Management of brain abscesses: where are we now?

Clinical infections in neurosurgical oncology: An overview

Central nervous system (CNS) infections are urgent conditions with high morbidity and mortality. Bacteria, viruses, parasites or fungi can cause them. Intracranial infections after craniotomies are an important complication of treatment, especially in oncological patients that are already immunologically compromised due to the disease and treatment. The consequence of CNS infections in oncological patients includes longer treatment with antibiotics, additional surgical procedures, higher treatment costs and poorer treatment outcomes. Additionally, the management of primary pathology may be prolonged or postponed as a result of the active infection. By introducing new and improved protocols, tightening controls on their implementation, constantly educating the entire team involved in patient treatment and educating both patients and relatives, the incidence of infections can be reduced effectively.

Outcome of medical treatment of otogenic brain abcess without therapeutic drainage: A case of central vertigo

Otogenic brain abscess is a severe infection that must be treated as early as possible. Rare cases with a high mortality rate can be reduced by recognizing the red flags of a brain abscess, such as headaches, mental status changes, fever, and focal neurological deficits. Those could be supported by modern diagnostic management and adequate antibiotic therapy that was able to penetrate the central nervous system and abscesses. We report a case of a cerebellar abscess of the 49-year-old man with the chief complaint of vertigo. It was accompanied by chronic progressive headache, fever, bidirectional nystagmus, abnormal Romberg test, and abnormal cerebellar signs. Magnetic resonance imaging (MRI) of the head with contrast showed a right cerebellar abscess with an infectious source of otitis media and mastoiditis. The MRI evaluation showed improvement after admistered metronidazole 500 mg every 6 hours (week 22) and cefixime 200 mg every 12 hours (week 13). Long-term antibiotic treatment can be an alternative if surgery cannot be performed. However, surgery is still considered if there is no good clinical response during medical therapy.

Endoscopic diving technique for surgery of brain abscess

BACKGROUND

Recent advances in neuroendoscopic surgery have led to the minimally invasive treatment of brain abscesses using various endoscopy techniques. The endoscopic diving technique (EDT) involving the formation of fluid lenses to improve the visibility of the endoscope has been reported to be useful in the endoscopic endonasal approach (EEA) for pituitary and midline cranial base lesions. Here, we report a case of brain abscess treated endoscopically using EDT in cylinder surgery.

CLINICAL PRESENTATION

A 29-year-old man with 11q trisomy syndrome developed a fever and progressive right hemiparesis was observed. A diagnosis of a brain abscess was made based on neuroradiological imaging, and endoscopic irrigation and drainage with EDT via a transparent endoscopic sheath were performed, which provided a clear operative field and allowed satisfactory irrigation without bacterial contamination. The bacterium identified by PCR was Streptococcus intermedius, and antibiotic therapy was administered. Postoperatively, his symptoms gradually improved.

CONCLUSION

This is the first technical case report describing the clinical experience of EDT in brain abscess surgery. EDT may be a useful technique not only in EEA but also in cylinder surgery for brain abscesses.

Giant Actinomyces brain abscess in an immunocompetent child: A management strategy

BACKGROUND

Intraparenchymal brain abscess is a collection of microbes caused by inoculation through direct extension or hematogenous spread. Although rare, intraparenchymal abscesses are potentially fatal and can be detected when patients are symptomatic due to local mass effect on adjacent neural tissue. Brain abscess treatment includes medical management with appropriate antibiotics alone or medical management in combination with surgical debridement. Treatment strategies depend on the size and location of disease, as well as the virulence of the microorganism. Similar to medical management strategies, surgical strategies among providers are not uniform, with variation in approaches from complete extirpation of the abscess, including the abscess wall, to minimally invasive stereotactic needle aspiration. In particular, for children, there are no guidelines for therapy.

CASE DESCRIPTION

We report a case of giant Actinomycosis right frontal brain abscess in an immunocompetent child without risk factors. A review of the literature for the treatment of brain abscess caused very rarely by Actinomyces in children is performed.

CONCLUSION

Successful treatment of brain access depends on organism and location. The even more uncommon giant intraparenchymal abscesses can be managed with minimal access and prolonged antibiosis, especially when slow-growing organisms are identified. Long-term follow-up should be employed to mitigate missed late failures.

Clinical features, microbiology, and management of pediatric brainstem abscess

PURPOSE

Brainstem abscess is a rare condition accounting for merely 1% of brain abscesses incidence in the pediatric population. This study aimed to present a single patient with a pontine abscess and review the literature to highlight clinical features, diagnosis, and management of brainstem abscess.

METHODS

The PubMed database was screened for English-language articles concerning pediatric brainstem abscess. We, therefore, identified 22 publications, which concisely depict 23 cases. Our study reports on the 24th pediatric patient diagnosed with that entity. All included reports were analyzed in terms of clinical presentation, diagnosis, management, and outcomes of described patients.

RESULTS

There was slight women predominance (15:9), with a mean age of occurrence 6.4 years, ranging from 7 months to 16 years. Pons was the most common location of brainstem abscess, occurring in 75% of patients. Clinically, they mostly presented with cranial nerves palsy (79.2%), hemiparesis (66.7%), and pyramidal signs (45.8%). The classic triad of symptoms, including fever, headache, and the focal neurologic deficit was present in 20.8% of patients. Positive pus cultures were obtained in 61.1%. Streptococci and Staphylococci were the most frequently identified pus microorganisms. Outcomes were satisfactory, with a 79.2% rate of general improvement.

CONCLUSIONS

Neurosurgical aspiration is a safe and beneficial therapeutic method. It should always be considered and should promptly be performed when the conservative treatment is not successful and clinical deterioration occurs. Prognosis in pediatric brainstem abscess is generally favorable. Most patients recover with minor neurologic deficits or improve completely.

HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease

Cerebral toxoplasmosis is the most common cause of expansive brain lesions in people living with HIV/AIDS (PLWHA) and continues to cause high morbidity and mortality. The most frequent characteristics are focal subacute neurological deficits and ring-enhancing brain lesions in the basal ganglia, but the spectrum of clinical and neuroradiological manifestations is broad. Early initiation of antitoxoplasma therapy is an important feature of the diagnostic approach of expansive brain lesions in PLWHA. Pyrimethamine-based regimens and trimethoprim-sulfamethoxazole (TMP-SMX) seem to present similar efficacy, but TMP-SMX shows potential practical advantages. The immune reconstitution inflammatory syndrome is uncommon in cerebral toxoplasmosis, and we now have more effective, safe, and friendly combined antiretroviral therapy (cART) options. As a consequence of these 2 variables, the initiation of cART can be performed within 2 weeks after initiation of antitoxoplasma therapy. Herein, we will review historical and current concepts of epidemiology, diagnosis, and treatment of HIV-related cerebral toxoplasmosis.