SUMMARY:We report the finding of restricted diffusion in an isolated abscess of the clivus and discuss the imaging differential diagnosis, with an emphasis on the usefulness of diffusion-weighted imaging.T he clivus is an uncommon location for intracranial lesions. Chordoma, chondrosarcoma, plasmocytoma, giant cell tumors, lymphangioma, adenocystic and nasopharyngeal carcinomas, and metastases are lesions known to develop in the clivus.1,2 Secondary clival involvement from sphenoid sinus abscesses and mucopyoceles have been reported and documented by CT and conventional MR imaging. 3,4 We describe the diffusion-weighted imaging (DWI) findings of a primarily clival abscess. Case ReportA 44-year-old woman presented with a 1-month history of progressively worsening hemifacial and hemicranial headaches, nausea, and vomiting. There were no visual complaints or previous history of sinusitis. At examination, the patient was awake and alert, afebrile, with no signs of meningeal irritation. Sensation in the face was intact. Hess screen chart examination revealed incomplete left sixth nerve palsy. CT showed a midline mass lesion with bone erosion, involving the upper clivus and sellar floor ( Fig 1A). MR imaging (1.5T scanners, Symphony and Avanto; Siemens, Erlangen, Germany) demonstrated a cystic-necrotic lesion, with a hypointense rim on T2-weighted turbo spin-echo images and thick peripheral enhancement ( Fig 1B, -C). DWI and apparent diffusion coefficient (ADC) maps demonstrated central restricted diffusion (Fig 2). DWI parameters were as follows: coronal plane, TR ϭ 170 ms, TE ϭ 94 ms, b ϭ 1000 s/mm 2 , section thickness ϭ 3 mm with a 0.5-mm gap, matrix ϭ 218 ϫ 256 ms, and FOV ϭ 20.9 cm. Laboratory analysis failed to reveal leukocytosis (9.7 ϫ 10 9 /L), elevated C-reactive protein (5.3 mg/L), or increased tumor markers. No primary malignancy was detected on cervical, chest, abdominal, or pelvic CT. After 3 weeks of treatment with highdose clindamycin and gentamicin without clinical improvement or imaging findings change, the patient underwent a pretemporal-transsylvian approach to the mass. A smoothened upper clivus due to an abscedated collection was found. No communication between the abscess and the sphenoid sinus was demonstrated. Pathologic examination revealed inflammatory cells but no organisms. Bacterial, mycobacterial, and fungal cultures were obtained, but no organism was cultured, presumably because of administered antibiotics. After surgery, there was resolution of the patient's complaints. Antibiotherapy was administered for another 4 weeks. Imaging follow-up at 3 months showed partial clival bone reconstitution. DiscussionInfectious lesions of the clivus are rare, mainly arising from the sphenoid sinus. Sphenoid mucopyoceles can expand posteriorly, eroding the posterior wall of the sphenoid sinus, and present as a clival mass entrapped by sphenoidal mucosa. The wall defect can be demonstrated either by imaging or by surgery. 3 Clival infection can also result from aggressive sphenoid sinusitis.4 Accura...
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