Presentation
8 days of asthenia, adynamia, headache with pulsatile characteristics and intensity 8/10, refer to an episode of loss of postural tone without sphincter relaxation for which decide consult.
Patient Data
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MRI shows well-defined round intra-axial lesions T1 hypointense and T2 hyperintense in the right and left frontal subcortical white matter. The lesions have a thick wall with dual rim sign best seen on T2WI, ring enhancement in post-contrast T1. The lesions show true restricted diffusion on DWI images (low signal on ADC). There is important perilesional edema.
Aspiration of the cerebral abscess.
Bacterial culture grows Streptococcus Intermedius.
Images courtesy of Dr. Johann Serrato, Neurosurgeon.HMC.
Case Discussion
The differential diagnosis for ring-enhancing cerebral lesions includes cerebral abscess, tuberculoma, neurocysticercosis, metastases, glioblastoma multiforme, demyelination (incomplete ring), etc. See mnemonic MAGIC DR.
The dual rim sign is a very specific imaging feature that is typically seen in pyogenic brain abscesses.
DWI is very useful and shows a high DWI signal that is usually present centrally.
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