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Objective To assess the usefulness of post contrast Fluid attenuated inversion recovery (FLAIR), 3D T1-SPACE, and T1W magnetic resonance imaging (MRI) sequences with fat suppression in diagnosis of infectious meningitis. Methods 75 patients with clinical suspicion of meningitis were evaluated with post contrast FLAIR (PC-FLAIR), post contrast T1-SPACE (PC-T1-SPACE), and post contrast T1WI (PC-T1WI). Sensitivity, specificity, positive predictive value, and negative predictive value of individual sequences were assessed. Results The sensitivity of PC-FLAIR (88.4%) was greater than PC-T1-SPACE (85.5%) and PC-T1WI (82.6%), considering cerebrospinal fluid (CSF) analysis as gold standard ( p < 0.05). Kappa inter-rater agreement between two radiologists was 0.921 for PC-T1-SPACE, 0.921 for PC-T1WI, and 1.0 for PC-FLAIR with a p value <0.05. Both PC-T1-SPACE and PC-FLAIR performed equally in sulcal space enhancement. PC-T1-SPACE and PC-T1WI performed better in evaluation of pachymeningeal enhancement, ependymal enhancement in cases of ventriculitis, whereas PC-FLAIR was more sensitive in assessment of basal cistern enhancement and enhancement along the cerebellar folia. Conclusion Meningeal enhancement could be better appreciated in PC-FLAIR image than PC-T1WI and PC-T1-SPACE. Enhancement in PC-T1-SPACE was comparable to that of PC-T1WI. Being a T1 based spin echo sequence, PC-T1-SPACE has all the advantages of PC-T1WI in addition to its ability to differentiate meningeal enhancement from leptomeningeal vessels. Hence, PC-T1WI can be replaced by PC-T1-SPACE and PC-FLAIR can be added to routine MRI protocol in suspected case of meningitis.

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Background Haemosuccus pancreaticus (HP), also known as pseudohaemobilia, is defined as upper gastrointestinal tract hemorrhage originating from the pancreatic duct into the duodenum via the ampulla of Vater or major pancreatic papilla. Pseudoaneurysm formation from the splenic artery is a common complication of pancreatitis; however, upper gastrointestinal bleed resulting from rupture of splenic artery pseudoaneurysm into the pancreatic duct is unusual and challenging to diagnose. Case presentation A 26-year-old patient presented with multiple episodes of hematemesis, melena, and intermittent abdominal pain. A contrast-enhanced computed tomography (CECT) scan was performed that demonstrated chronic calcific pancreatitis with a pseudoaneurysm in the splenic artery in close relation to the main pancreatic duct. The patient was immediately shifted for endovascular management, and the pseudoaneurysm was successfully embolized. Post embolization, the patient developed splenic abscess, which was managed by percutaneous catheter drainage. Conclusion Due to its rarity and being challenging to diagnose, the mortality rate of HP is high. A high level of expertise is required to diagnose HP, and it should be considered in all upper gastrointestinal bleed patients associated with acute or chronic pancreatitis. Rapid initial CECT and angiography should be performed to confirm the diagnosis, followed by embolization of the bleeding pseudoaneurysm to eliminate the need for surgery. This case report highlights the challenges in the diagnosis and management of HP.

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