New perspectives in the endoscopic treatment of brain purulent collections: targets, techniques, results in a case series, and overview of the literature

Endoscopic Ultrasonic Aspiration of Brain Abscess

Brain abscess is a focal infection occurring within the brain parenchyma consisting of a pus collection surrounded by a vascularized capsule and a fibrinous-caseous layer between the pus and capsule. Surgery is indicated for lesions with a diameter >25 mm. Different surgical approaches have been described, including puncturing of the abscess (under neuronavigation, stereotactic or echographic guidance) with aspiration of the purulent fluid through a catheter and craniotomy with microsurgical removal of the purulent material and surrounding capsule. In recent years, the endoscopic approach has become more frequently used to treat brain abscesses. The theoretical advantages are visual awareness of the completeness of pus removal and the possibility of also removing the more solid fibrinoid component, which could be the source of recurrence. Craniotomy is likewise avoided. We present the case of an 11-year-old boy affected by a parieto-occipital brain abscess and initial ventriculitis who underwent endoscopic surgery. An ultrasonic aspirator was used to wash and suck the purulent material and fragment and remove the more solid fibrinoid component. The occipital horn of the lateral ventricle was also entered, and pus was removed. At the end of the procedure, a ventricular drainage tube was left in the surgical cavity. It was removed 1 day later, because the cavity had completely collapsed. The key surgical steps are presented in Video 1.1-9 The procedure was uneventful, with very good clinical and radiological results. The endoscopic technique has been shown to be a safe and effective treatment option for intracranial abscess. In the case of large superficial lesions, the surgical risks appear similar to those of simple drainage through catheters, with a possible reduction of the 20% reported recurrence rate. The use of an ultrasonic aspirator could facilitate complete and faster pus removal, increasing the efficacy of the procedure. The patient and his parents consented to the procedure and the report of the patient's case details and imaging studies. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Endoscopic ultrasonic aspiration of posterior fossa abscess in Dandy-Walker malformation: case report

BACKGROUND

Dandy-Walker malformation (DWM) is a posterior fossa malformation characterized by a huge posterior fossa cyst in communication with the fourth ventricle. Hydrocephalus is associated with more than 80% of cases and is usually treated by shunting. Despite infection being a common complication of the shunt, abscess formation within the cyst was reported only once.

CASE REPORT

A neonate affected by DWM developed a posterior fossa abscess following a shunt infection. The purulent collection was refractory to standard treatment (antibiotics and burr hole drainage); therefore, an endoscopic approach was performed in order to remove the purulent collection under direct vision. This material was aspirated with the help of an endoscopic ultrasonic aspirator. The outcome was favorable, with a resolution of infection and re-implantation of the ventriculo-peritoneal shunt. Surprisingly, post-operative radiological examination showed substantial modification of the anatomy of the posterior fossa with disappearing of the Dandy-Walker cyst. To the best of our knowledge, this is the first documented report of a true Dandy-Walker malformation that modified its anatomical appearance over time.

DISCUSSION AND CONCLUSION

Endoscopic aspiration of intracranial purulent collection should be considered a valid option to manage complicated cases. An endoscopic ultrasonic aspirator may make the procedure more effective and faster.

Unusual intracranial suppuration: illustrative cases

BACKGROUND

Intracranial suppuration (ICS) is a rare complication that can arise from various disease processes and is composed of brain abscess, extradural empyema, and subdural empyema. Although significant progress has been achieved with antibiotics, neuroimaging, and neurosurgical technique, ICS remains a serious neurosurgical emergency. An uncommon presentation of ICS is sterile ICS, which has yet to be fully elucidated by clinicians. The authors present 2 cases of unusual sterile ICS: a sterile subdural empyema and a sterile brain abscess.

OBSERVATIONS

Both patients underwent surgical treatment consisting of craniotomy to evacuate the pus collection. The blood cultures from both the patients, the collected empyema, and the thick capsule from the brain abscess were sterile. However, the necrotic brain tissue surrounding the abscess contained inflammatory cells. The authors’ review of the literature emphasizes the rarity of sterile ICS and substantiates the necessity for additional studies to explore this field.

LESSONS

Sterile ICS is a disease entity that warrants further investigation to determine appropriate treatment to improve patient outcomes. This study highlights the paucity of data available regarding sterile ICS and supports the need for future studies to uncover the etiology of sterile ICS to better guide management of this condition.