Presentation
Acute onset left-sided facial weakness.
Patient Data
Intra-axial lesion centered at the right frontal lobe with surrounding vasogenic edema. Central contents are hypointense on T1-weighted sequence, heterogeneously hyperintense on T2-weighted sequence, is not suppressed on FLAIR and there is significant increased diffusion restriction. Complete rim of peripheral enhancement. No extensive T1 hyperintensity or susceptibility-related loss of signal suggestive of significant blood product.
Mass effect with localized sulcal effacement and midline shift towards the left side. No other intracranial lesion. No hydrocephalus.
Conclusion: Intra-axial lesion at the right frontal lobe with an appearance favoring an intracranial abscess.
Multiple pulmonary arteriovenous malformations with the largest located in the left lower lobe. Previous wedge resection demonstrated at the superior segment of the left lower lobe.
Mildly enlarged spleen with several hypoattenuating areas which vary from rounded appearances reflecting vascular malformation and linear or wedge-shaped appearances favoring previous infarction. Both splenic arteries and veins are enlarged and there is an inferiorly projecting saccular aneurysm of the mid splenic artery.
Liver, pancreas, kidneys, gallbladder and adrenals are of normal appearance. No abdominal or pelvic lymphadenopathy. Absence of intraperitoneal fluid or gas. No abdominal or pelvic collection. No osseous lesion.
Conclusion: The presence of multiple pulmonary arteriovenous malformations and vascular abnormalities in the right upper abdomen are suggestive of an underlying diagnosis of hereditary hemorrhagic telangiectasia.
Case Discussion
The patient underwent stereotactic burr hole drainage of the right frontal abscess. Intra-operatively, purulent fluid was aspirated from the cavity and specimen cultures were positive for Steptococcus anginosus.
A previous wedge resection was performed many years ago for which the patient could not recall the indication but this was likely for a pulmonary arteriovenous malformation. The intracranial abscess was likely the result of a paradoxical embolism due to the underlying right-to-left shunting.
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