2005 American Society of Neuroradiology


BRAIN

Diffusion-Weighted Imaging of Fungal Cerebral Infection
Paola Gaviania, Richard B. Schwartze,g, E. Tessa Hedley-Whyteb,g, Keith L. Ligonf,g, Ari Robicsekc, Pamela Schaeferd,g and John W. Hensona,d,g
a Stephen E. and Catherine Pappas Center for Neuro-oncology Unit, Massachusetts General Hospital, Boston
b Stephen E. and Catherine Pappas Center for Neuropathology Unit, Massachusetts General Hospital, Boston
c Stephen E. and Catherine Pappas Center for Infectious Disease Unit, Massachusetts General Hospital, Boston
d Division of Neuroradiology, Massachusetts General Hospital, Boston
e Division of Neuroradiology, Brigham and Women’s Hospital, Boston
f Division of Neuropathology, Brigham and Women’s Hospital, Boston
g Harvard Medical School, Boston

Address reprint requests to John W. Henson, MD, Stephen E. and Catherine Pappas Center for Neuro-oncology and Division of Neuroradiology, Massachusetts General Hospital, Yawkey 9E, Fruit Street, Boston, MA 02114

BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) is useful in diagnosing bacterial brain abscesses, but DWI features of fungal brain abscesses have not been characterized. Because fungal abscesses are not purulent, we hypothesized that their DWI characteristics are distinct from those of bacterial abscesses.

METHODS: We reviewed clinical, neuropathologic and neuroimaging findings of patients with fungal brain infections due to Aspergillus (n = 6), Rhizopus (n = 1), or Scedosporium (n = 1) species. DWI and apparent diffusion coefficient (ADC) maps were obtained before definitive diagnosis and antifungal therapy. ADC ratios (lesion/contralateral white matter) were calculated.

RESULTS: Two patients had a rapidly progressive, fatal course, with cerebritis and acute inflammation; fungal organisms were largely restricted to vessels. Lesions were predominantly nonenhancing and had heterogeneous foci of restricted diffusion. Six patients with subacute neurologic presentations had acute or chronic inflammation, capsule formation, focal necrosis, and fungal organisms disseminated throughout the lesion. Their abscesses were ring enhancing. In five, lesions had restricted diffusion in the central nonenhancing portions. The sixth patient had a lesion with a peripheral rim of restricted diffusion but elevated central diffusion; histopathology showed early abscess formation. Mean ADC for all lesions was 0.33 ± 0.06 x 10–3 mm2/s, with an average ADC ratio of 0.43.

CONCLUSION: Fungal cerebral abscesses may have central restricted diffusion similar to that of bacterial abscesses but with histologic features of acute or chronic inflammation and necrosis rather than suppuration. Altered water diffusion in these lesions likely reflects highly proteinaceous fluid and cellular infiltration.