Nonoperative treatment of cerebellar abscesses. A case report and review of the literature

Evaluation of Continuous Irrigation and Drainage with a Double-Cavity Sleeve Tube to Treat Brain Abscess

BACKGROUND

Brain abscesses carries a high morbidity and mortality, and despite medical advances, it continues to pose diagnostic and therapeutic challenges worldwide. The traditional surgical approaches to treating brain abscess (burr hole aspiration and craniotomy) have both advantages and disadvantages and remain controversial. Here we report a single institution's experience with a new surgical approach for brain abscess.

METHODS

We retrospectively analyzed 46 patients with intracranial abscess who underwent continuous irrigation and drainage through a double-cavity sleeve tube placed surgically in conjunction with a 4-week course of intravenous cefotaxime and metronidazole at Renmin Hospital of Wuhan University between January 2008 and December 2016. The patients' medical records were analyzed for demographic data, clinical presentation, predisposing factors, imaging findings, microbiological test results, treatments, surgical techniques, and outcomes.

RESULTS

The 46 patients included 29 males and 17 females, ranging in age from 22 to 74 years. A single abscess was detected in 34 patients, whereas 12 patients had multiple abscesses. The average duration of hospitalization was 12.6 days. After treatment, 38 of the 46 patients resumed a normal life despite minor deficits (Glasgow Outcome Score [GOS] 5), 6 patients exhibited slight neurologic deficits (GOS 4), and 2 patients died of severe systemic infection and multiorgan failure. In particular, a patient with a brain abscess broken into the ventricle recovered well (GOS 5). No patient required repeat aspiration or surgical excision.

CONCLUSIONS

Continuous brain abscess cavity irrigation and drainage with a double-cavity sleeve tube is an effective treatment for brain abscess and produces excellent results, especially for an abscess broken into the ventricle. It combines the advantages of burr hole aspiration and open craniotomy excision. It is easy to perform and reduces costs and damage to the patient, and also shortens hospitalization time and antibiotic treatment time, greatly reducing the likelihood of reoperation. This approach may be the optimal choice to treat brain abscess.

From Diagnostic Imaging to Management of Bacterial Brain Abscesses

Advances in neuroradiological investigation have revolutionised the diagnosis and treatment of brain abscesses. CT and MR scans offer diagnostic information, disclosing the exact location, morphology and stage of infection. When these examinations fail to define the type of lesions, nuclear medicine can be called into play with scintigraphy using labelled autologous leukocytes performed with SPECT for differential diagnosis.

Once the diagnosis of brain abscess is established, management is based on neuroradiological findings such as abscess stage, size, localisation and number and clinical information such as source of infection and the general clinical conditions of the patient. Conservative management is confined to small lesions at the early stage in patients whose general clinical condition is good and stable and there are no signs of intracranial hypertension. Surgery is required to treat large abscesses when the patient's general condition is poor. Different procedures are available, endoscopic evacuation aided by stereotactic systems now being the method of choice with respect to traditional excision. Neuroradiological monitoring is necessary whatever the treatment option to assess outcome and possible recurrence.

Brain abscess: analysis of results in a series of 51 patients with a combined surgical and medical approach during an 11-year period

OBJECT

In this study the authors' goal was to present the clinical and imaging results of the combined surgical and medical treatment of intracranial abscesses.

METHODS

The authors retrospectively analyzed the data in 51 patients with intracranial abscesses who underwent surgery between January 1997 and November 2007. Patients were treated with aspiration through a single bur hole, total resection with open craniotomy, or image-guided stereotactic aspiration. Computed tomography or magnetic resonance imaging was performed approximately 24 hours after surgery to evaluate the size of the abscess and almost weekly during follow-up until the abscess and/or cerebral edema was reduced. Clinical results were analyzed using modified Rankin Scale (mRS) scores.

RESULTS

There were 36 male and 15 female patients, and their ages ranged from 14 months to 58 years (mean 29 years). Adjacent localized cranial infection was the most common predisposing factor in 31 patients (61%). Thirty-two patients were treated by repeated aspiration via a single bur hole. Streptococcus and Staphylococcus species were isolated most frequently. No statistically significant difference between causative organisms and clinical outcome was identified (p > 0.05). Assessment of overall 1-year clinical outcomes was favorable (mRS Scores 0-2) in 76.5% of patients (39 of 51 patients). The initial neurological condition was strongly correlated with the clinical outcome (p < 0.001).

CONCLUSIONS

A combination of surgical aspiration or removal of all abscesses > 2.5 cm in diameter, a 6-week or longer course of intravenous antibiotics, and weekly neuroimaging should yield cure rates of > 90% in patients with intracranial abscesses.

Cerebellar abscess in a cynomolgus macaque (Macaca fascicularis)

BACKGROUND

A cynomolgus macaque (Macaca fascicularis) presented with decreased appetite, lethargy, ataxia, disorientation and visual impairment. It was used in a hepatitis B (HBV) study involving injections of HBV plasmid construct (450 microg) and aflatoxin B1 (25 microg/kg) in an effort to develop a model of liver cirrhosis and hepatocellular carcinoma.

METHODS

The case work-up included physical examination, including assessment of hydration, thoracic and abdominal radiographs and abdominal ultrasound. Clinical pathology included complete blood counts and tests for levels of plasma ammonia (NH(3)) and serum electrolytes, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, total bilirubin, and gamma-glutamyl transferase. Serum samples had also been serially tested for the presence of HBsAg, anti-HBc antibodies, HBV e-antigen, and HBV DNA. With a tentative diagnosis of hepatic encephalopathy, treatment with lactulose, antibiotics, and fluid therapy was initiated.

RESULTS

Clinical pathology and diagnostic imaging performed on the animal revealed no abnormalities except for the hyperammoniemia. Absence of HBV markers in the serum indicated unsuccessful inoculation. Not fully responding to therapeutic intervention, the animal was euthanized. Necropsy revealed fibrous peritoneal adhesions and an abscess in the cerebellopontine angle. Exudate culture indicated the presence of alpha-hemolytic streptococcus, Eubacterium lentum, and Bacteroides stercoris.

CONCLUSIONS

Brain abscesses are uncommon in non-human primates. This case of cerebellar abscess is characterized by important features similar to that found in humans, including the presenting signs and the presence of the above-cultured bacteria.

Petrositis and cerebellar abscess complicating chronic otitis media

A 12-year-old girl with chronic otitis media complicated by petrositis and cerebellar abscess is presented. Early surgical intervention, in combination with broad-spectrum antibiotics, provided a good outcome. Life-threatening complications of otitis media, although rare, still occur in developed countries.

Primary excision of pediatric posterior fossa abscesses--towards zero mortality? A series of nine cases and review

Nine children with infratentorial brain abscesses were treated at our institution over a 3-year period. Seven of them were boys and two were girls. In five cases, the abscesses were otogenic, and in two cases, the cause was tubercular (including one case of tubercular otitis). There were three cases of abscess formation in dermoids. All cases were managed with primary excision of the abscess. The average hospital stay was 12 days, and there was no mortality. The most common complication was hydrocephalus, noticed in three patients, of whom one eventually required shunt placement. Our policy of primary excision of these abscesses has yielded gratifying results. This approach also resulted in minimal morbidity and a substantially shortened hospital stay. Moreover, primary excision yields definitive histopathology of the lesion, especially in cases of tubercular and dermoid etiologies.