6 different regions of the brain and on both sides of the brain. In the 2nd set of findings there is a typo...where it says "PENS" should be PONS...that's the part of the brainstem I always refer to as having the 'GUT'...OR THE PROTRUDING BELLY compared to the medulla and the midbrain! LOL. Changes there essentially talk about chronic changes of microvascular ischemia in all likelihood and these are not entirely unexpected in a 52 year old's brain and again do not represent either anything acute going on or related even to the abscess or infection. If for instance the patient is a smoker, or exposed to second hand smoke, or has hypertension, or high cholesterol, or has diabetes then, microvascular changes that are reported would be considered expected findings. Furthermore, it is stated that the areas of signal intensity in the pons are related to NON-AXONAL HEMORRHAGIC INJURY. Bottom line is this: If the patient has not suffered from any form of traumatic brain injury in the recent past then, the abnormal areas identified as hemorrhagic axonal injuries may be due to septic emboli traveling through the brain to different locations. I don't know if this is secondary to venous sinus thromboses or something else but with the abscess being located where it was and even though it seemed to be resolving nicely the fact is he doesn't feel "well." To me this is a potentially ominous sign of something afoot and so time to act becomes critical. I believe he should get an MRI with contrast and also as importantly an MRV should be done as well (Magnetic Resonance Venography) to look for sinus venous thrombosis. I believe that there is a chance that the patient could develop complications and quickly and decompensate if not seen soon. Then, he's going to be behind the 8 ball and even the most aggressive treatments may not be able to catch up with what's going on in the head. If this answer satisfactorily addresses your question then, I'd appreciate the favor of a HIGH STAR RATING with some written feedback. Also, CLOSING THE QUERY on your end (if there are no further comments) will be most helpful and appreciated so that this question can be transacted and archived for further reference by colleagues as necessary. Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi All the best. The query has required a total of 87 minutes of physician specific time to read, research, and compile a return envoy to the patient.