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*[[Biopsy]] reveals [[white matter]] [[lesions]] and not well-circumscribed [[lesions]].
*[[Biopsy]] reveals [[white matter]] [[lesions]] and not well-circumscribed [[lesions]].
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{| class="wikitable"
|+Differentiating neurocysticercosis from other brain cyst lesions
!Disease
!Prominent clinical features
!Lab findings
!Radiological findings
|-
|Neurocysticercosis
|
* Presenting symptoms differ according to the site of the cysticerci. 
* [[Parenchymal]] neurocysticercosis causes all the symptoms and signs of [[Space occupying lesion|space occupying lesions]].
* Extraparenchymal neurocysticercosis causes manifestations of [[increased intracranial pressure]] if cysts are present in the [[subarachnoid space]] or in the [[ventricles]], manifestations of [[spinal cord compression]] if present in the spinal cord or causes eye disease if cysts are present in the [[orbit]].
|
* [[Immunoblot|CDC's immunoblot]] is based on detection of [[antibody]] to one or more of [[Glycoprotein|7 lentil-lectin purified structural glycoprotein]] [[antigens]] from the larval cysts.
* It is 100% [[Specificity (tests)|specific]] and has a [[sensitivity]] superior to that of any other test yet evaluated
|
* [[Computed tomography|Computerized tomography (CT)]] is superior to [[magnetic resonance imaging|magnetic resonance imaging (MRI)]] for demonstrating small [[calcification]]s.
* However, [[MRI]] shows [[cysts]] in some locations (cerebral convexity, [[Ependyma|ventricular ependyma]]) better than [[CT]], is more [[Sensitivity|sensitive]] than CT to demonstrate surrounding [[cerebral edema|edema]], and may show internal changes indicating the death of cysticerci.
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|[[Brain abscess]]
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* [[Headaches]] are the most common symptom. Usually, [[headaches]] occur on the same side of the [[Abscesses|abscess]] and tend to be severe (not responding to [[analgesics]]).
* [[Fever]] is not  a reliable sign.<ref name="pmid25075836">{{cite journal |vauthors=Brouwer MC, Tunkel AR, McKhann GM, van de Beek D |title=Brain abscess |journal=N. Engl. J. Med. |volume=371 |issue=5 |pages=447–56 |year=2014 |pmid=25075836 |doi=10.1056/NEJMra1301635 |url=}}</ref>
|
*[[Lumbar puncture]] is contraindicated but when done, it was variable between patients.
*Culture from the CT-guided aspirated lesion helps in identifying the causative agent.
|
* [[Contrast enhanced CT]] provides rapid assessment of the size and number of the abscesses.
* [[MRI|MRI:]] [[Diffusion-weighted imaging|Diffusion-weighted imaging (DWI)]] [[MRI]] can differentiate [[brain abscesses]] from [[Brain cyst|cystic brain lesions]] with [[Sensitivity|sensitivit]]<nowiki/>y and [[specificity]] of 96%.<ref name="urlBrain Abscess — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra1301635 |title=Brain Abscess — NEJM |format= |work= |accessdate=}}</ref>
|-
|[[Brain tumors]]
|
* Most common presenting symptom is [[Headache|dull aching headache]].
* Usually, it's associated with other symptoms of [[Increased intracranial pressure|increased intracranial pressure (ICP)]] as [[Seizure|seizures]], [[Visual disturbance|visual disturbances]], [[Nausea and vomiting|nausea, and vomiting]].<ref name="urlPrimary Brain Tumors in Adults - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2008/0515/p1423.html |title=Primary Brain Tumors in Adults - American Family Physician |format= |work= |accessdate=}}</ref>
|
|
* [[CT]] may be used in localizing the [[tumor]] and getting a rough estimate on the dimensions.
* [[MRI]]: [[MRI|Gadolinium-enhanced MRI]] is the preferred imaging modality for assessing the extension of the tumor and its exact location.<ref name="urlPrimary Brain Tumors in Adults - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2008/0515/p1423.html |title=Primary Brain Tumors in Adults - American Family Physician |format= |work= |accessdate=}}</ref>
|-
|[[Tuberculoma|Brain tuberculoma]]
|
* [[Tuberculoma|Brain tuberculomas]] has insidious onset of symptoms as compared to [[tuberculous meningitis]].
* Presentations are usually due to the pressure effect, not the [[Bacilli|T.B. bacilli]].
* Presenting symptoms and signs in order of occurrence:<ref name="urlThe Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF">{{cite web |url=http://www.jacpjournal.org/downloadpdf.asp?issn=2320-8775;year=2015;volume=3;issue=1;spage=3;epage=8;aulast=Mukherjee;type=2 |title=The Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF |format= |work= |accessdate=}}</ref>
# Episodes of [[focal seizures]]
# Signs of [[increased intracranial pressure]]
# [[Focal neurologic signs|Focal neurologic deficits]].
|
* [[TB|T.B.]] should be investigated everywhere else in the body (e.g. [[Lymphadenopathy|peripheral lymphadenopathy]], [[Sputum culture|sputum]] and [[blood culture]])
|
* [[CT]]: [[Contrast enhanced CT|Contrast-enhanced CT]] scan shows a ring enhancing lesion surrounded by an area of hypodensity ([[cerebritis]]) and the resulting [[mass effect]].
* [[MRI]]: Better than [[CT]] scan in assessing the site and size of the [[tuberculoma]]. Gadolinium-enhanced MRI shows a ring enhancing lesion between 1-5 cm in size (In NCC, the wall is thicker, [[Calcification|calcifications]] are eccentric and the diameter is less than 2 cm)
|-
|Neurosarcoidosis
|
* 70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:<ref name="urlNeurosarcoidosis">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975794/ |title=Neurosarcoidosis |format= |work= |accessdate=}}</ref>
# Cranial nerve neuropathies: [[Facial palsy]] is the most common presentation.
# [[Meningeal]] involvement: diffuse [[Meningitis|meningeal inflammation]] can cause diffuse [[Polyneuropathy|basilar polyneuropathy]] in 40% of the patients. with [[neurosarcoidosis]].
# Inflammatory [[spinal cord]] disease: Inflammatory span usually more than 3 spinal cord segments which helps to differentiate it from [[Multiple sclerosis|Multiple Sclerosis]].
# [[Peripheral neuropathy]]: [[Polyneuropathy|Asymmetric polyneuropathy]] or [[mononeuritis multiplex]]. It may also manifest as [[Guillain-Barré syndrome|Guillain-Barré syndrome (GBS)]] like presentation.
# [[Hypothalamic pituitary adrenal axis|HPO axis]] involvement: may present as [[diabetes insipidus]]. More than 50% of the cases have no radiological signs.
|
* [[Noninvasive test|Noninvasive tests]] have low [[sensitivity]] and [[specificity]].
* Serum [[ACE|ACE levels]] are elevated in 25% of the cases
* [[Lumbar puncture]] shows elevated [[CSF]] proteins together with mild-moderate [[pleocytosis]]. It is usually accompanied by [[oligoclonal bands]].<ref name="urlNeurosarcoidosis">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975794/ |title=Neurosarcoidosis |format= |work= |accessdate=}}</ref>
|
* [[Magnetic resonance imaging|MRI]] with [[contrast]] shows enhancement of the inflamed areas (i.e. [[cranial nerves]], [[meninges]] or [[Hypothalamic pituitary adrenal axis|HPO axis]])
|}
{| class="wikitable"
![[Image:cerebral-absceses.jpg|center|300px|thumb|MRI brain showing brain abscess - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4933"]]
![[Image:butterfly1802.jpg|center|300px|thumb|MRI brain showing Glioblastoma multiforme - Case courtesy of A.Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/28272">rID: 28272</a> ]]
![[Image:intracranial-tuberculoma-mri-brain.jpg|center|300px|thumb|MRI brain showing tuberculoma - Case courtesy of Dr G Balachandran, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/5489"]]
![[Image:neurosarcoidosis-and-chiari-i-malformation.jpg|center|300px|thumb|MRI brain showing Neurosarcoidosis - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4364S]]
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 20:14, 22 August 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

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Overview

Brain abscess must be differentiated from metastatic tumors, necrotic tumors, and lymphomas.[1][2]

Differential Diagnosis

Brain abscess must be differentiated from:

Metastatic Tumor

  • The big differential is that the abscess is often located in watershed regions, and tumors often enhance diffusely with contrast.

Necrotic Tumor

  • Diagnosis of brain abscesses and necrotic tumors is often impossible without conventional MR imaging.[1]
    • Several studies demonstrate the utility of Diffusion-weighted imaging (DWI) to differentiate between necrotic or cystic lesions and brain abscesses.[3]
    • DWI has a sensitivity and specificity of over 90% for distinguishing abscess (low ADC) from necrotic tumors (high ADC).

Lymphoma

  • Some studies suggest that indium scans can help differentiate abscess from CA, and thallium SPECT scans can distinguish CNS toxoplasmosis from lymphoma.[2]

Despite these differences, the true diagnosis is sometimes not made until biopsy.



Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[4][5] ✔ Cancer cells[6] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia, gradual progression of symptoms
Delirium tremens ✔ Clinical diagnosis ✔ ✔ ✔ ✔ ✔ ✔ Alcohol intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[7] ✔ Xanthochromia[8] CT scan without contrast[9][10] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ✔ Normal CT scan without contrast ✔ ✔ ✔ ✔ ✔ TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[11][12] ✔ ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[13]

✔ ✔ ✔ ✔ ✔ ✔ Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ✔ Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis ✔ Clinical assesment ✔ ✔ ✔ ✔ ✔ History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ✔ ✔ ✔ History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess ✔ ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

✔ ✔ ✔ ✔ ✔ ✔ ✔ History of drug abuse, endocarditis, ↓ immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity ✔ ✔ Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance ↓ or ↑ Depends on the cause ✔ ✔ Confusion, seizures
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG ✔ ✔ ✔ ✔ Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ✔ Clinical assesment and MRI ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or ↑ Serum blood glucose

HbA1c

✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness, low serum, glucose

Differentiating brain abscess in immunocompromised host

Brain abscess is common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. It should be differentiated from the following diseases:

Disease Differentiating signs and symptoms Differentiating tests
CNS lymphoma[14]
Disseminated tuberculosis[15]
Aspergillosis[16]
Cryptococcosis
Chagas disease[17]
CMV infection[18]
HSV infection[19]
Varicella Zoster infection[20]
Brain abscess[21][22]
Progressive multifocal leukoencephalopathy[23]
  • Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms
Differentiating neurocysticercosis from other brain cyst lesions
Disease Prominent clinical features Lab findings Radiological findings
Neurocysticercosis
Brain abscess
  • Lumbar puncture is contraindicated but when done, it was variable between patients.
  • Culture from the CT-guided aspirated lesion helps in identifying the causative agent.
Brain tumors
  • CT may be used in localizing the tumor and getting a rough estimate on the dimensions.
  • MRI: Gadolinium-enhanced MRI is the preferred imaging modality for assessing the extension of the tumor and its exact location.[26]
Brain tuberculoma
  • Presentations are usually due to the pressure effect, not the T.B. bacilli.
  • Presenting symptoms and signs in order of occurrence:[27]
  1. Episodes of focal seizures
  2. Signs of increased intracranial pressure
  3. Focal neurologic deficits.
  • CT: Contrast-enhanced CT scan shows a ring enhancing lesion surrounded by an area of hypodensity (cerebritis) and the resulting mass effect.
  • MRI: Better than CT scan in assessing the site and size of the tuberculoma. Gadolinium-enhanced MRI shows a ring enhancing lesion between 1-5 cm in size (In NCC, the wall is thicker, calcifications are eccentric and the diameter is less than 2 cm)
Neurosarcoidosis
  • 70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:[28]
  1. Cranial nerve neuropathies: Facial palsy is the most common presentation.
  2. Meningeal involvement: diffuse meningeal inflammation can cause diffuse basilar polyneuropathy in 40% of the patients. with neurosarcoidosis.
  3. Inflammatory spinal cord disease: Inflammatory span usually more than 3 spinal cord segments which helps to differentiate it from Multiple Sclerosis.
  4. Peripheral neuropathy: Asymmetric polyneuropathy or mononeuritis multiplex. It may also manifest as Guillain-Barré syndrome (GBS) like presentation.
  5. HPO axis involvement: may present as diabetes insipidus. More than 50% of the cases have no radiological signs.
MRI brain showing brain abscess - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4933"
MRI brain showing Glioblastoma multiforme - Case courtesy of A.Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/28272">rID: 28272</a>
MRI brain showing tuberculoma - Case courtesy of Dr G Balachandran, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/5489"
MRI brain showing Neurosarcoidosis - Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4364S

References

  1. ↑ 1.0 1.1 Desprechins B, Stadnik T, Koerts G, Shabana W, Breucq C, Osteaux M (1999). "Use of diffusion-weighted MR imaging in differential diagnosis between intracerebral necrotic tumors and cerebral abscesses". AJNR Am J Neuroradiol. 20 (7): 1252–7. PMID 10472982.
  2. ↑ 2.0 2.1 Ruiz A, Ganz WI, Post MJ, Camp A, Landy H, Mallin W; et al. (1994). "Use of thallium-201 brain SPECT to differentiate cerebral lymphoma from toxoplasma encephalitis in AIDS patients". AJNR Am J Neuroradiol. 15 (10): 1885–94. PMID 7863938.
  3. ↑ Bavelloni A, Piazzi M, Raffini M, Faenza I, Blalock WL (2015). "Prohibitin 2: At a communications crossroads". IUBMB Life. 67 (4): 239–54. doi:10.1002/iub.1366. PMID 25904163.
  4. ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  5. ↑
  6. ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  7. ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  8. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  9. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  10. ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  11. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  12. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  13. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  14. ↑ Gerstner ER, Batchelor TT (2010). "Primary central nervous system lymphoma". Arch. Neurol. 67 (3): 291–7. doi:10.1001/archneurol.2010.3. PMID 20212226.
  15. ↑ von Reyn CF, Kimambo S, Mtei L, Arbeit RD, Maro I, Bakari M, Matee M, Lahey T, Adams LV, Black W, Mackenzie T, Lyimo J, Tvaroha S, Waddell R, Kreiswirth B, Horsburgh CR, Pallangyo K (2011). "Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality". Int. J. Tuberc. Lung Dis. 15 (8): 1087–92. doi:10.5588/ijtld.10.0517. PMID 21740673.
  16. ↑ Latgé JP (1999). "Aspergillus fumigatus and aspergillosis". Clin. Microbiol. Rev. 12 (2): 310–50. PMC 88920. PMID 10194462.
  17. ↑ Rassi A, Rassi A, Marin-Neto JA (2010). "Chagas disease". Lancet. 375 (9723): 1388–402. doi:10.1016/S0140-6736(10)60061-X. PMID 20399979.
  18. ↑ Emery VC (2001). "Investigation of CMV disease in immunocompromised patients". J. Clin. Pathol. 54 (2): 84–8. PMC 1731357. PMID 11215290.
  19. ↑ Bustamante CI, Wade JC (1991). "Herpes simplex virus infection in the immunocompromised cancer patient". J. Clin. Oncol. 9 (10): 1903–15. doi:10.1200/JCO.1991.9.10.1903. PMID 1919640.
  20. ↑ Hambleton S (2005). "Chickenpox". Curr. Opin. Infect. Dis. 18 (3): 235–40. PMID 15864101.
  21. ↑ Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR (2013). "Brain abscess: Current management". J Neurosci Rural Pract. 4 (Suppl 1): S67–81. doi:10.4103/0976-3147.116472. PMC 3808066. PMID 24174804.
  22. ↑ Patel K, Clifford DB (2014). "Bacterial brain abscess". Neurohospitalist. 4 (4): 196–204. doi:10.1177/1941874414540684. PMC 4212419. PMID 25360205.
  23. ↑ Tan CS, Koralnik IJ (2010). "Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis". Lancet Neurol. 9 (4): 425–37. doi:10.1016/S1474-4422(10)70040-5. PMC 2880524. PMID 20298966.
  24. ↑ Brouwer MC, Tunkel AR, McKhann GM, van de Beek D (2014). "Brain abscess". N. Engl. J. Med. 371 (5): 447–56. doi:10.1056/NEJMra1301635. PMID 25075836.
  25. ↑ "Brain Abscess — NEJM".
  26. ↑ 26.0 26.1 "Primary Brain Tumors in Adults - American Family Physician".
  27. ↑ "The Journal of Association of Chest Physicians - Tuberculoma of the brain - A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF".
  28. ↑ 28.0 28.1 "Neurosarcoidosis".


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