Conglomerate ring and tract-like enhancement lesions: Neuroimaging in Listeria monocytogenes brain abscess

This report aims to describe a characteristic neuroimaging of Listeria monocytogenes brain abscess in predisposed patients. A 56-year-old man presented with fever and headache for 3 weeks. Cerebrospinal fluid (CSF) revealed pleocytosis with lymphocytosis, high protein, and low glucose. Both hemoculture and CSF culture yielded L monocytogenes. Another case is a 23-year-old woman with systemic lupus erythematosus, who presented with fever, headache and left hemiparesis. CSF showed pleocytosis with polymorphonuclear cells predominance and low glucose. Hemoculture positive for L monocytogenes. Their MRI brain revealed conglomerate ring and tract-like enhancement lesions at the right parietotemporal lobe. The patients were diagnosed with L monocytogenes brain abscess. They received a high dose of ceftriaxone and ampicillin for 6 weeks. The clinical and MRI at the end of treatment was a substantial improvement. Our information can help the physician concern about this pathogen in patients who presented with brain abscess and had these MRI findings.     

Polyvinylpyrrolidone contrast enhancement: abscess imaging.

Rabbits with thigh abscesses received an intravenous solution of polyvinylpyrrolidone (PVP) and metallic salts, resulting in a dense ring of contrast enhancement as determined by computed tomography (CT). Enhancement increased during the first two weeks, stabilized, then decreased to control levels at eight weeks. After antibiotics the ring of enhancement appeared to mark the abscess perimeter as it regressed. Normal muscle density did not change. The magnitude and duration of enhancement would improve CT detection of small lesions and be useful in evaluating the efficacy of therapy.     

Modeling water diffusion anisotropy within fixed newborn primate brain using Bayesian probability theory.

An active area of research involves optimally modeling brain diffusion MRI data for various applications. In this study Bayesian analysis procedures were used to evaluate three models applied to phase-sensitive diffusion MRI data obtained from formalin-fixed perinatal primate brain tissue: conventional diffusion tensor imaging (DTI), a cumulant expansion, and a family of modified DTI expressions. In the latter two cases the optimum expression was selected from the model family for each voxel in the image. The ability of each model to represent the data was evaluated by comparing the magnitude of the residuals to the thermal noise. Consistent with previous findings from other laboratories, the DTI model poorly represented the experimental data. In contrast, the cumulant expansion and modified DTI expressions were both capable of modeling the data to within the noise using six to eight adjustable parameters per voxel. In these cases the model selection results provided a valuable form of image contrast. The successful modeling procedures differ from the conventional DTI model in that they allow the MRI signal to decay to a positive offset. Intuitively, the positive offset can be thought of as spins that are sufficiently restricted to appear immobile over the sampled range of b-values.     

Formalin fixation alters water diffusion coefficient magnitude but not anisotropy in infarcted brain.

This study was designed to determine whether formalin fixation alters diffusion parameters in the infarcted brain. Diffusion tensor images were obtained from anesthetized mice 1 hr after middle cerebral artery occlusion and repeated after formalin fixation of brains. In live animals, there was a significant decrease in the trace of the diffusion tensor (Tr(D)) in infarcted cortex and external capsule compared with contralateral brain areas, with no change in relative anisotropy (RA). After formalin fixation, Tr(D) was reduced 30-80%. However, the Tr(D) differential present in vivo between injured and healthy tissues was lost, with Tr(D) reduced to similar values in all tissues except for the edge of the cortical infarction, where it was lower than in surrounding tissues. RA values were unchanged after fixation. This study supports the preservation of diffusion anisotropy for both healthy and injured white matter in fixed mouse brain. However, the sensitivity of water diffusion in detecting tissue injury in vivo is not preserved in fixed tissues.     

Discrimination of an infected brain tumor from a cerebral abscess by combined MR perfusion and diffusion imaging.

The aim of this study was to investigate the signal characteristics of the abscess wall and tumor wall on diffusion-weighted and perfusion-weighted images and thus to evaluate the feasibility of using combined MR diffusion and perfusion imaging to differentiate pyogenic cerebral abscess from infected brain tumor. The tumor wall of various types of cystic or necrotic brain tumor was significantly hyperintense relative to that of cerebral abscess wall on both diffusion-weighted images and regional cerebral blood volume maps.Sixteen patients who had cerebral masses with large cystic or necrotic cavities were imaged to generate diffusion-weighted images and regional cerebral blood volume maps using single-shot echoplanar imaging (EPI) pulse sequences. Apart from qualitative analysis, apparent diffusion coefficients (ADC) as well as regional cerebral blood volume (rCBV) ratios were calculated from the abscess wall and peripheral tumor wall and comparison was made by using Student's t-test. The tumor wall of various types of cystic or necrotic brain tumor had significantly lower ADCs relative to those of the abscess wall (P<0.005) and thus appeared relatively hyperintense on diffusion-weighted images. The mean rCBV ratio relative to normal white matter (2.90+/-0.62) of the peripheral tumor wall of various types of cystic or necrotic brain tumor were significantly larger than the mean rCBV ratio (0.45+/-0.11) of the pyogenic cerebral abscess wall (P<0.001) by Student's t-test. It is concluded that the combined MR diffusion and perfusion imaging might be capable of differentiating an infected brain tumor from a pyogenic cerebral abscess.     

In vivo demonstration of neuroinflammatory molecule expression in brain abscess with diffusion tensor imaging

BACKGROUND AND PURPOSE: Neuroinflammatory molecules, including tumor necrosis factor-α, interleukin1-β, lymphocyte function associated molecule-1, and intercellular cell adhesion molecule-1 contribute to the development of brain abscess. We hypothesized that the high fractional anisotropy (FA) in the brain abscess cavity reflects the upregulation of these neuroinflammatory molecules.Materials and METHODS: Diffusion tensor imaging (DTI) was performed in 24 patients with brain abscess and Staphylococcus aureus–treated as well as nontreated Jurket cell lines (at 4 time points: 1, 24, 48, and 72 hours). Neuroinflammatory molecules were quantified from the brain abscess cavity aspirate of the patients as well as from the heat-killed S aureus–treated and nontreated cell lines and correlated with DTI measures.RESULTS: The DTI-derived FA strongly correlated with the presence of neuroinflammatory molecules in the pus as well as in S aureus–treated cell lines; no such correlation was observed in nontreated cell lines.CONCLUSIONS: These data indicate that neuroinflammatory molecules confer high diffusion anisotropy inside the brain abscess cavity. We propose that increased FA reflects upregulated inflammatory response in brain abscess.

Despite significant advances in the diagnosis and treatment, brain abscess remains a potentially fatal central nervous system infection. Brain abscess develops in response to a parenchymal infection by bacteria, beginning as a localized area of cerebritis and evolving into a suppurative lesion surrounded by a well-vascularized fibrotic capsule. The leading etiologic agents of brain abscess are the Streptococcus species and Staphylococcus aureus, though a myriad of other organisms have also been implicated.^1,2 Animal models also implicate proinflammatory molecules such as tumor necrosis factor-alpha (TNF-α) and interleukin1-beta (IL1-β) in the development of brain abscess.³ These proinflammatory molecules, in turn, induce various cell adhesion molecules (CAMs), including selectins, intercellular cell adhesion molecules (ICAM-1), vascular cell adhesion molecules, and platelet-endothelial cell adhesion molecules. These CAMs facilitate the extravasation of peripheral immune cells, perpetuating the antibacterial immune response that is thought to contribute, at least in part, to the development of brain abscess.^4,5 Consistent with this mechanistic model, analysis of various neuroinflammatory molecules (NMs) shows an initial marked enhancement, persistence, and subsequent depletion with time in animal models of brain abscess.^5–8 Some of these findings have been reproduced in human brain cells, for example, TNF-α and IL1-β induce ICAM-1 expression in human brain endothelial cells.^6–8Diffusion tensor imaging (DTI) is a relatively new MR imaging technique that has been shown to provide tissue microstructural information.⁹ The commonly used DTI-derived metrics are fractional anisotropy (FA) and mean diffusivity (MD). Organized structures such as white matter tracts are characterized by high FA values. However, recently high FA in the brain abscess cavity has been reported.¹⁰ We hypothesized that the high FA in the brain abscess cavity reflects the upregulation of various adhesion molecules on inflammatory cells, which confers the structured orientation of these cells in the abscess cavity. In the current study, for the first time, we demonstrate a correlation between FA, as measured by in vivo DTI, and various NMs in the brain abscess cavity aspirate from 24 patients. We have also confirmed these observations through ex vivo assays, in which we have induced NMs in Jurket cell lines by exposing them to heat-killed S aureus. The results of these studies may have significant clinical implications and could provide a noninvasive way of detecting active inflammation in vivo.     

MR扩散加权成像在脑实质结核中的应用价值

目的：探讨MR扩散加权成像（DWI）在脑实质结核中的应用价值。方法：搜集脑实质结核病例48例,回顾性分析其DWI表现特点,并测量脑实质结核表观扩散系数（ADC）值。结果：脑实质结核的DWI表现复杂,病灶中心约1/2表现为等信号,余表现为高、低或混杂信号。测得在T1增强扫描上呈均匀强化、环形强化伴实性中心及环形强化伴液性中心的病灶中心平均ADC值分别为（0.92±0.14）×10-3mm2/s、（0.99±0.17）×10-3mm2/s和（2.00±0.55）×10-3mm2/s,环形强化病灶的壁平均ADC值为（1.05±0.19）×10-3mm2/s,病灶周围水肿平均ADC值为（1.18±0.24）×10-3mm2/s,均大于正常脑实质ADC值[（0.83±0.09）×10-3mm2/s],差异均具统计学意义（P〈0.05）。结论：脑实质结核病灶扩散不受限,DWI检查及ADC值的测量对脑实质结核的诊断及鉴别诊断具有一定的价值。     

Biological correlates of diffusivity in brain abscess.

Restricted diffusion in brain abscess is assumed to be due to a combination of inflammatory cells, necrotic debris, viscosity, and macromolecules present in the pus. We performed diffusion-weighted imaging (DWI) on 41 patients with proven brain abscesses (36 pyogenic and five tuberculous), and correlated the apparent diffusion coefficient (ADC) from the abscess cavity with viable cell density, viscosity, and extracellular-protein content quantified from the pus. On the basis of the correlation between cell density and ADC in animal tumor models and human tumors in the literature, we assumed that the restricted ADC represents the cellular portion in the abscess cavity. We calculated restricted and unrestricted lesion volumes, and modeled cell density over the restricted area with viable cell density per mm(3) obtained from the pus. The mean restricted ADC in the cavity (0.65 +/- 0.01 x 10(-3) mm(2)/s) correlated inversely with restricted cell density in both the pyogenic (r = -0.90, P = <0.05) and tuberculous (0.60 +/- 0.04 x 10(-3) mm(2)/s, r = -0.94, P = <0.05) abscesses. We conclude that viable cell density is the main biological parameter responsible for restricted diffusion in brain abscess, and it is not influenced by the etiological agents responsible for its causation.     

Biexponential diffusion tensor analysis of human brain diffusion data.

Several studies have shown that in tissues over an extended range of b-factors, the signal decay deviates significantly from the basic monoexponential model. The true nature of this departure has to date not been identified. For the current study, line scan diffusion images of brain suitable for biexponential diffusion tensor analysis were acquired in normal subjects on a clinical MR system. For each of six noncollinear directions, 32 images with b-factors ranging from 5 to 5000 s/mm2 were collected. Biexponential fits yielded parameter maps for a fast and a slow diffusion component. A subset of the diffusion data, consisting of the images obtained at the conventional range of b-factors between 5 and 972 s/mm2, was used for monoexponential diffusion tensor analysis. Fractional anisotropy (FA) of the fast-diffusion component and the monoexponential fit exhibited no significant difference. FA of the slow-diffusion biexponential component was significantly higher, particularly in areas of lower fiber density. The principal diffusion directions for the two biexponential components and the monoexponential solution were largely the same and in agreement with known fiber tracts. The second and third diffusion eigenvector directions also appeared to be aligned, but they exhibited significant deviations in localized areas.     

Extracellular apparent diffusion in rat brain.

The apparent diffusion coefficients (ADCs) of a series of markers concentrated in the extracellular space of normal rat brain were measured to evaluate, by inference, the ADC of water in the extracellular space. The markers (mannitol, phenylphosphonate, and polyethylene glycols) are defined as "compartment selective" because tissue culture experiments demonstrate some leakage into the intracellular space, making them less "compartment specific" than commonly believed. These primarily extracellular markers have ADCs similar to those of intracellular metabolites of comparable hydrodynamic radius, suggesting that water ADC values in the intra- and extracellular spaces are similar. If this is the case, then it is unlikely that a net shift of water from the extra- to the intracellular space contributes significantly to the reduction in water ADC detected following brain injury. Rather, this reduction is more likely due primarily to a reduction of the ADC of intracellular water associated with injury.     

Contrast dose for enhancement of computed tomograms of the brain.

This study shows that contrast enhancement of cerebral lesions can be adequately achieved with a bolus injection of 60 ml of sodium iothalamate 70%. While the infusion of a larger dose of contrast agent increases quantitatively the level of enhancement of a variety of lesions, this method of examination does not appear to provide any more useful diagnostic information, and it introduces added and unnecessary inconvenience, cost and potential hazard.     

Role of diffusion weighted imaging and proton magnetic resonance spectroscopy in ring enhancing brain lesions

Aim of the work

To assess and compare the usefulness and efficacy of both diffusion weighted imaging (DWI) and proton magnetic resonance spectroscopy (¹HMRS) in brain lesions with ring enhancement in post contrast T1WI and to determine which method is more effective.

Subjects and methods

Thirty patients with ring-enhanced brain lesions were classified into 2 groups, abscess group (11 patients) and tumor group (19 patients), were examined using diffusion-weighted imaging (DWI) and H-proton magnetic resonance spectroscopy (¹HMRS).

Results

Restricted diffusion and low ADC value were seen in 9 (81%) patients of brain abscesses, however, free diffusion and high ADC value were found in 18 (94%) patients with necrotic brain tumor. The abscess group showed aminoacids, acetate and lactate in 9 patients and extra peak of succinate was found in 1 patient; however in the tumor group lactate alone was found in 12 patients, lactate and choline were seen in 5 patients, none of the patients showed amino acids, succinate or acetate.

Conclusion

Both DWI and ¹HMRS are useful and efficient imaging techniques in ring enhancing brain lesions and differentiate between pyogenic brain abscesses and necrotic tumors, but DWI is accurate, has less imaging time than ¹HMRS, also is available in many imaging centers.     

MR Gd-DTPA enhancement of radiation brain injury.

MR examinations of 104 patients who had undergone radiotherapy to the brain were reviewed. Thirty-six patients received Gd-DTPA enhanced study during the course of MR evaluation and six of the patients showed enhancing radiation necrosis. Histopathological confirmations were obtained in three patients. Gd-DTPA enhancing radiation lesions were multiple and patchy in three patients, multiple and patchy with cyst formation in two and ring shaped in one. In terms of their distribution, enhancing lesions in four patients were seen only in the white matter within the irradiated field and these patients had undergone radiotherapy within five years. The interval after radiotherapy was more than eight years in two patients and their enhanced lesions were observed in both the white and gray matter. Histopathological findings of Gd-DTPA enhancing radiation necrosis were gliosis and coalescing vacuoles of the neural tissue. None of these enhanced radiation lesions showed significant mass effects. Patterns of the enhancement were not specific. It was considered to be difficult to differentiate tumor recurrence from radiation necrosis with conventional Gd-DTPA enhanced MR examinations. In one patient, delayed MR images after Gd-DTPA administration showed increases in the size and number of radiation enhanced lesions. Dynamic and delayed MR study might add more information to conventional imaging after Gd-DTPA. Further studies are necessary to differentiate radiation lesions from tumor recurrences.     

Orientational diffusion reflects fiber structure within a voxel.

Several new MR techniques have been introduced to infer direction through diffusion in multiple nerve fiber bundles within a voxel. To date, however, there has been no physical model reported to evaluate these methodologies and their ability to determine fiber orientation. In this article a model of diffusion analogous to nerve fibers is presented. Diffusion measurements at multiple closely spaced angles of 15 degrees in samples with different fiber orientations are compared with theoretical calculations for restricted diffusion in cylindrical geometry. Orientational diffusion measurements are shown to reflect fiber geometry and theoretical predictions to within 10%. Simulations of fiber crossings within a voxel suggest fiber orientation does not correspond to the direction of the largest measured diffusion coefficient, but theoretical knowledge of signal decay curves can predict the shape of these diffusion coefficient contours for given fiber orientation probabilities.     

Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse

BACKGROUND AND PURPOSE: Patients who have benign enlargement of the subarachnoid spaces (BESS) have long been suspected of having an increased propensity for subdural hematomas either spontaneously or as a result of accidental injury. Subdural hematomas in infants are often equated with nonaccidental trauma (NAT). A better understanding of the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental trauma may help distinguish this group of patients from those who suffer subdural hematomas as a result of NAT. The purpose of this study is to describe the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental injury in infants with BESS. METHODS: We conducted a retrospective review of all patients with BESS complicated by subdural hematomas evaluated at a single institution from 1998 to 2004. Data concerning the patient's clinical presentation, physical findings, imaging, and management are described. RESULTS: During the study period, 7 patients with BESS complicated by subdural hematoma were identified. Their mean age at identification of the subdural hematoma was 7.4 months of age. In 5 cases, there was no recognized trauma before identification of the subdural hematoma. In 3 cases, baseline CT or MR imaging was available, showing prominent subarachnoid spaces without any evidence of subdural hemorrhage. CONCLUSION: Although suspicious for NAT, subdural hematomas can occur in children either spontaneously or as a result of accidental trauma. Caution must be exercised when investigating for NAT based on the sole presence of subdural hematomas, especially in children who are otherwise well and who have BESS.     

Abnormal intracerebral thallium localization in a bacterial brain abscess.

A 56-yr-old man with a prior history of renal cell carcinoma had moderately intense abnormal localization of 201Tl-chloride in a solitary brain lesion which was discovered to be a bacterial abscess. The organisms isolated by culture included Actinomycosis odontolyticus, Peptostreptococcus and Hemophilus aphrophilus. Because of the clinical presentation, MRI characteristics and thallium scintigraphic findings, the lesion had been felt to represent either a primary or a metastatic neoplasm. This case illustrates the need for caution in the interpretation of thallium brain scintigram.     

Intracavitary urokinase for enhancement of percutaneous abscess drainage: phase II trial

OBJECTIVE: To evaluate the effectiveness of urokinase as an abscess-cavity irrigant during percutaneous abscess drainage. SUBJECTS AND METHODS: In a prospective study, approved by the Food and Drug Administration and the review board at our institution, urokinase and saline were used as abscess-cavity irrigants. In the study group of 42 patients, half the patients were randomly placed into the urokinase group and the other half were placed into the control saline group. Doses used varied with the size of the abscess. Data collected from patient charts were evaluated with standard statistical methods. RESULTS: The results indicate definite benefits of the urokinase treatment. The length of stay (p = 0.0025) and treatment costs (p = 0.0021) were significantly less for the urokinase group. Other clinical parameters, including the febrile course, elevated WBC, and days of drainage, trended in a favorable fashion. CONCLUSION: Urokinase injected intracavitarily is an effective technique for shortening the treatment time and improves the clinical course for patients treated with percutaneous drainage techniques.