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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 204-205

Imaging of a brain abscess with "raccoon eye"- like changes on imaging


Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China

Date of Submission04-Mar-2013
Date of Decision05-Mar-2013
Date of Acceptance28-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Guangxian Nan
Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111162

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How to cite this article:
Fu J, Nan G. Imaging of a brain abscess with "raccoon eye"- like changes on imaging. Neurol India 2013;61:204-5

How to cite this URL:
Fu J, Nan G. Imaging of a brain abscess with "raccoon eye"- like changes on imaging. Neurol India [serial online] 2013 [cited 2019 Aug 17];61:204-5. Available from: http://www.neurologyindia.com/text.asp?2013/61/2/204/111162


Sir,

Computed tomography (CT) and magnetic resonance imaging (MRI) are very helpful imaging modalities for the diagnosis of brain abscess. Here, we report the imaging findings of a brain abscess case with the CT and MRI images with a "raccoon eye" appearance.

A 52-year-old male was admitted with left ear hearing loss of 30 days duration, lethargy of 8 days and mental fatigue of 1 day duration. He developed left ear hearing loss following a lead acid storage battery explosion 30 days prior to admission. At that time, he did not have bleeding or leakage from the external auditory meatus and no head or body injuries. He was diagnosed to have explosion-related deafness. Eleven days before admission he had a feeling of fullness in the head and pain, brain CT carried out at that time did not show any abnormalities. His headache resolved rapidly with 125 mL mannitol. After discharge, the deafness improved to some extent, but he continued to be lethargic and was less talkative. One day before admission, he experienced mental fatigue, sialorrhea, and lethargy. Review of the most recent brain CT showed a hypodense shadow in bilateral basal ganglia surrounded by a circular hypodense zone, "raccoon eye." Neurologic examination revealed lethargic uncooperative patient. Deep tendon reflexes were elicitable and symmetrical. Rest of the neurologic examination could not be assessed properly. Repeat brain CT and MRI revealed changes in "raccoon eye" images [Figure 1] and [Figure 2]. White blood count, neutrophil count and percentage, C-reactive protein, and erythrocyte sedimentation rate 1 st h were above the reference range. Blood biochemistry and coagulation profile were normal. The diagnostic possibility of brain abscess was kept and supportive care was instituted. On day-5 of admission, he was started on intravenous meropenem 2 g every 8 h. During the course of disease, he developed bradycardia (40 beats/min), could not take adequate nutrition, developed urinary retention. He underwent temporary pacemaker placement for bradycardia. On day-13 of admission repeat, MRI showed multiloculated lesions in both the basal ganglia [Figure 3] and on day-18 of admission he had stereotactic drainage of a large amount of greenish-yellow pus. He was continued on meropenem. MRI carried out on day-41 of admission revealed a significant reduction of the abscess in the bilateral basal ganglia; enlargement of lesion next to the left ventricle, and a hematoma at the site of stereotactic puncture. On day-61 of admission patient underwent excision of the brain abscess under general anesthesia. Pathological examination results were consistent with a brain abscess. Post-operatively he was continued on meropenem. He was discharged on day-81 when he was totally symptom free. During the 4 months of telephonic follow-up, he had no recurrence of symptoms. Repeat MRI carried out at 4 months follow-up revealed near resolution of the lesions [Figure 4].
Figure 1: Brain computed tomography on day-6 of admission "raccoon eye" like changes

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Figure 2: Plain and contrast magnetic resonance imaging on day-2 days of admission. "raccoon eye"-like changes: (a-b) in the bilateral basal ganglia and posterior horn of the left lateral ventricle, nodular signal shadow (c) circular enhancement of smooth, even wall

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Figure 3: Magnetic resonance imaging enhancement at 13 days after admission: Multilocular changes

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Figure 4: Magnetic resonance imaging enhancement at 4 months after discharge

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The "raccoon eye" like imaging feature in this patient was identical to the images of the abscess capsule formation stage. [1] A low-signal "dark band" surrounding a necrotic zone and multiple chambers in the abscess cavity on T2-Weighted sequence during the capsule formation stage can be the characteristic manifestations of an abscess. [2] Our patients showed the dynamic changes in imaging feature during the entire course of illness. To some extent the imaging characteristics would determine the therapeutic options.

 
  References Top

1.Emejulu JK, Shokunbi MT, Malomo AO. Intracerebral abscesses: Outcome following management in the CT era. West Afr J Med 2004;23:54-7.  Back to cited text no. 1
    
2.Luthra G, Parihar A, Nath K, Jaiswal S, Prasad KN, Husain N, et al. Comparative evaluation of fungal, tubercular, and pyogenic brain abscesses with conventional and diffusion MR imaging and proton MR spectroscopy. AJNR Am J Neuroradiol 2007;28:1332-8.  Back to cited text no. 2
    


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