AssessmentofaRingEnhancing

IntracranialMass:Abscessor
Tumor?
SarahH.OConnell
MSIV
UniversityofTexasMedicalSchoolatHouston
September21,2009
 PatientJ.B.:HPI

HPI:
53yo womanwithh/o nonHodgkins
Lymphoma4yearsagos/p chemotherapy
treatment.
P/WHA,progressiveRightsidedweaknessX
36hours,andslurredspeechwithword
findingdifficulties.
Deniedfever,chills,N/V,diarrhea,productive
cough.
 PatientJ.B.:CTHeadShowingDiffuse
Edema

Subcortical white matter

hypodensity.

Loss of gray-white junction.

Effacement of sulci.

PACS, BIDMC
Axial CT These findings are suggestive of
diffuse edema.
CourtesyDr.Rafeeque Bhadelia
 PatientJ.B.CTHeadShowingOvoid
Lesion

Ovoid lesion with an isoechoic rim.

PACS, BIDMC
Axial CT

CourtesyDr.Rafeeque Bhadelia
PatientJ.B.hadanMRItobetter
evaluatetheabnormalityseenon
herHeadCT.
 PatientJ.B.:MRIShowingA
Hypointense Area

Area of Hypointensity.

PACS, BIDMC
MRIT1PreContrast

CourtesyDr.Rafeeque Bhadelia
 PatientJ.B.:MRIShowingARing
EnhancingLesion

Enhancement in the sulci

and subdural space.

Ring of enhancement around

an area of hypointensity.

PACS, BIDMC Next, lets take a look at

MRIT1PostContrast the FLAIR images
CourtesyDr.Rafeeque Bhadelia
 PatientJ.B.:MRI#1Showing
Vasogenic EdemaandMassLesion

Vasogenic edema.

Leftparietooccipitalmass.

PACS,BIDMC

MRIT2FLAIR

CourtesyDr.Rafeeque Bhadelia
 PatientJ.B.:MRI#2Showing
Vasogenic EdemaandMassLesion

Vasogenic edema.

Parietooccipital
mass.

PACS,BIDMC

MRIT2FLAIR

CourtesyDr.Rafeeque Bhadelia
Givenourpatientshistory,whatisthe
differentialdiagnosisforthislesion?

Howcanwedeterminethe
differential?
 AssessmentofIntracranialLesions
Intraaxial orExtraaxial?
Intraaxial massesarecompletelysurroundedbybrain.
Metastases
Intracranialhemorrhages
Primaryintracranialtumors(i.e.glioblastoma)
Abscesses

Extraaxial masseshaveabroaddural surface.

Subduralandepiduralhematomas
Meningiomas
Neuromas
Dermoid orEpidermoid cysts

SolitaryorMultiple?
Solitary duetoalocalizedprocess.
Multiple duetosystemicorwidespreaddisease.
 AssessmentofIntracranialLesionsCont.
InvolvementoftheGrayMatter,WhiteMatterorBoth?
Graymatterlesions infarct,traumaorencephalitis.
Whitematterexpansile lesionassociatedwithvasogenic edema tumor,
abscess,orhematoma.
Whitematterexpansionwithgraymatterinvolvementmeanscytotoxic
edemaispresent infarct,trauma,orencephalitis.

Distribution?
Vascularvs.traumaticvs.encephalitis.

PatternofContrastEnhancement?
Enhancement=breakdownofthebloodbrainbarrier.Considermalignancy,
infarct,encephalitis,hemorrhage,orabscess.
 PatientJ.B.:MRIShowingRing
EnhancingMasswithVasogenic Edema

PACS,BIDMC PACS,BIDMC
MRIFLAIR MRIT1PostContrast

Our patients lesion appears to be intraaxial, solitary, involving the

white matter and has surrounding vasogenic edema. It also exhibits
ring-enhancement and associated leptomeningeal and
pachymeningeal enhancement.
CourtesyDr.Rafeeque Bhadelia
Whatisthedifferentialdiagnosisfora
ringenhancingbrainlesion?
DifferentialDiagnosisofRingEnhancing
Lesions
Metastasis
Abscess
Gliomas
Infarct
Contusion
Demyelination
Radiationnecrosis
DDXofRingEnhancingLesionsCont.:
Reviewof221casesbySchwartzetal. 40%gliomas,
30%metastases,8%abscesses,6%demyelinating
disease.

45%ofmetastasesand77%ofgliomas weresingle
lesions.

Multiplelesionsseenin75%ofabscesscasesand85%
ofMScases.

Deepwhitematterlesionswithmasseffectand
vasogenic edemawereusuallyprimaryneoplasms or
abscesses.
 ImagingCharacteristics

Gliomas

MetastaticDisease

Abscesses
 ImagingCharacteristics:Gliomas on
MRI
CTorMRI
Expansile masswithcentralnecrosis.
Largesurroundingregionofvasogenic edema.

RingEnhancement
Thickirregular.
Shaggyinnermargin.
Multilocular ringpatterns.

Noncontrast CT
Typicallyheterogeneous.
Lobulated.
Markedsurroundingwhitematteredema.
Calcificationsoccasionally.
Necrosisandhemorrhagecommon.

MRI
TumorNidus showsT1andT2prolongation(darkonT1andbrightonT2).
 CompanionPatient#1:
Gliomablastoma Multiforme onMRI
MRIT1withcontrast

Expansile mass with

central necrosis.

Surrounding vasogenic
edema and mass effect.

Shaggy irregular ring-

enhancement.

Smirniotopoulos J G et al. From the Archives of the AFIP: Patterns of Contrast

Enhancement in the Brain and Meninges. Radiographics 2007;27:525-551
 ImagingCharacteristics:Metastatic
Disease
Intraaxial Metastases
Lung,breast,melanoma,andcoloncarcinomas.

Extraaxial Metastases
Breastcarcinoma,lymphoma,prostatecarcinoma,lung
carcinoma,andneuroblastoma.

CT/MRI
Classicappearance multiplefociatgraywhitematter
junction.
Hypodense onCT.
Hypointense onT1WIs.
VariablesignalintensityonT2WIs.
Markedvasogenic edemasurroundingeachlesion.
Intensenodularorringenhancement.
 CompanionPatient#2:MetastaticBreast
CanceronMRI
MRIT1withcontrast

Ringenhancinglesionsnearthe
cortex,deepgraymatter,orthegray
matterwhitematterjunction.

Smirniotopoulos J G et al. From the Archives of the AFIP: Patterns of Contrast

Enhancement in the Brain and Meninges. Radiographics 2007;27:525-551
 ImagingCharacteristics:Abscess
OnContrastenhancedCTandMR
Welldefinedrimofenhancement.
Thin(27mm),uniformlyconvex,smoothinnerandouter
margins(lateabscess).
Capsuleisisointense orhyperintense towhitematteronT1.
Capsuleishypointense towhitematteronT2.

AreaofCentralNecrosis
LowdensityonCT.
LowsignalonT1.
Highsignalonintermediateimages,FLAIRimages,andT2.

Prominentsurroundingvasogenic edemausuallypresent.
 CompanionPatient#3:Intracranial
AbscessonMRI
MRIT1withcontrast

Thinrimofenhancement
withsmoothinner
margin.

Areaoflowsignal
representingcentralnecrosis.

Smirniotopoulos J G et al. From the Archives of the AFIP: Patterns of

Contrast Enhancement in the Brain and Meninges. Radiographics
2007;27:525-551
 CompanionPatient#3:Intracranial
AbscessonMRI
MRIT2

Abscesswall.

Surroundingvasogenic
edemaandmass
effect.

Smirniotopoulos J G et al. From the Archives of the AFIP:

Patterns of Contrast Enhancement in the Brain and Meninges.
Radiographics 2007;27:525-551
 CompanionPatients#s1and3:Comparisonof
MRIFindings

Noticetheabscesswallisdark
onT2,thisisincontrasttothe
Glioblastoma wherethewall
ofthelesioninbrightonT2.

Smirniotopoulos J G et al. From the Archives of the AFIP: Patterns of Contrast Enhancement in the Brain
and Meninges. Radiographics 2007;27:525-551
 IstheMassaTumororanAbscess?

Despitethesedifferencesdistinguishingbetween
anecrotictumorandcerebralabscessisoften
difficultwithCTorconventionalMRI.

DiffusionWeightedImaging(DWI)andApparent
DiffusionCoefficient(ADC)mappingcanhelp
differentiatethetwo.

ProtonMRSpectroscopy improvingthe
accuracyofdiagnosiswithMR.
 DWIandADC
DWI
Restrictedmotionofwatermoleculesappearsbright(CSF
willbeblack).
Asintracellularwaterincreases(i.e.cytotoxic edema)
increasedrestrictionofmoleculesrelativetoextracellular
water brighteronDWI.
Withtumor,trauma,andinfection,bothintracellularand
extracellularwatermayincrease givesanambiguous
appearanceonDWI.

ADCMaps
AccountsforT2effectsofextracellularedemaand
subtracts themout.
BrightonDWIanddarkonADC =truerestricted
diffusion.
 NecroticTumorvs.Pyogenic Abscess:
DifferentiationbyDWIandADC

NecroticTumor
Decreased signalintensityonDWimages.
Increased signalintensityonADCmaps.

Pyogenic Abscess
Increased signalintensityonDWimages.
Markedlydecreased signalintensityonADCmaps.
Nowletsreturntoourpatient,
J.B.
 PatientJ.B.:DWIandADCWeightedMRI
Scans MRIADCMap
MRIDWI

PACS, BIDMC PACS, BIDMC

Wecanseefromourpatientsimagesthatthelesionisbright
ontheDWI(showingincreasedsignal),anddark(indicativeof
lowsignal)ontheADCmap.Thisisconsistentwithanabscess.

CourtesyDr.Rafeeque Bhadelia
 Thefindingofanabscessimpactedthe
patient'smanagement.Insteadofwaiting
untilMondaytohavesurgeryonapresumed
metastaticlymphomalesion,sheunderwent
immediatesurgeryovertheweekend.Her
lesionwasculturedanditgrewStreptococcus
milleri.
 Abscess:Pathogenesis
Directspreadfromcontiguoussite:
2060%ofcases.
Resultsinsinglefocusofinfection.
Usualsourcesofinfection subacute orchronicsinusitis,
mastoiditis,otitis media,dentalinfections.

Hematogenous spread:
Resultsinmultipleabscesses,mostcommonlylocatedin
distributionofthemiddlecerebralartery.
Formatgraywhitematterjunction.
Sitesofprimaryinfection bacterialendocarditis (24%of
cases),lungabscessandempyema,skin,pelvicor
intraabdominal infections,esophagealdilationand
endoscopicsclerosisofesophagealvarices,cyanotic
congenitalheartdiseases.
 Abscess:PathogenesisCont.
Abscessdevelopmentoccursoverseveralweeks.

EarlyCerebritis:
Lesionispoorlydemarcatedandassociatedwithlocalized
edema.
Imagingcharacteristicsarenonspecific.

LateCerebritis CapsuleStage:
Occurs12weeksafterinfection.
Increaseinnecrosiscentrally,feworganismspresent.
Capsuleformationwithcollagenandreticulin.
Surroundingvasogenic edema.
Characteristicringenhancementisnowevident.
 Abscess:Etiology
Dependsonprimarysiteofinfection,patientsageandimmunestatus.

Mostcommon Anaerobes.

Postsurgical/trauma Staphylococcusaureus.

ImmunoComprisedHostsToxoplasma gondii,Fungal,Listeria,Parasitic.

AlsoGramNegativeRods,Pneumococcus,Streptococcus,Nocardia,and
Actinomyces.

Streptococcusmilleri common,itpossessesproteolytic enzymesthat

predisposetotissuenecrosisandtheformationofabscesses.

Noidentifiablesourceinapproximately25%ofpatients.
 Abscess:PresentationandTreatment
Manifestations:
Symptomsmaybemildorsevere.
Headache.
Varyingdegreesoflethargy,obtundation,nausea,vomiting,andfever.
Feverabsent>50%ofthetime.
Meningeal signspresentin30%ofpatients.
Focalneurologicdeficits,papilledema,nuchal rigidity,andseizuresmaydeveloprapidly
(fewdays).
ElevatedWBCcount.
CSFfindingsarenonspecific,andusuallynotobtainedbecauseoftheriskoflumbar
punctureinthesettingofabrainmass.

Treatment:
Surgicalaspirationorexcisionfollowedbyantibiotictherapy.
Corticosteroidsperioperatively toreduceintracranialpressureandpreventbrain
herniation.
Antiepilepticsforseizureprevention.
Smallabscesses<2.5cmmayrespondtoantibioticsalone.
Mortalityrates030%.
Earlydiagnosisandtreatmentareimportanttoreducemorbidityandmortality!
 MRSpectroscopy
Oftenstilldifficulttodistinguishanabscessfromanecrotic/cystictumor
ormetastasiswithMRIandDWtechniques.

ConventionalMRImaging:
Diagnosticaccuracy61.4%.
Sensitivity61.9%.
Specificity60.9%.

MRSpectroscopydetermineschemicalmakeupofbrainlesions.

MRSpectroscopy diagnosticaccuracyindifferentiatingsimilarappearing
brainlesionsrangesfrom8592%.

WhencombinedwithconventionalMRimagingandDWimaging:
Diagnosticaccuracy97.7%.
Sensitivity95.2%.
Specificity100%.

Canidentifycausativeorganismbasedonthespectroscopicpattern:
CanidentifyAnaerobes,obligateaerobesorfacultativeanaerobes,
Streptococcus,Staphylococcus,orMycobacterial species.
 Summary
Characteristics(location,number,distribution,
enhancementpattern)ofanintracraniallesion
arehelpfulinnarrowingthedifferential.

ConventionalMRandDWimaginghelp
differentiateanabscessfromanecrotic/cystic
tumorormetastasis.

MRSpectroscopyincreasesthediagnostic
accuracyofconventionalMRandDWimagingin
theidentificationofsimilarappearingbrain
lesions.
 Acknowledgements

ThankYoutothefollowingpeople

Dr.Rafeeque Bhadelia

Dr.GillianLieberman

Ms.MariaLevantakis
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