Neuroradiological Findings Research Articles

Familial Hypercholesterolemia, as an Independent Risk of Cerebral Small Vessel Disease.

Familial hypercholesterolemia (FH) is characterized by elevated levels of LDL-C (low-density lipoprotein cholesterol) since birth. However, the association between FH and cerebrovascular diseases, including cerebral small vessel disease (CSVD), is controversial. To investigate the association between FH and CSVD, we compared the prevalence and severity of CSVD neuroradiological findings between patients with FH and control participants. Patients with FH who visited the lipid clinic and underwent brain magnetic resonance imaging at the National Cerebral and Cardiovascular Center in Japan from November 2006 to April 2021 and control participants who voluntarily underwent brain magnetic resonance imaging as a checkup between December 2000 and December 2010 at the Health Science Center Shimane, Japan, were enrolled into the study. The prevalence and severity of CSVD neuroradiological findings were investigated in patients with FH and control participants, and potential risk factors for CSVD development were identified using multivariable logistic and quasi-Poisson regression analyses. A total of 151 patients with FH and 3172 control participants were enrolled in this study. FH was identified as an independent risk factor of prevalent lacunes (adjusted odds ratio, 1.60 [95% CI, 1.03-2.51]; P=0.039) and increased number of lacunes (1.67 times [95% CI, 1.17-2.31]; P=0.003). Furthermore, FH was also an independent risk factor of prevalent cerebral microbleeds (adjusted odds ratio, 9.42 [95% CI, 5.81-15.28]; P<0.001) and increased number of cerebral microbleeds (6.95 times [95% CI, 4.34-10.83]; P<0.001). The association of FH with lacunes and cerebral microbleeds may warrant routine brain imaging for primary prevention of symptomatic stroke in patients with FH.

Enteroviral Transverse Myelitis Presenting as Acute Ataxia in Children: A Case Series

Background: Enteroviruses, members of the Picornaviridae family, typically cause asymptomatic or mild infections. However, they can also result in central nervous system (CNS) involvement, with transverse myelitis (TM) occurring only on rare occasions. TM is a syndrome characterized by acute or subacute spinal cord dysfunction, leading to neurological deficits below the level of the lesion. Case report: We report a case series of eight pediatric patients admitted over a three-month period, June to August 2024. All patients presented with ataxia and/or other neurological symptoms, alongside abnormal cerebrospinal fluid (CSF) findings. Although ataxia is commonly associated with cerebellitis, magnetic resonance imaging (MRI) in this cohort revealed findings consistent with TM. Notably, all patients demonstrated similar MRI abnormalities. The onset of symptoms occurred over a short time during an enterovirus epidemic. Enteroviral RNA was detected, or the virus was isolated in seven patients, while one patient had a close epidemiological link to the virus. All patients achieved full recovery following immunomodulatory therapy. Conclusions: This case series underscores that ataxia may be an atypical symptom associated with TM. Furthermore, there was a notable distinction between the clinical presentation and neuroradiological findings. Immunomodulatory therapy with immunoglobulins and corticosteroids has been shown to be effective and safe, supporting the hypothesis of an immune-mediated pathogenesis in these patients.

Prospective neuroimaging and neuropsychological evaluation in adults with newly diagnosed focal epilepsy.

Few prospective studies exist on newly diagnosed focal epilepsy (NDFE), a critical period for understanding epilepsy's biology and identifying biomarkers and potential interventions. We report a prospective cohort study in patients with NDFE and age-, sex-, and education-matched healthy controls. We recruited 104 patients with NDFE and 45 controls for research-grade 3 Tesla multi-modal magnetic resonance imaging (MRI), electroencephalography (EEG), comprehensive neuropsychological testing, and blood biomarker investigations. Baseline clinical, neuroradiological, MRI morphometric, and neuropsychological findings are reported in this article. Following neuroradiological reporting, MRI was unremarkable in 38% of patients, showed lesions associated with epilepsy in 12%, abnormalities of unknown significance in 49%, and incidental findings in 23%. For controls, these figures were 56%, 7%, 33%, and 16%, respectively. Patients had more white matter hyperintensities, classified as abnormalities of unknown significance, than controls. Reduced bihemispheric frontal lobe cortical thickness and thalamic volumes with moderate effect sizes were observed in patients. Compared to controls, patients scored lower on executive function, processing speed, and visual, delayed, and immediate memory tasks, and higher on depression and anxiety assessments. Cluster analysis identified four distinct patient cognitive profiles, two of which were associated with high levels of anxiety and depression and lower executive function and memory scores. Adults with focal NDFE have more MRI-positive findings than previously reported. Subtle white matter lesions may have clinical significance and a pathophysiological basis in focal epilepsy. Morphometric and neuropsychological changes at epilepsy diagnosis suggest that brain and cognitive alterations are not solely due to chronic epilepsy.

Bilateral vestibulopathy in Alexander disease type II- a case report.

Alexander disease (AxD) is rare leukodystrophy caused by a mutation in the glial fibrillary acidic protein (GFAP) gene. Astrocyte dysfunction leads to myelinization disturbances and white matter damage, resulting in distinct neurological symptoms and neuroradiological findings. Our patient, a 46-year old male, showed typical symptoms of AxD, including myoclonus of the soft palate, nystagmus, and cerebellar ataxia, as well as typical radiological findings found in AxD. The results of a device-based vestibular examination, including a video head-impulse test, showed a bilaterally decreased gain of vestibulo-ocular reflex of all semicircular canals suggestive of a bilateral vestibulopathy (BVP), a novel aspect of AxD. Symptomatic treatment of cerebellar ataxia and BVP with 4-aminopyridine (4-AP) led to an improvement of several device-examined vestibular parameters, but without subjective improvements in balance. This case report describes BVP in a patient suffering from AxD, a novel phenotype of the disease. In leukodystrophies, such as AxD, central vestibular symptoms should be assessed early on to evaluate the potential use of 4-AP.

Sleep Disorders in a Sample of Patients with Pediatric-Onset Multiple Sclerosis: Focus on Restless Legs Syndrome.

Background/Objectives: Sleep disorders (SDs) and Restless Legs Syndrome (RLS) have been reported with high prevalence in Multiple Sclerosis (MS), but data on Pediatric-Onset MS (POMS) are scarce. This study aims to assess the prevalence of SDs, particularly RLS, in a POMS cohort and examine associated clinical features. Methods: We recruited POMS patients who attended the POMS Center of the Bambino Gesù Children's Hospital between September 2021 and February 2023; they were evaluated for SDs using the Pittsburgh Sleep Quality Index (PSQI) or the Sleep Disturbance Scale for Children (SDSC) and screened for RLS. Correlations with demographical, clinical, neuroradiological, and laboratory findings were analyzed. Results: We recruited 44 POMS patients, of whom 39% were classified as "good sleepers" and 61% were identified as "poor sleepers." RLS was diagnosed in 10 patients (22.7%). Those with RLS were older and had higher Expanded Disability Status Scale (EDSS) scores compared to non-RLS patients (p = 0.028; p = 0.03). The presence of RLS did not show any significant correlation with MRI lesion load or laboratory data. Conclusions: Our findings suggest an increased rate of SDs and RLS in pediatric MS patients compared to the general pediatric population. Clinical data could support a secondary form of RLS in this population, but results need further confirmation.

No brain MRI abnormalities after mild-to-moderate COVID-19: an observational study.

To assess COVID-19-related morphological brain changes in individuals who recovered from mild-to-moderate COVID-19. This prospective cohort study enrolled 112 consecutive individuals who recovered from mild-to-moderate COVID-19 and underwent an MRI of the brain between September 2020 and March 2022. MR exams were consistently obtained on a clinical 3T MR scanner in all study participants and 50 age-matched matched controls. The following clinical neuroradiological MR imaging findings were analyzed: post- and acute ischemic lesions, cortical signal alterations, microbleeds, perfusion abnormalities, cytotoxic lesions of the corpus callosum, and vascular abnormalities. Additionally, we manually quantified white matter lesion loads and the number of perivascular spaces and performed an automated brain volumetric analysis. In 112 consecutive individuals the mean age was 45 years, female: male = 70:42, mean days at MRI after SARS CoV-2 infection: 228 (sd: 140), and hospitalized: non-hospitalized ratio = 30:82. Using general linear regression models, adjusting for age and gender, the frequency of white matter hyperintensities was not significantly different between subjects who recovered from COVID-19 and matched controls: 9.8 (sd: 17.3) vs. 7.6 (sd: 12.7), p = 0.590. Similarly, the number of enlarged perivascular spaces was not significantly different between the two groups: 62.7 (sd: 43.5) vs. 61.3 (sd: 47.2), p = 0.902. A subgroup analysis between those who were hospitalized in the course of the disease, in which no one required intensive care, and those who remained outpatients, also did not reveal any differences in MRI measures. We did not find evidence for perfusion-/diffusion abnormalities, (micro-)hemorrhages, or cortical abnormalities. In the present cohort, there was currently no evidence of COVID-19-related morphological brain changes in individuals who recovered from mild-to-moderate COVID-19.

Crossed Cerebellar Diaschisis in a Patient with MELAS Syndrome: A Case Report.

Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) is a rare genetic disorder from a spectrum of mitochondrial diseases. Most commonly it presents with stroke-like symptoms, seizures, encephalopathy and myopathy. As it affects predominantly metabolically active organs, it can cause cardiomyopathy, diabetes mellitus, etc. We report a case of a young male patient with genetically proven MELAS who had a history of periodical generalized tonic-clonic seizures and then developed recurrent transient paresthesia of the right extremities, speech disturbance and apraxia. During work-up, an MRI done after a generalized tonic-clonic seizure showed hypoperfusion and edema in right cerebellar hemisphere caused by the contralateral cerebral acute ischemic lesion in left insular cortex which produced initial symptoms. This interesting finding is called crossed cerebellar diaschisis (CCD). CCD is a rare entity which refers to a decrease in metabolism, perfusion, and overall function in a cerebellar hemisphere because of a contralateral cerebral lesion. The disturbance of the function in an area distant from the location of initial brain lesion is possible because the two areas are connected via fiber tracts. This pathology most commonly occurs after ischemic stroke but also after seizures, supratentorial tumors, encephalitis etc. Our patient continued to have recurrent occasional transient paresthesia of the right extremities, but the follow-up MRI showed complete regression of hyperintensities in the left cerebral cortex and edema in right cerebellar hemisphere. In this paper we report co-existence of a rare neuroradiological finding such as CCD, in patient with rare cerebrovascular disease.

Rupture of a true anterior spinal artery aneurysm at its intracranial origin: a short report.

Rupture of an anterior spinal artery (ASA) aneurysm at its intracranial origin is an exceptionally rare cause of subarachnoid hemorrhage (SAH). We report a case of a 69- year old adult male presented with agitation and neck pain, initially without neurological deficit, which worsened to coma upon admission to our center, approximately 8h after the onset of symptoms. Computerized tomography (CT) revealed massive SAH in the basal cisterns with intraventricular extension (Fisher IV), and CT angiography identified a ruptured aneurysm at the ASA origin, with no visualization of the distal ASA. The only surgical procedure performed was external ventricular drainage due to the development of obstructive hydrocephalus, together with conservative management based on the patient's clinical status and neuroradiological findings, with a fatal outcome 17 days later. This is the first reported case of a ruptured intracranial ASA aneurysm originating directly from the ASA main stem, and highlights the challenges of managing SAH combined with catastrophic spinal cord damage.

Neuroradiologic Findings Associated with Tuberous Sclerosis Complex: A Comprehensive Analysis of 24 Cases

Background: This study aims to comprehensively analyze the radiological findings of 24 TSC patients to determine the radiological profile of the disease and potential diagnostic and therapeutic imp-lications. Materials and Methods: This retrospective study was approved by the Ethics Committee of Harran University. A total of 24 genetically diagnosed TSC patients who underwent brain MRI between 2020-2024 were included. Imaging was performed using a 3 Tesla MRI scanner, employing T2 IDEAL, 3D T1 VIBRANT, and contrast-enhanced T1 sequences. Data were analyzed using IBM SPSS Statistics software, focusing on demographic characteristics and radiological findings. Results: The study included 24 TSC patients (14 males, 10 females) with a mean age of 8.43±10.24 years (range: 1-46 years). Cortical/subcortical tubers and subependymal hamartomas were identi-fied in all patients (100%). Radial bands were observed in 83.3%, infarctions in 50%, and corpus callosum dysgenesis in 41.6%. Subependymal giant cell astrocytoma (SGCA) was present in 12.5% of cases, while arachnoid cysts were noted in 20.8%. Conclusions: This study revealed a higher CNS involvement rate in TSC patients compared to the literature, with a higher prevalence among male patients. These findings emphasize the importan-ce of detailed radiological and clinical evaluations in understanding the disease. Changes in radio-logical findings with age and disease progression can contribute to optimizing treatment protocols.

Axis I Psychiatric Disorders and Substance Abuse: A Systematic Review of Neuroimaging Findings.

Background/Objectives: The present systematic review analyses the neuroradiological findings in subjects with axis I psychiatric disorders (i.e., bipolar, major depressive, schizophrenic, anxiety, and post-traumatic stress disorders) and comorbid substance use disorder in order to elucidate the organic changes that occur in the brains of people suffering from both conditions. Methods: We analysed and compared the different neuroimaging findings extracted from 93 studies and 10,823 patients; articles were obtained from three databases (Scopus, PubMed [Medline], and the Cochrane Controlled Register of Trials [Central]) and subjected to specific eligibility criteria. We selected articles that assessed patients with axis I psychiatric conditions and a comorbid substance abuse disorder; articles had to report relevant neuroimaging findings and bias was assessed via the Newcastle-Ottawa scale. Results: Significant findings were found on the structure or function of psychiatric patients' brains with comorbid substance abuse, with certain key areas that were further affected by substance use, especially in areas involved in reward processing, with reductions in volume and connectivity and the augmentation of stimuli-related activity. Conclusions: These results present important implications on the current understanding of psychiatric disorders and comorbid substance use, on the importance of neuroradiological tools in the diagnosis and treatment of these disorders, and on the search for potential new targets for the treatment of psychiatric disease and substance addiction.

Clinical, Neuroradiological and Molecular Genetic Characteristics of 13 Patients Followed up for Growth Hormone Deficiency

Objective: Growth hormone-releasing hormone (GHRH) and somatostatin are hypothalamic peptides that regulate pulsatile growth hormone (GH) secretion. GHRH binding to its receptor activates signaling, promoting cell proliferation, GH synthesis, and secretion. Mutations in the growth hormone-releasing hormone receptor (GHRHR) and growth hormone 1 (GH1) genes, which are involved in this pathway, occur as a rare cause of isolated growth hormone deficiency (IGHD). This study aimed to evaluate the clinical features, neuroradiological findings, and molecular genetic test results of 13 patients diagnosed with IGHD, as well as their responses to growth hormone treatment. Methods: The study included 13 patients from six different consanguineous families who were being followed for isolated growth hormone deficiency. Using next-generation sequencing, biallelic disease-causing variants in the GHRHR and GH1 genes were identified in these patients. Clinical findings, family history, parental consanguinity, and neuroradiological images of the patients were retrospectively obtained from hospital records. Results: Biallelic variants were identified in the GHRHR gene in nine patients and in the GH1 gene in four patients. The potential impact of these variants on protein structure was assessed using in silico prediction tools, including SIFT, MutationTaster, REVEL, and PolyPhen-2. Conclusion: Screening for variants in the GH1 and GHRHR genes is recommended for patients with severe growth retardation, short stature. It is important to consider the possibility of multiple affected individuals presenting with similar phenotypes, particularly in regions with a high prevalence of consanguineous marriages. Therefore, comprehensive family screening should be conducted when appropriate.

Novel intronic variant in NDUFS7 gene results in mitochondrial complex I assembly defect with early basal ganglia and midbrain involvement with progressive neuroimaging findings.

Novel intronic variant in NDUFS7 gene results in mitochondrial complex I assembly defect with early basal ganglia and midbrain involvement with progressive neuroimaging findings.

Cerebral Amyloid Angiopathy: Clinical Presentation, Sequelae and Neuroimaging Features-An Update.

The prevalence of cerebral amyloid angiopathy (CAA) has been shown to increase with age, with rates reported to be around 50-60% in individuals over 80 years old who have cognitive impairment. The disease often presents as spontaneous lobar intracerebral hemorrhage (ICH), which carries a high risk of recurrence, along with transient focal neurologic episodes (TFNE) and progressive cognitive decline, potentially leading to Alzheimer's disease (AD). In addition to ICH, neuroradiologic findings of CAA include cortical and subcortical microbleeds (MB), cortical subarachnoid hemorrhage (cSAH) and cortical superficial siderosis (cSS). Non-hemorrhagic pathologies include dilated perivascular spaces in the centrum semiovale and multiple hyperintense lesions on T2-weighted magnetic resonance imaging (MRI). A definitive diagnosis of CAA still requires histological confirmation. The Boston criteria allow for the diagnosis of a probable or possible CAA by considering specific neurological and MRI findings. The recent version, 2.0, which includes additional non-hemorrhagic MRI findings, increases sensitivity while maintaining the same specificity. The characteristic MRI findings of autoantibody-related CAA-related inflammation (CAA-ri) are similar to the so-called "amyloid related imaging abnormalities" (ARIA) observed with amyloid antibody therapies, presenting in two variants: (a) vasogenic edema and leptomeningeal effusions (ARIA-E) and (b) hemorrhagic lesions (ARIA-H). Clinical and MRI findings enable the diagnosis of a probable or possible CAA-ri, with biopsy remaining the gold standard for confirmation. In contrast to spontaneous CAA-ri, only about 20% of patients treated with monoclonal antibodies who show proven ARIA on MRI also experience clinical symptoms, including headache, confusion, other psychopathological abnormalities, visual disturbances, nausea and vomiting. Recent findings indicate that treatment should be continued in cases of mild ARIA, with ongoing MRI and clinical monitoring. This review offers a concise update on CAA and its associated consequences.

An atypical presentation in a child with propionic acidemia? Better think twice!

This report details the case of an infant with confirmed propionic acidemia who presented with progressive neurological deterioration and recurrent episodes of metabolic decompensation with elevated lactate levels, but without hyperammonemia. The child's clinical course and neuroradiological findings increasingly deviated from the known clinical and neuroradiological spectrum of propionic acidemia. A rapid trio exome sequencing identified SLC19A3-related thiamine metabolism dysfunction syndrome 2 as a second genetic disease. The pathomechanisms of both diseases synergize in the impairment of brain energy metabolism, and the associated clinical phenotypes partially overlap, which explains the severe and atypical course of propionic acidemia in the reported case.

Spinal cord involvement in primary central nervous system vasculitis. A systematic review of clinical, neuroradiological and pathological findings.

Primary Angiitis of Central Nervous System (PACNS) is a rare disease featured by transmural inflammation in vessels pertaining to brain, leptomeninges and spinal cord. It is a rare disease and the involvement of the spinal cord represents a rarer and not yet completely investigated subtype. We performed a systematic search of the available literature on Pubmed and Embase, adding backward and forward citations, in order to retrieve the reported cases of PACNS i9nvolvimeng the spinal cord without time limitations. The main aim is to retrieve information about clinical and demographic features, pathological and neuroradiological findings on brain and spinal cord, and, finally, treatment and outcome. RESULTS: The search provided 33 papers (mainly individual case reports) and 38 patients, with a large age frame (from 12 to 70 years of age), mainly adults. Among these ones 36/38 received a pathological diagnosis and granulomatous pattern was the main reported one. The description of spinal cord involvement in MRI is variable form extensive tumefactive lesions to spinal roots prominent involvement. The mortality is high (29% at the end of the individual follow-up). DISCUSSION: As in non-spinal involvement, the main limitation of the retrieved cases is the inhomogeneity of the diagnostic and therapeutic pathway with underusing and underreporting of neuroradiolgoical techniques relevant for the diagnosis according with the available diagnostic criteria. Spinal cord involvement confirms its rarity, but it has been associated to a high disability and mortality and the diagnosis of PACNS has therapeutic consequences. CONCLUSIONS: Spinal cord involvement is present in a minority of PACNS cases with a variety of neuroradiological and pathological findings. The standardization of the diagnostic pathway could help to improve the quality of information in prospective studies.

Non-Thrombotic Filling Defects in Cerebral Veins and Sinuses: When Normal Structures Mimic a Disease.

Cerebral venous thrombosis (CVT) is a rare and potentially critical cerebrovascular disease involving intracranial dural sinuses and veins. The diagnosis is a stepwise pathway starting from clinical suspicion and employing several neuroradiological techniques, mainly Computed Tomography (CT)-based and Magnetic Resonance Imaging (MRI)-based modalities. The neuroradiological findings, both in the diagnostic phase and in the follow-up phase, may provide some results at risk for misdiagnosis. Non-thrombotic filling defects of intracranial dural sinuses are among them, and the potential sources are artefactual and or anatomical (venous septa and arachnoid granulations). The misdiagnosis of these findings as CVT is potentially linked to dangerous consequences. A potential strategy to avoid this is to increase the knowledge about technical and anatomical reasons for non-thrombotic filling defects of intracranial dural sinuses and their imaging features. The main aim of this review is to address these issues, including the variability of the intracranial venous pathways, providing the solutions for overcoming the above-cited potential misdiagnosis of non-thrombotic filling defects as CVT.

Posterior cortical atrophy presenting with agraphia for kanji and statokinetic dissociation (Riddoch phenomenon): a case report

We report a patient with posterior cortical atrophy (PCA) who manifested as agraphia for kanji and statokinetic dissociation (Riddoch phenomenon). A 52-year-old, right-handed woman complained that beginning at age 50, she could write only kana (a phonographic script) but not kanji (a morphographic script). She could not write even her own name in kanji. Neuropsychologic examinations disclosed kanji-dominant agraphia, acalculia, right-left disorientation, finger agnosia, constructional apraxia, and simultanagnosia. Many of these, including agraphia, are components of Gerstmann syndrome. She manifested no aphasia or alexia, while not only writing but also copying of kanji was impaired. Speech functions, behavior, and personality were relatively spared. The patient also displayed statokinetic dissociation (Riddoch phenomenon): kinetic Goldmann fields were normal, but static Humphrey visual fields showed an incongruous right homonymous hemianopsia. MRI showed atrophy of the left parietal lobe. 99mTc ethyl cysteinate dimer (ECD) single-photon emission computed tomography (SPECT) showed hypoperfusion , predominantly in the left hemisphere and especially left the parietal lobe . These clinical and neuroradiologic findings are consistent with PCA. In patients with PCA, suspected incomplete homonymous hemianopsia should be confirmed with a Humphrey visual field test. Ishihara pseudoisochromatic plates may not be reliable; color vision should be checked using the panel D-15 test.

Nicorandil-induced Isolated Abducens Nerve Palsy: A Case Report.

Nicorandil is commonly used to treat angina pectoris. However, the adverse neurological effects of nicorandil remain unclear. Herein, we report the case of a patient who presented with isolated abducens nerve palsy associated with the administration of nicorandil. A 74-year-old man presented to our hospital with abducens nerve palsy and headaches. The patient had started nicorandil treatment one week prior. No abnormalities were observed in the laboratory tests or neuroradiological findings. The patient recovered immediately after the discontinuation of nicorandil treatment. In cases of cranial nerve palsy after the initiation of nicorandil treatment, consideration of the involvement of nicorandil is necessary.

Congenital fibrosis of extraocular muscles – A rare case

Congenital fibrosis of extraocular muscles (CFEOM) is an inherited restrictive ocular motility disorder characterized by unilateral or bilateral horizontal and/or vertical gaze impairment with ptosis. We report the clinical and neuro-radiological findings in a patient with CFEOM. An 18-year-old male patient presented to the ophthalmology outpatient department (OPD) seeking a visually disabled certificate. His best-corrected visual acuity was finger counting at half a meter in both eyes. Clinical examination revealed bilateral congenital ptosis, exotropia in both eyes, and severely restricted vertical and horizontal eye movements. Both eyes were fixed in a downward and outward position, accompanied by an abnormal head posture, predominantly chin -up. The patient also exhibited sluggishly reacting pupils in both eyes. Fundus examination revealed bilateral optic disc hypoplasia. Family history was negative. The forced duction test was positive. A definitive diagnosis was established by integrating findings from the clinical examination, fundus photography, forced duction test, and neuro- radiological investigations. MRI of the orbit demonstrated atrophy of all extraocular muscles except the lateral rectus.

Fungal Cerebritis Mimicking as Cerebral Infarction: A Diagnostic Dilemma

Fungal infections affecting the central nervous system are uncommon in the general population and typically arise as a secondary condition from a primary site of infection. These infections are predominantly observed in immunocompromised individuals, such as those with acquired immunodeficiency syndrome or those who have undergone organ transplantation. The absence of a significant inflammatory response often leads to nonspecific neuroradiological findings, which can be confused with conditions like tuberculous meningitis, pyogenic abscesses, or brain tumours and infarctions. The identification of intracranial fungal infections has increased, attributed to the rising number of AIDS cases, advancements in radiological imaging and improved microbiological detection methods, While various fungi can lead to encephalitis, cryptococcal meningoencephalitis is the most commonly encountered followed by infections Caused by aspergillus and candida species. Although radiographic findings alone may lack specificity, correlating the clinical context with computed tomography or magnetic resonance imaging can aid in reaching an accurate diagnosis. We are discussing a case of a 47-year-old male who presented in the ER with left-sided weakness. He was diagnosed with a right Middle Cerebral Artery infarct case. He underwent a Decompressive Craniotomy in which pus flakes were found on Interhemispheric tissue. Pus was sent for a culture and Sensitivity test which showed fungal hyphae on smear.