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MRI diffusion restriction abscess — SCE Neurology MCQ

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HardNeurological InvestigationsMRI diffusion restriction abscessSCE Neurology

Fever, seizure and raised intracranial pressure accompany a frontal ring-enhancing lesion with central diffusion restriction. What is the immediate management priority?

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Correct answer: C — Urgent neurosurgical and microbiology review for aspiration or drainage plus empirical intravenous antimicrobials

The best answer is “Urgent neurosurgical and microbiology review for aspiration or drainage plus empirical intravenous antimicrobials”. Central restricted diffusion strongly suggests brain abscess; mass effect makes lumbar puncture hazardous and source control plus antimicrobials is urgent. “Lumbar puncture despite papilloedema” is a credible alternative elsewhere, but it fails the decisive discriminator in this case. “High-dose corticosteroid monotherapy” is a credible alternative elsewhere, but it fails the decisive discriminator in this case. “Intravenous aciclovir as the only antimicrobial” is a credible alternative elsewhere, but it fails the decisive discriminator in this case. “Observe until serial imaging confirms enlargement” is a credible alternative elsewhere, but it fails the decisive discriminator in this case.

Reference: ESCMID guideline on brain abscess: https://pubmed.ncbi.nlm.nih.gov/37648062/