Cerebral abscesses imaging: A practical approach

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Paola Feraco https://orcid.org/0000-0002-3707-018X
Davide Donner
Cesare Gagliardo https://orcid.org/0000-0003-4088-2020
Irene Leonardi
Silvia Piccinini
Anna Del Poggio
Rossana Franciosi
Benedetto Petralia
Luc van den Hauwe


brain abscess, magnetic resonance imaging (MRI), diffusion weighted imaging (DWI), magnetic resonance spectroscopy (MRS)


Brain abscesses (BAs) are focal infections of the central nervous system (CNS) that start as a localised area of weakening of the brain parenchyma (cerebritis) and develops into a collection of pus surrounded by a capsule. Pyogenic (bacterial) BAs represent the majority of all BAs; in some cases, the diagnostic and therapeutic management can be challenging. Imaging has a primary role in differentiating BAs from other lesions. Conventional magnetic resonance imaging (cMRI) is essential for the identification of the lesion, its localisation and its morphological features. However, cMRI does not allow to reliably differentiate BAs from other intracranial mass lesions such as necrotic tumours. Advanced sequences, such as diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI) and proton MR spectroscopy (1H-MRS) are very useful in the differential diagnosis from other brain lesions, such as non-pyogenic abscesses or necrotic tumours, and provide essential information on structural, vascular and meta-bolic characteristics allowing greater neuroradiological confidence. The aim of this pictorial review is to provide a practical approach showing the added value of more advanced MRI techniques in their diagnostic management.

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1. Osenbach RK, Loftus CM. Diagnosis and management of brain abscess. Neurosurg Clin North Am. 1992;3:403–420. https://doi.org/10.1016/ S1042-3680(18)30671-5

2. Brouwer MC, Coutinho JM, van de Beek D. Clinical characteristics and outcome of brain abscess: Systematic review and meta-analysis. Neurology. 2014;82:806–13; https://doi.org/10. 1212/WNL.0000000000000172

3. Osborn AG, Hedlund GL. Congenital, acquired pyogenic, and acquired viral infections. In Osborn’s brain, imaging, pathology, and anatomy, 2nd ed. Salt Lake City, UT: Elsevier, Inc.; 2017. p. 353–8.

4. Brouwer MC, Tunkel AR, McKhann GM 2nd, van de Beek D. Brain abscess. N Engl J Med. 2014  Jul 31;371:447–56. https://doi.org/10.1056/ NEJMra1301635

5. Muccio CF, Caranci F, D’arco F, et al. Magnetic resonance features of pyogenic brain abscesses and differential diagnosis using morphological and functional imaging studies: A pictorial essay. J Neuroradiol. 2014 Jul; 41(3):153–67. https://doi.org/10.1016/j.neurad. 2014.05.004.

6. Haimes AB, Zimmerman RD, Morgello S, et al. MR imaging of brain abscesses. Am J Roentgenol. 1989;152:1073–85. https://doi.org/10.2214/ajr. 152.5.1073

7. Luthra G, Parihar A, Nath K, et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. Am J Neuroradiol. 2007;28:1332–8. https://doi.org/10. 3174/ajnr.A0548.

8. Toh CH, Wei KC, Chang CN et al. Differentiation of pyogenic brain abscesses from necrotic glioblastomas with use of susceptibility-weighted imaging. Am J Neuroradiol. 2012;33:1534–8. https://doi.org/10.3174/ajnr.A2986

9. Karampekios S, Hesselink J. Cerebral infections. Eur Radiol. 2005;15:485–93; https://doi.org/ 10.1007/s00330-004-2556-1

10. Antulov R, Dolic K, Fruehwald-Pallamar J, et al. Differentiation of pyogenic and fungal brain abscesses with susceptibility-weighted MR sequences. Neuroradiology. 2014;56:937–45. https://doi.org/10.1007/s00234-014-1411-6.

11. Muccio CF, Esposito G, Bartolini A, et al. Cerebral abscess and necrotic cerebral tumours: Differential diagnosis by perfusion-weighted  magnetic resonance imaging. Radiol Med.  2008;113:747–57. https://doi.org/10.1007/ s11547-008-0254-9.

12. Cartes-Zulmelzu FW, Stavrou Ioannis, Castillo M, et al. Diffusion-weighted imaging in the assessment of brain abscesses therapy. Am J Neuroradiol. 2004;25:1310–17.

13. Finelli PF, Foxman EB. The etiology of ring lesions on diffusion-weighted imaging. Neuroradiol J. 2014 Jun;27(3):280–7. https://doi.org/10.15274/ NRJ-2014-10036.

14. Hartmann M, Jansen O, Heiland S, et al. Restricted diffusion within ring enhancement is not pathognomonic for brain abscess. Am J Neuroradiol. 2001;22:1738–42.

15. Gupta RK, Jobanputra KJ, Yadav A. MR spectroscopy in brain infections. Neuroimag Clin N Am. 2013;23:475–98. https://doi.org/10.1016/j. nic.2013.03.004.

16. Chiang IC, Hsieh TJ, Chiu ML, et al. Distinction between pyogenic brain abscess and necrotic brain tumour using 3-tesla MR spectroscopy, diffusion and perfusion imaging. Br J Radiol. 2009 Oct;82:813–20. https://doi.org/10.1259/bjr/ 90100265.

17. Rahmana TW, Walea DJ, Vigliantia BL, et al. The impact of infection and inflammation in onco-logic 18F-FDG PET/CT imaging. Biomed Pharmacother. 2019;117:109168. https://doi. org/10.1016/j.biopha.2019.109168

18. Dethy S, Manto M, Kentos A, et al. PET findings in a brain abscess associated with a silent atrial septal defect. Clin Neurol Neurosurg. 1995;97:349–53. https://doi.org/10.1016/0303-8467(95)00067-T

19. Tsuyuguchi N, Sunada I, Ohata K, et al. Evaluation of treatment effects in brain abscess with positron emission tomography: Comparison of fluorine-18-fluorodeoxyglucose and carbon-11-methionine. Ann Nucl Med. 2003;17: 47–51. https://doi.org/10.1007/BF02988258

20. Jamar F, Buscombe J, Chiti A, et al. EANM/ SNMMI guideline for 18F-FDG use in inflammation and infection. J Nucl Med. 2013;54:647–58. https://doi.org/10.2967/jnumed.112.112524

21. Signore A, Jamar F, Israel O, et al. Clinical indications, image acquisition and data interpretation for white blood cells and anti-granulocyte monoclonal antibody scintigraphy: An EANM procedural guideline. Eur J Nucl Med Mol Imag. 2018;45:1816–31. https://doi.org/10.1007/ s00259-018-4052-x

22. Roche AD, Rowley D, Brett FM, et al. Concentric and eccentric target MRI signs in a case of HIV-associated cerebral toxoplasmosis. Case Rep Neurol Med. 2018:9876514:3. https://doi.org/10. 1155/2018/9876514

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