Neuroimaging Cases 008

Intraventricular rupture of brain abscess (IVROBA)

Over the past two years we have created neuroimaging presentations which we will continue to add to. Today we present the second in our Neuroimaging Case Studies Series in which we share a clinical case, brief literature review, and concise summary recommendations.

Images, text and cases collated by L. Erin Miller MD, Teresa Crow MD, Troy Carnwath MD, Scott DiMeo MD, and Natalie Rall MD. First published on EMGuideWire.com and peer reviewed by Professor Michael Gibbs.

Summary

• Early identification and prompt initiation of appropriate treatment is crucial to provide the best opportunity for improved long-term outcomes.
• If a diagnosis of IVROBA is suspected based on the clinical history and initial CT finds, antibiotics should be given at once, i.e. before MRI.
• It is important to differentiate a ring-enhancing abscess from a cystic tumour. On MRI abscesses have restricted diffusion and demonstrate a white (hyperintense) central core on DWI and a dark (hypointense) central core on ADC. The reverse is true for cystic tumours.
• Definitive treatment involves a combination of surgical EVD drainage and targeted antibiotic therapies.

References

• Brouwer MC, Tunkel AR, van de Beek D. Brain abscess. N Engl J Med. 2014 Oct 30;371(18):1758.
• Takeshita M, Kawamata T, Izawa M, Hori T. Prodromal signs and clinical factors influencing outcome in patients with intraventricular rupture of purulent brain abscess. Neurosurgery. 2001 Feb;48(2):310-6; discussion 316-7.
• Lee TH, Chang WN, Su TM, Chang HW, Lui CC, Ho JT, Wang HC, Lu CH. Clinical features and predictive factors of intraventricular rupture in patients who have bacterial brain abscesses. J Neurol Neurosurg Psychiatry. 2007 Mar;78(3):303-9. 
• Reddy JS, Mishra AM, Behari S, Husain M, Gupta V, Rastogi M, Gupta RK. The role of diffusion-weighted imaging in the differential diagnosis of intracranial cystic mass lesions: a report of 147 lesions. Surg Neurol. 2006 Sep;66(3):246-50; discussion 250-1.

This neuroimaging interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center. The goal is to promote widespread mastery of CXR interpretation. There is no personal health information [PHI] within, and ages have been changed to protect patient confidentiality.