Abstract: A 65-year-old man with end-stage renal disease on peritoneal dialysis was admitted for new onset binocular double vision, failure to thrive, and debilitating right-sided headaches. Medical history was significant for tympanomastoidectomy for polymicrobial mastoiditis and treatment with IV antibiotics. MRI brain without contrast was read by radiology initially as showing expected postsurgical changes; however, given patient's history of mastoiditis infection, there was a high clinical suspicion for Gradenigo syndrome. MRI brain was repeated with gadoxetate contrast to minimize the risk of nephrogenic systemic fibrosis (NSF) in a patient with severe renal disease and this revealed an intracranial empyema involving both the trigeminal and abducens nerves confirming the diagnosis of Gradenigo syndrome. This case presented a diagnostic challenge because of suboptimal visualization on initial nonenhanced MRI. Gadoxetate was chosen because of its unique properties including high hepatobilia ry excretion making it a safer form of gadolinium-based contrast agent that may not have the potential to precipitate NSF. Address Correspondence to Collin M. McClelland, MD, Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Phillips-Wangensteen Building, Floor 9, 516 Delaware Street SE, Minneapolis, MN 55455; E-mail: cmc@umn.edu The authors report no conflicts of interest. © 2021 by North American Neuro-Ophthalmology Society
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