J Korean Neurosurg Soc.  2017 Jan;60(1):118-124. 10.3340/jkns.2015.0707.023.

Brain Abscesses Associated with Asymptomatic Pulmonary Arteriovenous Fistulas

Affiliations
  • 1Department of Neurosurgery, Chung-Ang University College of Medicine, Seoul, Korea. cuttage@cau.ac.kr

Abstract

Brain abscess commonly occurs secondary to an adjacent infection (mostly in the middle ear or paranasal sinuses) or due to hematogenous spread from a distant infection or trauma. Pulmonary arteriovenous fistulas (AVFs) are abnormal direct communications between the pulmonary artery and vein. We present two cases of brain abscess associated with asymptomatic pulmonary AVF. A 65-year-old woman was admitted with a headache and cognitive impairment that aggravated 10 days prior. An magnetic resonance (MR) imaging revealed a brain abscess with severe edema in the right frontal lobe. We performed a craniotomy and abscess removal. Bacteriological culture proved negative. Her chest computed tomography (CT) showed multiple AVFs. Therapeutic embolization of multiple pulmonary AVFs was performed and antibiotics were administered for 8 weeks. A 45-year-old woman presented with a 7-day history of progressive left hemiparesis. She had no remarkable past medical history or family history. On admission, blood examination showed a white blood cell count of 6290 cells/uL and a high sensitive C-reactive protein of 2.62 mg/L. CT and MR imaging with MR spectroscopy revealed an enhancing lesion involving the right motor and sensory cortex with marked perilesional edema that suggested a brain abscess. A chest CT revealed a pulmonary AVF in the right upper lung. The pulmonary AVF was obliterated with embolization. There needs to consider pulmonary AVF as an etiology of cerebral abscess when routine investigations fail to detect a source.

Keyword

Arteriovenous fistula; Arteriovenous malformations; Brain abscess; Pulmonary

MeSH Terms

Abscess
Aged
Anti-Bacterial Agents
Arteriovenous Fistula*
Arteriovenous Malformations
Brain Abscess*
Brain*
C-Reactive Protein
Cognition Disorders
Craniotomy
Ear, Middle
Edema
Embolization, Therapeutic
Female
Frontal Lobe
Headache
Humans
Leukocyte Count
Lung
Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Middle Aged
Paresis
Pulmonary Artery
Thorax
Tomography, X-Ray Computed
Veins
Anti-Bacterial Agents
C-Reactive Protein

Figure

  • Fig. 1 Brain magnetic resonance imaging of case 1. A 4×3-cm ring-enhanced mass in the right frontal lobe, which was associated with severe edema and midline shifting to the left side (A). Diffusion restriction of the enhancing area suggests that the lesion is an abscess (B).

  • Fig. 2 Chest computed tomography (A) and angiography (B) of case 1. Fistulous vascular abnormality on the left lower lung field (A). A catheter is used to perform embolization (white arrow). Another lesion on the left upper lung field was already embolized with coils (black arrow; B).

  • Fig. 3 A 45-year-old woman (case 2) presented with a 7-day history of a progressive left hemiparesis. Enhanced brain magnetic resonance (MR) imaging shows a well-enhancing ovoid mass on the right motor and sensory cortex measuring 1.5×0.9 cm (A). Diffusion weighted MR reveals restriction of the mass (B).

  • Fig. 4 Chest computed tomography (A) and angiography (B) of case 2. Fistulous dilatation of the pulmonary vasculature on the right upper lung field (A). The lesion is approached with a catheter to perform embolization. It was a single lesion (B).


Reference

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