CENTRAL NERVOUS SYSTEM

INFECTIONS
OLINOR V. MAMBUAY, MD
RADIOLOGY RESIDENT
• Congenital infections of the fetal and neonatal
brain are commonly referred to as the group of
TORCH infections
• Toxoplasmosis
• Other infections (such as syphilis and varicella)
• Rubella
• Cytomegalovirus
• Herpes simplex (and HIV)
• Transmitted transplacentally in utero or during
the birth process
• Neuroimaging is an important tool used in the evaluation
and
• treatment of infections of the central nervous system
(CNS).
• MR is usually
• the imaging modality of choice for CNS infections because
• of its improved sensitivity and specifi city compared to CT.
• However, CT can be preferred for unstable and/or
uncooperative
• patients because it allows much shorter imaging times and
• easier patient monitoring.
• Cytomegalovirus (CMV)
is a member of the
herpes family of viruses
and is the most common
cause of congenital CNS
infection
• multiplies along the
ependyma and germinal
matrix, resulting in a
periventricular pattern of
injury and development
of dystrophic
calcifications.
• Nonenhanced CT
(NECT) image shows
multiple periventricular
• hyperdense calcifi
cations. The calcifi
cations in congenital
CMV infection
• tend to be
periventricular only, as
in this case..
 EXTRA-AXIAL INFECTIONS:
Subdural and Epidural Infections
• Extra-axial pyogenic infections can involve the
epidural or subdural spaces
• may result from paranasal sinusitis,
otomastoiditis, orbital infections, penetrating
injuries, surgery, or superinfection of preexisting
extra-axial collections
• CT and MR scans show an extra-axial collection
with increased density or increased T1 and T2
signal intensity compared to CSF
• MR is more sensitive than CT
Contrast enhanced CT Transaxial T2Wi DWI
• Contrast-enhanced CT image of a
• 13-year-old child presenting with frontal sinusitis and
headaches.
• There are two adjacent anterior frontal lentiform-shaped
epidural collections
• ( arrowhead ) of intermediate-density pus. One of the
collections
• extends across midline anterior to the falx.
Subdural Empyema. A. Transaxial T2WI of
• this 8-year-old child shows a thin hyperintense subdural
• fl uid collection along the left cerebral hemisphere with
• mass effect.
• C. Diffusion-weighted imaging (DWI) shows increased signal
• intensity of the fl uid, indicating an empyema
 Meningitis
• Meningitis can be caused by bacteria,
mycobacteria, fungi, parasites, or viruses
• Bacterial meningitis is caused by Haemophilus infl
uenzae (in children), Neisseria meningitidis
• (in teenagers and young adults), and
Streptococcus pneumoniae (in older adults) in
more than 80% of cases
• Meningitis caused by group B streptococcus and
Escherichia coli occurs in neonates, whereas that
caused by Citrobacter is seen commonly in
premature newborns
• Neuroimaging is perhaps used more
importantly later in
• the course of meningitis when there are
suspected complications
• such as hydrocephalus, cerebritis or abscess
(to be discussed
• later), arterial or venous infarction, subdural
effusion
• or empyema, and herniation.
 Bacterial Meningitis

Contrast enhanced CT
• Bacterial Meningitis. A.
Initial contrast- enhanced
CT
• (CECT) scan on this 3-
month-old boy is normal. B.
CECT scan
• obtained 1 day later shows
marked brain swelling with
focal areas of
• low density representing
edema or ischemia in the
frontal and occipital
• lobes.
 Tuberculous meningitis
• is the most common form
of CNS tuberculosis
• occurs in all age groups
but particularly in
children and the elderly,
patients with AIDS,
prisoners, and
immigrants
• Imaging studies will show
enhancing, thickened
meninges, especially
along the basal cisterns
Contrast enhanced CT
• Contrast-enhanced CT image
• shows markedly abnormal contrast enhancement
in the left sylvian
• fi ssure, interhemispheric fi ssure, ambient
cistern, and along the tentorium.
• This thick, irregular enhancement in the basal
cisterns is typical
• of a pachymeningitis such as tuberculous or
fungal meningitis. CT
• scans in patients with bacterial meningitis are
usually normal or may
• reveal subtle hyperdensity or enhancement in the
peripheral sulci.
 PARENCHYMAL INFECTIONS:
Pyogenic Cerebritis and Abscess
 Pyogenic Cerebritis and Abscess
• direct extension following • Headache is common
trauma, surgery, paranasal • lethargy, obtundation, nausea,
sinusitis, otomastoiditis, or vomiting, and fever
dental infections
• Fever is absent more than 50% of
• Hematogenously spread the time
• Infection with S. aureus is
common after surgery or • Meningeal signs are present in
only 30% of patients
trauma • The imaging appearance of
cerebritis and brain abscesses
• the frontal and parietal
• evolves and corresponds with
• lobes (middle cerebral four pathologically described
artery distribution) are most • stages:
commonly involved
 Early Cerebritis
• Within the first few days
of infection, the infected
portion of the brain is
swollen and edematous
• CT scans may be normal
or show an area of low
density
• On MR, the lesion is
hypointense or
isointense on T1WI and
hyperintense on T2WI
and FLAIR images
CONTRAST
ENHANCED CT
• Contrast-enhanced CT
scan shows a subtle
area of decreased
density in the left
frontal lobe (
arrowhead ).
 Late cerebritis
• occurs within 1 or 2 weeks of
infection
• Central necrosis progresses
and begins to coalesce
• Vascular proliferation at the
periphery of the lesion, with
more inflammatory cells and
early granulation tissue.
• this corresponds to irregular
contrast enhancement at the
edges of the lesion on
CONTRAST
imaging ENHANCED CT
• Contrast-enhanced CT
scan demonstrates
• irregular enhancement
peripherally and low
density centrally.
• There is surrounding
hypodense vasogenic
edema.
 Early Capsule
• Within 2 weeks, the
infection is walled off as a
capsule of collagen and
reticulin forms along the
inflammatory, vascular
margin of the infection
• Contrast-enhanced CT
and MR scans show a
well-defined, usually
smooth and thin, rim of
enhancement
CONTRAST ENHANACED
T1WI
• contrast-enhanced
T1WI shows a
• ring-enhancing abscess
with an early capsule
 Late Capsule
• In the late capsule
stage, the rim of
enhancement becomes
even better defined and
thicker, reflecting more
complete collagen in
the abscess wall

TRANSAXIAL T2WI
• Transaxial T2WI
• reveals a right parietal
lesion with hyperintensity
centrally and
• hypointensity peripherally
within the capsule. There
is surrounding
• hyperintense vasogenic
edema. Two smaller
hyperintense lesions are
• present on the left.
 Mycobacterial Infections
• Most tuberculomas in
adults are supratentorial,
involving the frontal or
parietal lobes
• Sixty percent of
tuberculomas in children
are in the posterior fossa,
usually the cerebellum
• Multiple and miliary
lesions are common

FLAIR
• A. Transaxial fluid-
attenuated inversion
recovery image shows
multiple small areas of
• T2-hyperintensity and
mild edema bilaterally.
 Fungal Infections
• The most common • Opportunistic Fungal
endemic fungal Infections
infections • The most common
coccidioidomycosis, opportunistic fungal
North American CNS infections are
blastomycosis, and cryptococcosis,
histoplasmosis aspergillosis,
mucormycosis, and
candidiasis
 Parasitic Infections
• common throughout much of the developing
world
• Malaria and amebiasis are the two most
common causes of mortality from parasitic
infections worldwide
 Viral Infections
• Herpes simplex
encephalitis occurs in
immunocompetent
patients of all ages, and
is the most common
cause of sporadic
encephalitis

CONTRAST ENHANCED CT
• Contrast-enhanced CT
• scan (A) on this 8-year-
old boy with decreased
level of consciousness
• reveals subtle low
density in the right
temporal
• lobe ( arrowheads ).
 AIDS-RELATED INFECTIONS
• Toxoplasmosis is the most
common opportunistic
CNS infection and brain
mass in patients with
AIDS, occurring in about
13% to 33% of these
patients with CNS
complications
• multiple enhancing
parenchymal lesions with
surrounding vasogenic
edema CONTRAST ENHANCED CT
• Toxoplasmosis. Contrast-
enhanced CT scan reveals
• bilateral ring-enhancing
lesions ( short arrows ) in
the basal ganglia of
• this patient with AIDS.
There is marked
surrounding hypodense
• edema. The basal ganglia
are commonly affected by
toxoplasmosis