Findings
- Axial T1, T2, T2 FLAIR, DWI, axial & sagittal post contrast sequences reveal a well defined peripherally enhancing heterogeneous T2 hyperintense, T1 hypointense intra-axial lesion with central restricted diffusion, no blooming in inferior aspect of right cerebellar hemisphere extending posteriorly through a defect in dura into extradural location along posterior, inferolateral aspect of right cerebellar hemisphere, tracking inferiorly along right mastoid. Moderate adjacent vasogenic edema is seen with mass effect in the form of compression, anterolateral displacement of fourth ventricle causing minimal obstructive hydrocephalus with periventricular ooze. Compression and anterior displacement of brainstem also noted with cerebellar tonsillar herniation through foramen magnum. Flow voids of right transverse, sigmoid sinus and visualized internal jugular vein are not visualized – likely compressed/thrombosed.
- Thick pachymeningeal enhancement is seen along right cerebellar hemisphere, right temporal lobe and right cerebellar tentorium with adjacent subdural effusion.
- Thin leptomeningeal enhancement is seen along basal cisterns.
Diagnosis
Tubercular / pyogenic cerebellar abscess with subdural effusion and meningitis.
Summary
Ring enhancing lesion with thin wall and central restricted diffusion in brain parenchyma suggests abscess. Entire abscess cavity shows restricted diffusion in pyogenic and tubercular abscesses. A ring enhancing lesion showing irregular walls, intracavitary projections with restricted diffusion of intracavitary projections suggests fungal abscess. Central cavity in fungal abscess do not show restricted diffusion. MR spectroscopy helps in differentiating pyogenic from tubercular abscesses.
Further reads
Luthra, G., Parihar, A., Nath, K., Jaiswal, S., Prasad, K. N., Husain, N., Husain, M., Singh, S., Behari, S., & Gupta, R. K. (2007). Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR. American journal of neuroradiology, 28(7), 1332–1338. https://doi.org/10.3174/ajnr.A0548
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