Interactive Transcript
0:01
So we're still in scenario number five,
0:03
where we have a patient who has a fever and
0:06
a new seizure disorder, and therefore we're
0:09
still worried about infectious etiologies.
0:12
Here we have a patient that, as we scroll up the FLAIR
0:15
scan, we see immediately a large lesion that is
0:19
present in the left frontal lobe with surrounding edema.
0:23
It has sort of a rim of darker signal
0:26
intensity on the FLAIR images that
0:30
is worrisome.
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We note that the patient has adjacent sinusitis
0:34
of the frontal sinus associated with this mass.
0:38
On the diffusion-weighted imaging, we see bright signal
0:42
intensity on the DWI that is also associated with
0:47
bright signal intensity in the medial frontal sinuses.
0:51
Is this T2 shine-through?
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Well, if we go to the ADC map, what we find is
0:57
dark signal intensity, not bright signal intensity,
1:01
suggesting that this does indeed show restricted diffusion.
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This is a pattern that is highly
1:08
suggestive of a brain abscess.
1:10
In this case, what we're seeing as
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the dark signal intensity is not from
1:14
cytotoxic edema and cellular death.
1:17
What we're seeing is the dark
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signal intensity from purulent material.
1:21
Pus in the center of this abscess that is being
1:25
demonstrated on the FLAIR and the diffusion-weighted
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imaging. There's a lot of mass effect in this case.
1:33
Now, when we look at patients who have abscesses
1:37
in the brain, we are usually worried about things
1:40
like septic emboli leading to an abscess.
1:43
But when it's in the periphery of
1:45
the brain, we also worry about.
1:48
Spread from adjacent infections in the
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perinasal sinuses, mastoid air cells,
1:56
middle ear cavity, or a puncture wound into
1:59
the brain—an open fracture, for example.
2:03
So this presence of sinus opacification of the frontal
2:07
sinuses that we're seeing on the FLAIR scan and the
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presence of bright signal intensity in the sinus,
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suggesting purulent material in the medial
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frontal sinuses, is worrisome that this is a spread
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from the sinuses to the brain with an abscess.
2:26
Let's look at the post-gadolinium enhanced scan.
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In fact, we will magnify this.
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So here on the post-gadolinium enhanced scan, as
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we proceed upward immediately, we see that there
2:35
is thickening and abnormal enhancement of the dura.
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So this is inflamed dura.
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We're suggesting that there is a
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meningeal inflammatory process going on.
2:47
We see that the patient has an abscess cavity with
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a nice surrounding enhancing rim, and as we go
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further inferiorly, we again see that inflammation
3:00
of the frontal sinus with subdural enhancement.
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Why is this important?
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Well, we can still treat the abscess and drain
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the abscess 'cause it's got so much mass effect.
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But the underlying condition, which led to
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the abscess, is the frontal sinus, which also
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probably should be addressed at the same
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time, either with functional endoscopic sinus
3:23
surgery or aggressive intravenous antibiotics.
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This—
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Ring-enhancing lesion by itself would lead
3:33
to a differential diagnosis of a high-grade
3:37
astrocytoma or a metastasis, but the presence
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of the restricted diffusion on the ADC map
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is what gives this away as being an abscess.
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