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Rachel Berger Preisser, M.D. August 27, 2010

Explore a detailed neuro MRI case of a 39-year-old male with headaches and visual changes. Learn about the imaging findings, differential diagnoses, presentation symptoms, and treatment options for Nocardia Cerebral Abscess.

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Rachel Berger Preisser, M.D. August 27, 2010

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  1. Best CaseNeuro MRI Rachel Berger Preisser, M.D. August 27, 2010 Department of Radiology Allegheny General Hospital

  2. History • 39-year old male with headaches and visual changes of 3 weeks duration.

  3. Images T2 FLAIR T1

  4. Images DWI ADC

  5. Images T1 post contrast

  6. Findings • Multicystic 3cm temporooccipital mass • T2W: hypointense rim, hyperintense center • FLAIR: hypointense center (fluid) • T1W: hyperintense rim, hypointense center • Restricted diffusion • Adjacent edema • Local mass effect and mild midline shift • Ring enhancement

  7. Findings Mass effect Edema Central necrosis T2 FLAIR T1

  8. Findings: restricted diffusion DWI bright ADC dark

  9. Findings: ring enhancement T1 post contrast

  10. Differential Cerebral ring-enhancing lesions MAGIC DR • Metastasis • Abscess • Glioma • Infarct (resolving) • Contusion (resolving hematoma) • Demyelinating disease (Tumefactive MS) • Radiation Necrosis

  11. Diagnosis • Nocardia Cerebral Abscess

  12. Presentation: Headache (50-90%) Focal neuro deficit (50%) Altered mental status (50%) Seizure (40%) Other: nausea, vomiting, stiff neck, fever Frequency: 1500-2500 cases/yr in US Morbiditiy: 10% overall 80% with intraventricular rupture. Discussion A brain abscess is a focal pyogenic infection of parenchyma • Diagnostic Pearl: Unlike abscesses located in other parts of the body, cerebral abscess rarely contains gas • Locations: • Usually supratentorial • Periventricular white matter most common in neonates • Subcortical white matter and basal ganglia most common in children

  13. Discussion • Epidemiology: • AIDS: Toxoplasmosis, mycobacterium • Post-transplant: Nocardia, Aspergillus, Candida • Bacterial:Staphylococcus, Streptococcus, Pneumococus • Neonates: Proteus, Serratia, Psuedomonas, Citrobacter, Staphlococcus aureus • Treatment: • Surgical drainage/ excision first line • Antibiotics if <2.5cm • Steroids for mass effect

  14. Discussion • Pathologic stages: - Early Cerebritis: 3-5 days - Late Cerebritis: 4 days- 2 weeks - Early Capsule: 2 weeks - Late Capsule: weeks to months • Resolution: • Decreasing T2 hyperintense rim • Increase in ADC signal • Enhancement is last to resolve

  15. Discussion Stage T1W T2W DWI Contrast Temporal variation of imaging findings: Early Cerebritis Mixed Hypo-Isointense Mass, Ill-defined margin Hyperintense, Ill-defined margin Hyperintense DWI signal Patchy or no enhancement Hyperintense edema and center, Hypointense rim, Intense, but irregular enhancement Late Cerebritis Develops hypointense center Hyperintense DWI signal Rim Iso/Hyper to white matter Center Hyper to CSF Hyperintense DWI signal ADC markedly decreased Well defined, thin wall of enhancement Early Capsule Hypointese Rim Hyperintense DWI signal ADC markedly decreased Cavity shrinks Capsule thickens Decreasing edema and mass effect Thickened enhancing rim, esp. near cortex Late Capsule

  16. Reference(s) • Grant, P. Ellen; “Brain Abscess” Statdx. https://my.statdx.com. Accessed Accessed August 24, 2010. • Thomas, Lisa; “Brain Abscess”, eMedicine. http://emedicine.medscape.com Accessed September 12, 2010. • https://my.statdx.com.

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