key: cord-0772032-zd5wl8bi authors: Kaushik, Kavya S.; Ananthasivan, Rupa; Acharya, Ullas V.; Rawat, Sudarshan; Patil, Uday Damodar; Shankar, Balasubramanyam; Jose, Abin title: Spectrum of intracranial complications of rhino-orbito-cerebral mucormycosis — resurgence in the era of COVID-19 pandemic: a pictorial essay date: 2021-10-04 journal: Emerg Radiol DOI: 10.1007/s10140-021-01987-2 sha: 827d9409cfd21149d3d755b0f29f95365589a6f3 doc_id: 772032 cord_uid: zd5wl8bi Rhino-orbito-cerebral mucormycosis (ROCM) has regained significance following its resurgence in the second wave of the COVID-19 pandemic in India. Rapid and progressive intracranial spread occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of sinuses, or angioinvasion. Having known to have a high mortality rate, especially with intracranial extension of disease, it becomes imperative to familiarise oneself with its imaging features. MRI is the imaging modality of choice. This pictorial essay aims to depict and detail the various intracranial complications of mucormycosis and to serve as a broad checklist of structures and pathologies that must be looked for in a known or suspected case of ROCM. Mucormycosis is an invasive, potentially fatal, opportunistic fungal infection, caused by saprophytic fungi of the order Mucorales. A rapid surge in its incidence has been witnessed in the second wave of the COVID-19 pandemic in India. The proposed predisposing factors include hypoxia, uncontrolled blood sugars either steroid induced or due to diabetes mellitus, and prolonged multipronged immunosuppression [1] . Though it can involve different organ systems, the most common type is rhino-orbitocerebral mucormycosis (ROCM) [2] . The route of infection is usually by inhalation of the spores which invade the mucosa of nasal cavity and sinuses causing rhinosinusitis. Further rapid and progressive intracranial spread of the fungus occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of the frontal and sphenoid sinuses, or angioinvasion of the walls of the arteries and veins, causing vascular thrombosis, occlusion, and infarction [3] [4] [5] . Symptoms of intracranial extension include altered sensorium, diplopia, ophthalmoplegia, cranial nerve deficits, and focal neurological deficits based on the region of spread. With the intracranial extension of disease, mortality is greater than 80% [3] . Early imaging is crucial and aids in assessing the extent of involvement of disease and assists in prompt initiation aggressive antifungal treatment and surgical debridement. Magnetic resonance imaging is the imaging modality of choice. Restricted diffusion in ROCM indicates tissue ischaemia and necrosis resulting from the angioinvasive property of the fungus and thereby the path of spread of fungal infection [6] . This pictorial review will showcase the MR imaging features of intracranial complications of ROCM. The commonest intracranial manifestations are cavernous sinus extension, narrowing or occlusion of the internal carotid artery (ICA), and infarction [7] . Cavernous sinus involvement can occur through the ethmoidal and orbital veins that drain into it, through direct extension from sphenoid sinus, or from perineural spread along neural foraminae [3] [4] [5] . Bulging of the lateral walls of the sinus, abnormal dural enhancement of the lateral wall, abnormal signal intensity of the sinus (iso-hypointensity on T1 and hyperintensity on T2), and presence of filling defects on post contrast scans ( Fig. 1 ) indicate cavernous sinus thrombosis [8, 9] . Paracavernous soft tissue extension can also be seen (Figs. 1 and Angioinvasion of internal carotid artery across the sphenoid sinus or cavernous sinus and retrograde extension of mucor thrombus from the smaller ophthalmic arteries are the mechanisms involved. It can be evaluated on CT but is best evaluated on MRI. It presents as abnormal T2 signal intensity and post contrast enhancement in the wall (vasculitis) (Fig. 3) , progressing to infiltration causing irregular luminal narrowing and ultimately complete thrombosis (Fig. 2) which is seen as loss of flow void on T2-weighted images [4] . Involvement of the internal carotid artery can result in cerebral infarcts in the watershed territory, embolic in nature (Fig. 4) . Infarcts can also occur secondary to direct vessel invasion (Fig. 5) , which then harbour the fungal elements, visualised as blooming within the infarct on susceptibility weighted images [4] . Two unique characteristics of cranial nerve involvement by ROCM are described below: • Ischaemic neuropathy. The optic nerve and the trigeminal nerve are the most commonly involved cranial nerves. Optic nerve infarction results from angioinvasion and thrombotic occlusion of the central retinal artery or ophthalmic artery or by direct infiltration of the nerve by the fungus. Trigeminal nerve infarction can also occur in a similar fashion. It is visualised as restricted diffusion along the affected nerve (Figs. 6 and 7) , usually without any enlargement, altered T2/STIR signal intensity or post contrast enhancement [10, 11] . • Perineural spread. On MRI, direct findings suggestive of perineural spread are enlargement/thickening of the nerve, irregularity and excessive enhancement of the cranial nerve or its branch (within the cistern, canal, or foramen) (Fig. 8) , loss of the normal fat pad adjacent to the foramen, widening or excessive enhancement within the pterygopalatine fossa, Meckel's cave, or the cavernous sinus [12, 13] . Perineural spread serves as a conduit of spread -for instance, from the orbit intracranially along the optic nerve, and along the trigeminal nerve to the brainstem (Fig. 7) . Hyphal arterial invasion can result in septic emboli. They manifest as peripheral ring enhancing lesions, with central restricted diffusion and perilesional FLAIR hyperintense oedema, usually located at the grey matter -white matter junctions, predominantly in the middle cerebral artery territory (Fig. 9 ) [14] . Septic emboli may also be seen as multiple microhaemorrhages on Susceptibility weighted images [15] . It presents on CT as ill-defined intraparenchymal hypodense lesions with scattered areas of increased attenuation due to either haemorrhage or increased concentration of metal ions. On MRI, early cerebritis appears as a cortical-subcortical T1 iso-hypointense, T2/FLAIR hyperintense area with patchy restricted diffusion, and no post contrast enhancement. Progressive peripheral enhancement may be seen in late cerebritis (Fig. 10 ) [16] . Cerebral parenchymal abscess due to Mucor are most often seen in the frontal lobe or temporal lobes. They appear as irregularly marginated T2 hyperintense lesions with T2 hypointense, irregular peripherally enhancing walls with intracavitary non-enhancing projections with characteristic restricted diffusion of the intracavitary projections and of the wall. Susceptibility artefacts may be seen in the periphery of the abscess indicating a fungal composition [10] . Ventriculitis (Fig. 12 ) and subdural/extradural abscesses are rare may be seen in advanced disease. Intracerebral haematoma is a rare manifestation of ROCM, seen as a result of possible ruptured mycotic aneurysm which are most often seen in the anterior circulation [9, 16] Leptomeningitis/pachymeningitis MR images demonstrate thick, often nodular, meningeal enhancement on post contrast T1-weighted and FLAIR images, due to thick gelatinous exudates containing inflammatory cells, fibrin, and haemorrhage leading to arachnoiditis which in turn can lead to secondary hydrocephalus (Fig. 12 ) [16] . Dural thickening and enhancement (Figs. 13 and 14) is commonly in seen in the middle cranial fossa and paracavernous dura as well as along the frontal convexities and, rarely, can be diffuse. Being an angioinvasive fungus, bony involvement is not common and is usually seen only in chronic forms of the disease. However, early involvement of the bone marrow can be picked up on MRI, seen as patchy STIR hyperintense marrow oedema (Fig. 15 ) and heterogeneous post contrast enhancement [17] . Chronic forms can be visualised on CT as rarefaction, osteolysis, erosions, and sclerosis [18] . An exponential increase in the incidence of ROCM was witnessed in the second wave of the COVID-19 pandemic in India, reiterating the importance of familiarising oneself with its varied but crucial manifestations on imaging. MRI with contrast forms the crux of patient management and the Base of skull involvement: Patchy STIR hyperintensity in the A right pterygoid and B clivus, represents marrow oedema brain has to be imaged in every case. It aids in diagnosis, assessment of extent of disease, and early identification of intracranial extension which may contribute to the reduction of mortality as it allows for timely initiation of aggressive treatment. Funding This study was not supported by any funding. Data availability Not applicable. Code availability Not applicable. The authors declare that they have no conflict of interest. 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