Ina Sorge (Universität Leipzig)  

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9 Years  

Male  

Head-Brain and brain nerves  

inflammatory or infectious  

9 year-old boy, images received from an outside hospital after a longstanding nasopharygeal viral infection. Spiking fevers up to 40° C have been reported. Now, after a fall, the patient is dazed. The patient underwent a CT with the concern for cerebral hemorrhage. Only mild leucocytosis.

CT 1: slight frontal edema bilaterally. Result of trauma? Infection? After 5 days, the child was transferred to the children's hospital because of progressing impairment of consiousness.  

Proof of pathogen in the abscesses: Staphylococcus.

The etiology of bacterial cerebral abscesses can be hematogenic (often endocarditis), after trauma or can be due to direct extension from a neighbouring infectious process. A common cause is sinusitis with a concurring bony defect in the posterior wall of the frontal sinus (as in this case). In immune-competent patients, fungal pathogens should also be considered besides a bacterial infection.
 

<- view CT 1

CT 1: outside CT: Bifrontal hypodensities (edema): Result of trauma after fall?




<- view MRI 1

MRI 1: T1-weighted image after contrast administration directly after admission: Bifrontally, two large colliquation zones with intense wall enhancement.




<- view MRI 2

MRI 2: T1-weighted after contrast administration directly after admission: Subdural and epidural fluid capsule with intense wall enhancement frontoparietal as well as temporal and basal.




<- view MRI 3

MRI 3: No MRI, rather a supplemental CT: Left upper corner: Single slice in bone window. Right lower corner: 3D reconstruction in the area of the frontal sinuses: Defect in the right, posterior frontal sinus wall.




<- view MRI 4

MRI 4: T1-weighted, after contrast administration: Treatment of the frontal sinuses in the ENT unit, neurosurgical trepanation on the right side. The intraparenchymal changes do not show any change (increase of the focal edema, on T1-weighted images signal focal signal loss)




<- view MRI 5

MRI 5: T1-weighted, after contrast administration: After 2 months of conservative treatment and without further surgical intervention (hyperbaric oxygenation, antibiotics), further decrease of the frontal intracerebral lesions. Only small enhancing rests left with minimal surrounding residual edema.

 

Surgery / Histo  

Glioblastoma, in a purely intracerebral location also pilocytotic astrocytoma  

Clinically it often starts subtle. Commonly, there is only a moderate leucocytosis. In chronic courses and a thick abscess membrane, it might be mistaken with a glioblastoma multiforme is possible, since both changes commonly show a perifocal edema.  

N/A  

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1. Medline:
Giannoni C, Sulek M, Friedman EM.
Intracranial complications of sinusitis: a pediatric series.
Am J Rhinol. 1998 May-Jun;12(3):173-8.

2. Medline:
Lee GY, Daniel RT, Brophy BP, Reilly PL.
Surgical treatment of nocardial brain abscesses.
Neurosurgery. 2002 Sep;51(3):668-71  

Brain, Abscess, Frontal, Sinus, Brain abscess with frontal sinus defect, sinus frontalis, Brain abscess, Frontal sinus, child, childhood, pediatric radiology  

Ina Sorge. Brain Abscess with Frontal Sinus Defect. PedRad [serial online] vol 3, no. 12.
URL: www.PedRad.info/?search=20031225185135