IMAGING CONTRIBUTION IN CEREBRAL EMPYEMA: - PowerPoint Presentation

Slide1

IMAGING CONTRIBUTION IN CEREBRAL EMPYEMA:ABOUT CASE 3.

E. GAMY; J. MAHLAOU., S. SEMLALI; S.CHAOUIR, T. AMIL; A.HANINE. M.MAHI, S. AKJOUJMedical Imaging. Military Instruction Hospital Mohamed V Rabat.

NR1Slide2

Introduction

Brain empyema = rare since the use of antibioticOften secondary to a sinus infection.

Neurosurgical emergency.

The modern imaging techniques, especially spiral CT and MRI have significantly reduced mortality by allowing earlier diagnosis.

We report 3 cases of extradural empyema complicating sinusitis.Slide3

Materials and methods

Case 1:

Patient, 17 years old , suffering from sinusitis and shuffling with a sudden disturbance of the functions above type of confusion.

We performed emergency brain scans

The early establishment of a regimen including anti-coagulants and anti-infective therapy were done

A rapid clinical improvement without neurological squeal were shownSlide4

Case 2:Patient, 19 years old , with impaired consciousness fever

Case 3:Child 15 years ,

well

vaccinated

,

ATCD: RAS

Medical

history

:

since

2

months

,

vomiting

,

impaired

general

condition and a

fever

of 40 ° C.

No

neurological

disorders

.

Laboratory

tests:

Leucocytosis

to 15,000 per mm3,

                               CRP 200 mg / l.

                               The CSF

analysis

was

normal.

Blood cultures:

Sreptocoque

sp

.

IDR and HIV: normal.Slide5

Results

A BRAIN SCAN performed in emergency showed a:Right frontal extra axial collection, heterogeneous with a spontaneously hyperdensity posterior related bleeding.

There is also another collection in small controlateral frontal (extradural).

In bone window: through the paranasal sinuses show a left frontal sinusitis and ethmidale.Slide6

The additional MRI found both frontal extradural collections, although limited medially by the dura mater in hypo T2 signal.

The subsequent hemorrhagic component is hyperintense T1 and T2 signal hypothesis. The peripheral contrast enhancement is evident and the mass effect on midline structures. The MRI also found the heterogeneous aspect of superior sagittal sinus.Slide7

The MR angiography confirmed the cerebral venous thrombosis .

The patient is put on triple antibiotic therapy and underwent emergency surgery. We evacuated 200 ml of pus mixed with blood and found a right frontal osteitis.

Also we realized drainage of the maxillary sinuses.

  Control is satisfactory postoperativeSlide8

Figure 1: Axial CT scan after injection of the PC shows the existence of a left frontal sinus with lysis of the posterior wall of the latter (a), two collections of extra-cerebral, frontal hypodense, biconvex, associated with contrast enhancement and a thickening of the dura mater from them. This is suggestive of extra-dural empyema (b and c). Within the superior sagittal sinus, near the empyema, there hypodensity (arrowheads Fig 1b) visible in several sections (Fig. 1d) showing the existence of cerebral thrombophlebitis

A

B

C

DSlide9

Fig 2 a and b: Axial CT scan of the facial bone and brain window in (c): ethmoid and left frontal sinusitis associated with extradural empyema

A

B

CSlide10

Fig 3: MRI axial section T1-weighted (a), T1 gado

(b) and 3D AMR venous (c)

A

B

CSlide11

Fig 4: CT scan without contrast in axial section of the PC.

Fig 5: AMR vein: normalization of the signal of superior sagittal sinus.

.Slide12

DISCUSSION

Empyema is a collection tank perished brain, usually secondary to infection neighborhood especially in contact aeric face cavities . It grows on the convexities in 80% of cases, particularly the frontal lobes . It can be inter hemispheric in 12% of cases .

The subdural empyema (ESD) represents 13-20% of all intracranial suppurations, against 20 to 33% in the extradural empyema (EED) .

Empyema secondary to sinus infection symptoms are usually noisy with fast installation .

Febrile headache, usually frontal, are prominent and visible signs of intracranial hypertension and disorders of consciousness. The seizures are not uncommon .Slide13

Conversely, the ESD is soon threatened, because of a faster increase in volume, as well as retrograde propagation through cortical veins thrombophlebitis of explaining the parenchymal lesions.

The most frequent germs are anaerobic streptococci .These collections are more visible in MRI than CT. The protein content differentiates their signal from that of the LCR and identifies them.

Compared to the brain collection appears hypointense signal on T1-weighted sequences and hyperintense on T2-weighted images.Slide14

Gadolinium injection produces a contrast enhancement of the Dura and leptomeninges and therefore shows a border of hyper signal between the collection and parenchyma on the one hand, between the collection and vault on the other.

Generally, there are signal changes parenchyma neighborhood and sometimes a seeding of the brain with onset of an abscessThe EED is characterized by the image of the dura mater, T2 hypointense signal, enhanced by gadolinium injection, and the collection between the brain and by the topography and possible detachment of the venous sinuses.Slide15

Ultrasound in infants, according to the topography, can show a collection perished brain and heterogeneous echogenic or transonic sometimes with an echogenic inner boundary .

In CT, the existence of contrast uptake in the periphery of the collection is characteristic Slide16

Differential diagnosis

May arise with:A chronic subdural hematoma in post traumatic stress disorder (hypo signal in T1 and T2) or a hygroma (hypo T1 signal and hyperintense T2). While on the scanner all the lesions are hypo dense [6].Septic thrombosis of intracranial venous sinus is also secondary to infection neighborhood. Their mortality is heavy, close 50% [10]. The MRI demonstrates thrombosis, venous infarction and meningeal reactions accompanying [10].

The superior sagittal sinus thrombosis is the classical representation the most telling, as is the case with our patient. When the clinic is raised (convulsion and / or increase of impaired consciousness), replaces the MRI scanner and, mostly, to angiography [1].

It allows using the sequences of angio-MRI in phase contrast to detect direct signs of venous thrombosis.Slide17

CONCLUSION

The sequence of sinusitis complications, empyema - thrombophlebitis is classic.At the initial stage of empyema diagnosis can be difficult on CT.

MRI more sensitive and specific, allows early diagnosis, therapeutic monitoring post and helps improve the prognosis