Typical and Atypical Diffusion-

Weighted Imaging Features in Brain

Abscesses

1 1
John D. Grimme , J. Keith Smith ,
2 1
Majda M. Thurnher and Mauricio Castillo

1
University of North Carolina
2
University Hospital Vienna
 OUTLINE OF CONTENTS:
• Usual MRI findings for cerebral abscess, including
diffusion-weighted imaging (DWI)

• Examples of typical DWI appearance of cerebral abscess

• Examples of atypical DWI appearances of cerebral abscess

• Examples of DWI in abscesses due to atypical organisms

• Examples where DWI was used in the management of

patients with cerebral abscess
 USUAL APPEARANCE OF
CEREBRAL ABSCESS ON MRI

• Abscess center is typically hypointense on T1-weighted

images (T1WI) and hyperintense on T2-weighted images
(T2WI); surrounding vasogenic edema has similar
characteristics.

• Abscess wall shows ring enhancement following

intravenous gadolinium (Gd) administration.

• As the abscess matures, the capsule shows decreased low

T2 signal.
 USUAL APPEARANCE OF
CEREBRAL ABSCESS ON MRI
On trace DWI abscesses are typically hyperintense,
indicating decreased diffusion of water.

– This is secondary to increased viscosity of pus which

contains, in addition to cellular debris and bacteria, large
molecules such as fibrinogen, which bind water
molecules and add to the effect of restricted diffusion.

– This can be confirmed with an apparent diffusion

coefficient (ADC) map where abscesses are of low
signal
 USUAL APPEARANCE OF
CEREBRAL ABSCESS ON MRI

Post-Gd T1WI: Abscess in

the right thalamus shows low
signal intensity within its
cavity and an enhancing rim.
Note subtle hypointense outer
rim, corresponding to edema.
 USUAL APPEARANCE OF
CEREBRAL ABSCESS ON MRI
T2WI: Same patient with
right thalamic abscess. There
is high signal in the abscess
cavity and in the surrounding
edema. Note low signal
intensity in the rim
surrounding the cavity which
is thought to be secondary to
susceptibility artifact from
presence of local free radicals,
and indicates a mature
abscess.
 USUAL APPEARANCE OF
CEREBRAL ABSCESS ON MRI
DWI: Same patient in
previous two slides. There
is marked high signal
intensity in the abscess
corresponding to restricted
diffusion of water
molecules in the cavity.
Note mild hyperintensity
surrounding the cavity due
to “T2 shine through”
from edema.
 USUAL APPEARANCE OF
CEREBRAL ABSCESS ON MRI
Left and right frontal abscesses: Another example of the expected appearance
of abscesses on MRI. The abscess cavities show low and high signal on T1- and
T2WI, respectively. There is surrounding vasogenic edema and mature capsules.
There is corresponding high signal on trace DWI. Dark signal on ADC map
confirms restricted diffusion.

35-year-old male presenting with seizure, left sided weakness, and urinary incontinence.
Drainage was performed and cultures grew Streptococcus anginosus.
 ATYPICAL APPEARANCE OF
BACTERIAL ABSCESS ON DWI
Mixed signal: Abscess located in the left temporooccipital region. There is
a hypointense cavity with an enhancing rim on the post-Gd T1WI. FLAIR
image (middle) shows high signal in the rim, surrounding tissues and in the
anterior part of the cavity corresponding to areas of edema and pus. There
are also isointense areas in the cavity. (Continued)
 ATYPICAL APPEARANCE OF
BACTERIAL ABSCESS ON DWI
Mixed signal: (Continued) DWI (right) shows high signal in
the cavity corresponding to the region of hyperintensity on the
FLAIR image and decreased signal corresponding to
isointense region which indicates either free diffusion or
susceptibility, such as that from focal hemorrhage.
 ATYPICAL APPEARANCE OF
BACTERIAL ABSCESS ON DWI
Postoperative abscess: Images from a surgically drained left frontal
abscess. There is heterogeneous signal in the abscess cavity on T1WI,
FLAIR, and DWI. ADC map (far right) shows no restricted diffusion.
Mixed signal on DWI may be related to surgical irrigation, blood products,
or a combination of these. Reaccumulation of pus is less likely as there is no
restricted diffusion.
 TUBERCULOMA
• Early lesions are usually isointense on T1-
and T2WI, and have variable Gd
enhancement.

• Mature lesions have ring enhancement on

post-Gd T1WI and low signal centrally on
T2WI.

• Normal DWI signal is common even in

mature tuberculomas.
 TUBERCULOMA
Normal DWI signal: Images show a tuberculoma in the left frontotemporal
region. There is bright rim enhancement, characteristic hypointensity in its
central portion on T2WI and vasogenic edema. The central area is isointenste
to gray matter DWI and there is mild “T2 shine through” from edema. ADC
map (far right) shows minimally restricted diffusion.

3-year-old female with miliary TB. At biopsy, fluid could noto be aspirated from the cavity.
 TUBERCULOMA

Two examples of
tuberculomas with low
signal on DWI: DWI of
right occipital (top) and right
cerebellar (bottom) show that
neither of these lesions have
restricted diffusion.
 ASPERGILLOMA

DWI and ADC axial images at

the same level show multi-focal
disease with patchy areas of
edema. There are two lesions in
the left frontal lobe which are
brighter than edema on DWI.
Restricted diffusion is
confirmed on ADC map. This
appearance is similar to that
seen with bacterial abscesses.
 ASPERGILLOMA
T2WI, DWI and ADC map of a patient with aspergillosis. There are
bilateral foci of patchy increased T2 signal consistent with edema.
Much of the bright signal on DWI is from “T2 shine through,” but
some areas show restricted diffusion on ADC map.
 ASPERGILLOMA
Lesions in left basal ganglia and occipital lobes. High signal in basal
ganglia and right occipital lobe on DWI (right) is consistent with restricted
diffusion in the cavitary lesions seen on the post-Gd T1WI (left) and T2WI
(middle). The high signal in the left occipital region on DWI likely
represents “T2 shine through.”
TOXOPLASMOSIS
Variable appearance on DWI: Post-
Gd T1- and DWI in three patients with
toxoplasmosis. Lesions are in the left
basal ganglia, occipital lobes, and
right basal ganglia, respectively. In
the first two patients the centers of the
lesions are isointense on DWI. The
third has low signal on DWI and ADC
map (not shown)confirmed restricted
diffusion. DWI with ADC maps are
useful in differentiating toxoplasmosis
from lymphoma in AIDS patients
(Camacho, et al.).
 NOCARDIA

Renal transplant patient:

Post-Gd T1WI (top) shows
multiple punctate lesions.
Note that individual lesions
are not discriminated on the
trace DWI and that the
abnormalities are seen as
confluent areas of high
signal due to “T2 shine
through.”
METASTATIC LUNG CANCER
MIMICKING ABSCESS
55-year-old female with metastatic non-small cell lung cancer. In
addition to lesions in the periventricular white matter, there is a mass
in the right occipital lobe with ring enhancement, surrounding edema,
a hypointense rim on T2WI (2nd from left) and restricted diffusion on
DWI (3rd from left) and ADC map (far right).
 MONITORING TREATMENT
WITH DWI

• The following are three examples of

cerebral abscesses which were followed
with serial MRI examinations, including
DWI after surgical drainage.

• The appearance of the abscess cavity on

DWI can indicate success or failure of
treatment.
Example 1: 2-year-old female with seizures and right-
sided paraparesis. Initial MRI shows a left posterior
frontal abscess. The edema is best seen on T2WI (far
left) and the mild peripheral enhancement on post-Gd
T1WI (2nd from left). There is restricted diffusion in the
cavity (DWI image, 3rd from left) confirmed on ADC
map (far right). (Continued)
Example 1: (Continued) Images one day after craniotomy
and drainage (cultures grew Streptococcus viridans). There is
persistent edema and rim enhancement, but the abscess cavity is
smaller. DWI and ADC map show no restricted diffusion. The
low signal on DWI may represent surgical irrigation fluid or a
combination of CSF, blood and serum. (Continued)
Example 1: (Continued) Images obtained approximately 2
months after surgery. In the region of the abscess there is a non-
enhancing linear area without abnormal signal on DWI,
consistent with focal gliosis (no recurrence). Clinically, the
patient was cured.
Example 2: Serial MRI studies
(post-Gd T1WI, DWI, ADC)
obtained at one-week intervals in
a 40-year-old man presenting
with fever, headache and vision
disturbance. The left occipital
abscess was drained. The lesion
has similar characteristics to that
shown in the previous case with
a notable change on DWI
following drainage and
resolution of the lesion over
time.
Example 3: Serial MRI studies (post-Gd
T1WI, DWI, ADC) obtained at one-week
intervals in a 31-year-old man presenting
with fever, left arm weakness, left hand
paresthesia and seizures. The right frontal
abscess was drained and the first post
operative study shows low signal on DWI;
however, unlike the previous two examples,
instead of continued resolution, there was re-
appearance of high DWI signal in the cavity
on the second post operative study. This
prompted a repeated drainage procedure
where presence of pus cavity was confirmed.
Note resolution of high DWI signal in the
last study.
 CONCLUSIONS
• Pyogenic abscesses have a typical appearance on
DWI

• TB and toxoplasmosis usually little restriction of

water motion when compared to pyogenic
abscesses

• Fungal abscess have a variable DWI appearance

• DWI can be use to monitor cerebral abscesses

during the course of therapy
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