Presentation
Patient with known hypoxic ischemic encephalopathy who developed altered conscious level and seizures.
Patient Data
Multiple intraparenchymal cortically located cystic lesions of varying sizes are seen in the frontal, parietal and insular regions of the left cerebral hemisphere. These display marginal enhancement with hypodense contents and surrounded by massive perifocal edema. Associated involutional changes are noted.
The cystic lesions walls show isointense signal on T1 and FLAIR and low signal on T2. The walls show irregular ring enhancement after contrast with focal nodular enhancement of the lesions at the insular region as well. On DWI/ADC the walls as well as the nodular soft tissue display diffusion restriction while the contents don't show restriction. There is grade III edema that involves the whole cerebral hemisphere with mild mass effect upon the ipsilateral lateral ventricle.
Case Discussion
The pattern of diffusion restriction of the wall without the center correlates with a fungal abscess rather than a pyogenic abscess. The nodular soft tissue seen along the medial walls of insular cystic lesions is believed to be fungal hyphae. The low T2 signal of the lesion walls is believed to be due to increased iron in fungal elements.
Biopsy from the lesion revealed Aspergillus species and the patient was found to be immunocompromised.
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