Inflammatory and infectious

intracranial cysts

• 20-brain abscess
• 21-cysticercosis
• 22-hydatid cyst.
• 23-amoebic abscess

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Brain Abscess

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Brain abscess..

poorly defined area of posterior parietal brain edema (arrows). Early cerebritis
may not outline a focal mass clearly
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 Brain abscess.

a poorly defined pattern of mass effect and low attenuation in the left temporal lobe.
Of early cerebritis
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 Brain abscess.

An area of ring like enhancement (yellow arrow) is noted within a much larger pattern of
edema (white arrow). The central core of the abscess (black arrow) does not enhance
(central necrosis) Dr Ahmed Esawy
temporal lobe abscess, extracranial, subdural, and intracerebral abscesses

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 Brain abscess.
depressed skull fracture. The left parietal cranial injury an abscess of the subgaleal
space (SGA) the epidural space (EDA) the left cerebral hemisphere (CA).

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Brain abscess. Axial T1 +C ,T2-weighted MRI in a patient with a right frontal abscess.

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 T1-contras Brain abscess T1-contras

The right frontal lobe of the

brain is shifted across the
midline (double arrow) by an
intracranial abscess (single
black arrow) that has extended
upward from the medial right
orbit and medial ethmoid air
cells (curved dotted arrow).

T1-contras
the enhancement within the right ethmoid
sinuses from which the infection arose.
The medial superior right maxillary sinus
has been destroyed (yellow arrow).

An abscess is noted within the medial inferior right orbit. The right maxillary sinus
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(double white arrows) contains infected secretions and mucus
 Brain abscess. (FLAIR) MRI
in a patient with abscess of the
cerebellar vermis (black arrow).
T2- MRI abscess of the midline
cerebellum. the large area of
increased signal, both within the
abscess and within the surrounding
cerebellum (black arrow).

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 Brain abscess. T1-enhanced
central zone of enhancement
within the abscess, with a zone of
decreased brightness (edema,
white arrow).
Brain abscess. T1enhanced
enhanced mass within the right medial
cerebellum (yellow arrow). The thick-
walled cystic mass was opened.

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CEREBRAL ABSCESS ON DW 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
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signal ,markedly reduced ADC
 Diffusion-weighted Imaging
ADC maps are of great value in
distinguishing neoplasms in ADC maps is
more often have facilitated diffusion,

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Post-Gd T1WI: T2WI DWI

CEREBRAL THALAMIC ABSCESS ON MRI

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 Left and right frontal abscesses:

T1WI T2WI DWI ADC

35-year-old male.
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 Pyogenic Abscess

T2 T1 T1/Gd DWI

bright on DWI

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Abscess (purulent)
ADC decreased
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 7. 8.

DD : tumour

central hypointensity on diffusion-weighted image and hyperintensity on ADC

map, consistent with the diagnosis of tumor.

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 7. 8.

DD : tumour

Central hypointensity is seen on the diffusion-weighted image and hyperintensity

on the ADC map, consistent with the diagnosis of tumor.

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 Brain abscess primary and secondary (daughter

Fluid and necrotic tissue (bright area) . edema surrounds surrounding the abscess does not enhance
the abscess cavities (black arrows). (white arrows).

T1/Gd
DWI

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 Brain abscess (FLAIR)

left occipital-parietal brain abscess.

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T1/Gd
MRI Brain
abscess
DWI

T2

Dr Ahmed Esawy well-defined hypointense

capsule
 MR Spectroscopy
• .Typical MR spectroscopic features of brain
abscesses include

• elevated peaks of amino acid, lactate,

alanine, acetate, pyruvate, and succinate

• absent signals of NAA, creatine, and choline.

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 MR spectroscopy
• shed light on which organism is
responsible for the abscess
• because the presence of anaerobic
bacteria tends to cause elevated acetate
and succinate peaks.

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 DD : NEOPLASM
• Elevation of choline and absence of
signal from a variety of amino acids,
acetate and succinate favours
neoplastic process

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Dr Ahmed Esawy
Dr Ahmed Esawy
 Pyogenic brain abscesses
MRS elevated peaks of amino acid,
lactate, alanine, acetate,
pyruvate, and succinate
absent signals of NAA,
creatine, and choline
DW restricted diffusion
bright
ADC markedly reduced ADC maps.
MR PERFUSION capsule of an abscess tends to
have lower rTBV
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necrotic or cystic neoplasms
Elevated choline , decrease
NAA
facilitate diffusion
dark
Bright on ADC map
The walls of necrotic or cystic
tumors have a lower ADC
value than of an abscess
wall of necrotic or cystic
neoplasms tends to have higher
rTBV
 Signal volume MR spectra of
abscess

Short-echo MRS shows depression of the

NAA, choline (Cho) and creatine (Cr)
as well as elevation of the amino acid,
lactate (Lac), acetate and
Dr Ahmed Esawysuccinate.
 T2 T1+C DW hyperintense
signal in centre

Brain abscess
Single voxel MRS peaks representing
alanine, lactate and amino acids

ADC decrease signal

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in centre
brain abscess

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well-defined cystic structure with low-
level echoes (arrowheads) in the left
posterior parietal region

Brain abscess in a 28-week gestation

preterm newborn abscess has ring enhancement
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cysticercosis

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Cystercercus cellulosae - (3-20 mm)
regular round thin walled cyst,
produces only mild inflammation
larva in cyst
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 Calcification in cysticercosis

• Calcification in burned out residues of cysticercosis

scattered throughoutDr Ahmed Esawy
the brain in later stages
 NEUROCYSTICERCOSIS

Multiple neurocysticercosis cysts

of various sizes. Some contain
visible scolices (arrows). MR
image shows

T1 innumerable tiny low-signal-intensity

neurocyticercosis cysts in brain
parenchyma and subarachnoid spaces.
Most contain small “dot” that represents
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the scolex (arrows
Intraparenchymal cysticercal cyst
Scolex within each cyst

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 Differential Diagnosis

• abscess (T2-hypointense rim (

• Tuberculosis (profoundly hypointense on T2 ,meningitis)

• toxoplasmosis

• neoplasm primary or metastatic

• enlarged PVSs same appearance as CSF at all MR

sequences and do not enhance)

• NEUROCYSTICERCOSIS characteristic “cyst with dot”

appearance .
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 multiloculated
amebic abscess

partially cystic mixed-signal-intensity

.subcortical mass (arrow)T1

some enhancement around complex cystic

mass (arrow)T1+CONTRAST
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 Differential Diagnosis

• Complex conglomerated parasitic cysts of

any origin may mimic primary or
metastatic brain tumor .

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 hydatid cyst
CT Unilocular cyst CSF density No edema no enhancement ± calcification
MRI low signal T1 , high signal T2 Dr Ahmed Esawy
T1

hydatid cyst

T2

T1+C

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 HYDATID CYSTS

• 5 year child

very large nonenhancing cystic mass

.without surrounding edema (arrows)
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 Differential Diagnosis

• arachnoid cyst
• epidermoid cyst
• neurocysticercosis

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 Tuberculous abscesses

T1- multiple scattered ring-enhancing lesions

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 MRS
• Tuberculous abscesses typically have high
lipid and lactate peaks.
• These abscesses have no peaks for amino
acids (leucine, isoleucine, and valine) at 0.9
ppm, succinate at 2.41 ppm, acetate at 1.92
ppm, and alanine at 1.48 ppm,
• in contrast to pyogenic abscesses, which
have peaks for all these metabolites.

Dr Ahmed Esawy