T2-weighted MR angiography substantially increases the detection of hemorrhage in the wall of brain abscess: implications in clinical interpretation

Introduction The purpose of the present study was to identify the true prevalence of hemorrhage in the abscess using T2*-weighted angiography (SWAN) imaging and to study its influence on diffusion tensor imaging (DTI) metrics. Methods Fifteen patients of brain abscess underwent conventional, SWAN, and DT imaging on a 3-T MRI followed by its confirmation with histology. DTI metrics were quantified by region-of-interest analysis on hemorrhagic and non-hemorrhagic regions of the abscess wall. Prussian blue staining was performed on excised abscess walls to confirm hemorrhage on histology. Results Eleven of 15 patients showed evidence of hemorrhage on both Prussian blue staining as well as SWAN imaging. Fractional anisotropy (FA) and linear anisotropy (CL) values were significantly higher, while spherical anisotropy was significantly lower in hemorrhagic compared to non-hemorrhagic regions of the abscess wall. Conclusion Hemorrhage in the abscess wall is a common feature and may not always indicate neoplasm. The presence of intracellular iron in addition to concentrically laid collagen fibers may have synergistic effect on FA and CL values in the abscess wall. Inclusion of SWAN to MRI protocol will define the true prevalence of hemorrhage in brain abscess.