Asymptomatic diffuse cerebritis presenting as middle cerebral artery infarct: A case report and review of literature

Abstract

Diffuse cerebritis is a devastating disease presenting with features of raised intracranial tension, deficits, and features of meningeal and neural irritation. The most common feature is seizures which may persist despite normal antiepileptic medication. We present a patient with diffuse cerebritis who presented as a subacute middle cerebral artery (MCA) territory infarct without any symptoms of meningeal irritation or infection. The patient once admitted deteriorated with pupillary asymmetry and loss of consciousness. A computerized tomography scan revealed a massive increase in cerebral edema of the infarcted brain with midline shift and mass effect. In view of the serious threat to life, a decompressive craniectomy was done. Once the dura was opened, pus was seen subpially oozing into the subdural space. This was sampled for analysis and the scalp flap was closed with a drain. The patient improved well post surgically and was gradually extubated. His pus was found to grow Klebsiella pneumoniae sensitive to amikacin and gentamicin. A prolonged course of antibiotics was started. An angiogram done to determine the cause of the infarct showed only distal MCA branches (M4) occluded. The patient later deteriorated with venous thrombosis and succumbed to his illness later. We present a discussion on the etiology of the patient's condition and possible treatment options when faced with such situations.