Cerebral abscesses: medically managed

Case contributed by A.Prof Frank Gaillard

Presentation

Headaches

Patient Data

Age: 65 years
Modality: MRI

Multiple peripherally enhancing lesions with central profound restricted diffusion and surrounding vasogenic oedema are noted. Also note the presence of a complete thin rim of T2 signal loss. No susceptibility artefact to suggest haemorrhage within these lesions. No evidence of ventriculitis. 

Conclusion:

Multiple parenchymal cystic mass lesions with diffusion restriction contents are consistent with cerebral abscesses. 

The patient had the posterior fossa abscess drained and the rest were medically treated. 

Microbiology:

MICROSCOPY GRAM STAIN:

  • Leucocytes +++
  • Gram positive bacilli +

CULTURE:

  • Nocardia farcinica ++

 

 

What follows are a summary of medical management of the remaining lesions, focusing on the changes in diffusion restriction. 

 

Day 0 - selected images

Modality: MRI

D0 study (i.e. same as the complete study above, pre-op)

 

ADC 529 x 10-6 cm2/s

Day 3 - selected images

Modality: MRI

Day 3 post op. 

ADC 600 x 10-6 cm2/s

Day 10 - selected images

Modality: MRI

Day 10 post surgery

ADC 794 x 10-6 cm2/s

Day 20 - selected images

Modality: MRI

Day 20 post op: the morphology of the abscesses remains very similar, as does the degree of oedema. ADC have however normalized. 

ADC 2,200 x 10-6 cm2/s

 

Combo

Modality: MRI

Combo image showing how unreliable T1 C+, T2 and FLAIR are at assessing medical response. Note how ADC values progressively increase with successful management. 

Case Discussion

When assessing medical management of abscesses it is important to realize that morphology is not a great feature. Rather, measure ADC values which will normalize as treatment is effective. 

PlayAdd to Share

Case Information

rID: 45183
Case created: 17th May 2016
Last edited: 20th Jul 2016
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.