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MAGNETIC RESONANCE FEATURES OF PYOGENIC BRAIN ABSCESSES AND DIFFERENTIAL
DIAGNOSIS
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Summary Etiology, Pathogenesis, Clinical
Features of Pyogenic Cerebritis and Brain Abscesses.
Imaging (MRI, DWI, PWI, MRS, SWI)
Differential Diagnosis, Treatment Planning, Follow-up
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Cerebritis and Brain Abscess in Children
1-2 % of brain occupying lesions in western countries – 8% in developing countries
15-30 % of the cases involve young patients (< 15 yo)
Pyogenic brain abscesses: 1/3 of all cerebral abscesses.
Muccio et al. J Neuroradiol 2014 Jul:41(3):153-167
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Bacteria entering the CNS… How?
Hematogenous Spread (distant infection, sepsis)
Extension from Contiguous Infections (otomastoiditis, sinusitis, meningitis)
Direct Traumatic Implantation (craniofacial trauma, neurosurgery)
Association with Cardiopulmonary Malformation (congenital heart disease, hereditary Hemorragic telangiectasia)
Tortori-Donati P, Rossi A, Bianchieri R. Pediatric neuroradiology: Brain, Head, Neck and Spine. Springer 2005. pp 498-511
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Who? Aerobic: Staphylococcus, Streptococcus,
Pneumococcus. Anaerobic: Clostridium species, Actinomyces.
Neonatal Age
Commonly brain abscesses complicate meningitis
Gram -
Fitz CR. Inflammatory diseases of the brain in childhood.AJNR Am J Neuroradiol 1992; 13:551–567.
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Supratentorial Region in subcortical white matter (+++) hematogeneous spread
Basal Ganglia (rare)
Where?
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Temporal Lobe and Cerebellum (middle ear otitis)
Multiple Lesions (immunocompromised)
Neonatal Age
Multiple Lesions Periventricular location
Where?
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Clinical Features Non-specific
Fever (??) common condition in hospitalized children, only 55% body temp > 38.5°
Focal Neurological Signs (40-60%) location
Seizure, Vomiting, Lethargy
Sign of increase ICP (newborns) Head Circ.
Erdogan E et al. Pyogenic brain abscess. Neurosurg Focus 2008;24(6):E2
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Clinical Features COMPLICATIONS: - Intraventricular Rupture
- Dissemination
- Acute Hydrocephalus
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Clinical Features COMPLICATIONS: Sinus Thrombosis
Cerebellar Abscess in 8-year-old boy with Otomastoiditis (*) complicated by thrombosis of the sigmoid sinus and jugular vein (arrows)
Tortori-Donati P, Rossi A, Bianchieri R. Pediatric neuroradiology: Brain, Head, Neck and Spine. Springer 2005. pp 498-511
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Anatomical Theatre , University of Padua - Italy (1594)
Andrea Vesalius, De Humani Corporis Fabrica (1542)
…what we see in imaging has an anatomical/pathological correlation…
…remember the lesson of the masters…
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From focal cerebritis to mature abscess…
Tortori-Donati P, Rossi A, Bianchieri R. Pediatric neuroradiology: Brain, Head, Neck and Spine. Springer 2005. pp 498-511
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Early Cerebritis
Days 1-3 following inoculation Injury of brain microvasculature due to
bacteria Spread of the bacteria across wall of
injured vessel to GM/WM Local inflammation, vascular congestion,
necrosis, microhemorrhages, perivascualr edema
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Early Cerebritis
Osborn – Brain 2014
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Early Cerebritis
Tortori-Donati P, Rossi A, Bianchieri R. Pediatric neuroradiology: Brain, Head, Neck and Spine. Springer 2005. pp 498-511
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Days 4-9
Necrotic center confined by an irregular layer of inflammatory granulation tissue
In absence of treatment host response formation of abscess capsule
Late Cerebritis
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Late Cerebritis Initial necrosis
Peripheral rim (not completely formed)
More mass effect
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Late Cerebritis
Tortori-Donati P, Rossi A, Bianchieri R. Pediatric neuroradiology: Brain, Head,
Neck and Spine. Springer 2005. pp 498-511
Central necrosis (*)
Not complete encapsulation
Peripheral C.E.
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From focal cerebritis to mature abscess…
Tortori-Donati P, Rossi A, Bianchieri R. Pediatric neuroradiology: Brain, Head, Neck and Spine. Springer 2005. pp 498-511
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From focal cerebritis to mature abscess…
Barkovich AJ, Raybaud C. Pediatric Neuroimaging. LWW 2012
Neonate Diffuse areas of
restriction Hemorrhagic
necrosis on T2* Patchy cortical-
subcortical c.e. Mild mass effect
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From focal cerebritis to mature abscess… (5 DAYS LATER…)
Barkovich AJ, Raybaud C. Pediatric Neuroimaging. LWW 2012
DWI : large confluent frontal WM restriction Enhancing capsule +++ Mass effect (subfalcine herniation)
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Days 10 and later 5 layers:
- Necrotic centre
- Granulation tissue- Lymphocytes and plasma cells- Dense fibrous tissue - Surrounding edema/gliosis
Abscesscapsule
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Abscess
Necrosis
Capsule
Transition zone (edema/gliosis)
Normal Brain
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Stage III (early capsule) VS Stage IV(mature capsule)
Bilocular lesion Difference in capsule! *edema Tortori-Donati P, Rossi A, Bianchieri R.
Pediatric neuroradiology: Brain, Head, Neck and Spine. Springer 2005. pp 498-
511
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Abscess: Imaging Central necrosis : T2 Hyper, T1 Hypo
(sometimes variable T2 signal intensity!!!) External capsule: T2 Hypo, T1 Hyper
(possible non typical signal: Iso/Hypo T1- Hyper T2)*
Surrounding Edema: T2 Hyper, T1 Hypo Rim enhancement
*collagen fibers-macrophages releasing free radicals with paramagnetic effect.
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• * Core • capsule• edema
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External capsule: non typical signal
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Core: variable signal Satellite Abscesses
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Neonates and Small Infants
Gram Negative (Serratia, Pseudomonas, Proteus), S.Aureus
Complication of Meningitis
Multiple, PV white matter: rupture in lateral ventricles
Larger
Incomplete: without well definite capsule -> rapid enlargement
Muccio et al. J Neuroradiol 2014 Jul:41(3):153-167
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Citrobacter Diversus, 5 weeks Old Infant. Multiple infected cavities with rim enhancement, daughter cysts and fluid with different signal intensity (blood and pus).
Blaser S, Jay V et al. MRI of the Neonatal Brain. Chapter 10 (Rutherford M.)
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Critical support in the diagnosis of cerebral abscesses
Central necrotic area: proteins, bacterial and cellular debris
Hyper DWI – Low ADC (0.28 – 0.73 x 10-13 mm2/s)
Wide range of ADC: type of bacteria, immune response
Diffusion Weighted Imaging
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Lee EJ et al. Unusual findings in cerebral Abscess: report of two cases. Br J Radiol 2006;79:e156-61
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Hernandez M I et al. Stroke Patterns in Neonatal Group B Streptococcal Meningitis. Pediatr Neurol. 2011; 44(4):282-8
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Central Necrotic area: lipids+lactate (0.8/1.2 – 1.3 ppm). No NAA and Cho
Alanine (1.5 ppm) and other amino acids (0.9 ppm): proteolisis enzymes released by neurtrophils
Acetate (1.9 ppm), succinate (2.4 ppm): bacterial glicolisis and fermentation
MR-spectroscopy
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Type A: Lac, aa, ala, acetate, succinate and lipids obligate anaerobes
Type B: Lac, aa obligate aerobes
Type C: lac alone streptococcus and treated abscesses
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Type A: Lac, aa, ala, acetate, succinate and lipids obligate anaerobes
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Few studies
Low perfusion in capsule (compared to WM)
Useful for differential diagnosis
Late stage: fibroblasts low CBV
Perfusion Weighted Imaging
Harris M et al. Differentiation of infective from neoplastic brain lesions by dynamic contrast-enhanced MR. Neuroradiology 2008;50:590-603
Erdogan C et al. Brain abscess and cistic brain tumor: discriminationwith dynamic susceptibility contrast-perfusion-weighted MRI. J Comput Assist Tomogr 2005;29:663-7
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Differential Diagnosis Necrotic Brain Tumors
Fungal Abscesses
Tubercular Abscesses
Toxoplasmosis
Neurocysticercosis
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Necrotic Brain TumorsHGG and Meta
Rim: T2 hypo but often NOT COMPLETE
Rim: non-homogeneous c.e. (meta can have complete rim c.e. similar to pyogenic abscesses!)
Nodular c.e. in the cavity
Increase rCBV
H-MRS: no aa, acetate, succinate
DWI: hypo (often)
SWI “double rim” sign : present in abscess but no in necrotic gliomas (Toh et al AJNR 2012)
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DWI restriction described in metastases from lung, breast, colorectal, testicular and bladder cancers
DWI increased signal: intratumoral hemorrhage
Necrotic Brain TumorsHGG and Meta
Park SH et al. Diffusion Weighted MRI in cystic or neurotic intracranial lesions. Neuroradiology 2000;42:716-21
Duygulu G et al. Intracranial metastases showing restricted diffusion: correlation with histopathological findings. Eur J Radiol 2010;74:117-20
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Toh et al. Differentiation of pyogenic brain abscesses from necrotic glioblastoma with use of susceptibility-weigthed imaging. AJNR 2012;33(8):1534-8
Fibrocollagenous capsule
Granulation tissue
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Rare
Rim c.e. and DWI/ADC similar to pyogenic abscesses
More often hemorrhagic strokes (but also Strepto in neonates!!!)
Look for primary aspergillosis (lungs, paranasal sinuses)
Fungal Abscesses
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Rim: T2 hypo and c.e. (similar to PA)
Core variable in T2 and DWI (caseous or liquefactive necrosis)
High peripheral rCBV !!
Association with meningitis
Tuberculoma
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Type 1: Caseous Necrosis, T2 HYPO, high ADC
Type 2: slightly hypertnese in T2 , intermediate ADC
Type 3: Liquefactive necrosis, strongy HYPER T2, low ADC (similar PA)
Tuberculoma: core
Gupta RK et al. Eu J Radiol 2005, 85(3): 384-92
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Immunocompromised patients, multiple lesions
“Eccentric Target Sing” : eccentric area of c.e.
“Concentric Target Sign” :T2 concentric alternating zones of hypo- and hyperintensity
DWI / ADC : hypo / high (useful in dd with PA) CBV similar to PA
Cerebral Toxoplasmosis
Mahadevan A et al. Neuropatological correlate of the “concentric target sign” in MRI of HIV associated cerebral toxoplasmosis. J Magn Reson Imaging 2013;38(2):488-95
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Neurocysticercosis Core Hypo T1, Hper T2
Capsule: hypo T2 with c.e.
SCOLEX: eccentric hypo T2 nodule with c.e.
Interventricular spread (54%)
DWI / ADC: hypo / high (dd with PA)
Low rCBV (similar to PA)
Sinha S, Sharma B. Intraventricular neurocysticercosis: a review of current status and management issues. Br J Neurosurg 2012;26(3):305-9
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THANK YOU