The use of computed tomography-guided stereotactic techniques in the treatment of brain stem abscesses

A case of a brain stem abscess with a favorable outcome

Background:

A brain stem abscess is a rare and severe medical condition. Here, we present a rare case of a brain stem abscess in a young pregnant woman, requiring acute stereotactic intervention.

Case Description:

A 36-year-old woman presented with a headache, nausea, and vomiting, and computed tomography showed a space-occupying lesion in the brain stem. She became shortly after comatose, and we decided to perform an acute stereotactic aspiration of the abscess. Soon after surgery, her neurological condition improved dramatically.

Conclusion:

A brainstem abscess is a life-threatening condition with a potentially good outcome if treated adequately.

Idiopathic pontine Streptococcus salivarius abscess in an immunocompetent patient: management lessons through case illustration and literature review

A 55-y-old woman with no previous medical history presented with a 3-day history of progressive headache, nausea, emesis, right-sided facial numbness, and right-sided extremity weakness. Serial magnetic resonance imaging demonstrated rapid enlargement of a left-sided ring-enhancing dorsal pontine lesion with an exophytic portion, raising concern for an abscess. A stereotactically guided left-sided retrosigmoid craniotomy for abscess incision and decompression was performed given the rapid progression of her neurological deficits. Streptococcus salivarius was isolated from the intra-operative samples. After an extensive evaluation, no source for the S. salivarius was identified. Solitary brainstem abscesses are uncommon intracranial infections with high morbidity and mortality. Patients can present with non-specific symptoms and often have no previous medical history. Since 1974, 40 patients with solitary brainstem abscess have survived to hospital discharge. We outline management strategies for solitary brainstem abscess based on a literature review of survivors.

Brainstem abscess caused by Haemophilus influenza and Peptostreptococcus species

We present a patient with a solitary brainstem abscess caused by Haemophilus influenza type b (Hib) and Peptostreptococcus species. This is the first report of a Hib brainstem abscess in the English literature. Hib has been mainly associated with respiratory or nasal infections, and a few cases of intracerebral abscesses, but no brainstem abscesses have been described. The literature on solitary brainstem abscesses was reviewed and an overview of the literature between January 1984 and May 2009 is presented.

Brain-stem abscess successfully treated by microsurgical drainage: a case report

Brain-stem abscess is an uncommon condition associated with high mortality. The best method of treatment is not yet defined. It can be managed by medical treatment alone, stereotactic aspiration of the pus and medical treatment, or surgical excision/drainage of the abscess. We present a case of large brain-stem abscess, treated successfully by surgical drainage after the failure of medical treatment. The patient had a large brain-stem abscess extending from the mid-brain down to the lower pons. She was in a poor neurological condition pre-operatively, and was worsening despite intravenous antibiotics. The abscess was coming close to the surface in the lateral aspect of the mid-brain. The presumed source of infection was multiple dental abscesses. The brain-stem abscess was approached by a subtemporal transzygomatic approach and drained completely after making an incision on the lateral surface of the mid-brain. After the operation, the patient showed steady improvement. At six months after the surgery, the patient was fully conscious, talking fluently, and walking with the help of a walker. Her hemiparesis and co-ordination were improving. Surgical drainage of a brain-stem abscess is indicated when medical therapy fails. Proper anatomical knowledge of the brain-stem and the selection of appropriate surgical approach is important for safe drainage of the abscess.

Successful treatment of brainstem abscess with stereotactic aspiration

BACKGROUND

Brainstem abscess is an uncommon condition associated with a high mortality. We report a case of brainstem abscess in a 51-year-old female with a pulmonary arteriovenous fistula that was cured after appropriate antibiotic therapy following stereotactic aspiration. The value of stereotactic aspiration in the management of brainstem abscess is documented with a review of the relevant literature.

CASE REPORT

A 51-year-old female with a pulmonary arteriovenous fistula suffered fever, diplopia and weakness on the right side. Magnetic resonance (MR) imaging of the brain showed a large cystic mass with ring-like enhancement in the brainstem. A diagnosis of brainstem abscess as a complication of pulmonary arteriovenous fistula was made. MR imaging-guided stereotactic exploration was carried out via the suboccipital transcerebellar approach and the pathogen of the brainstem abscess was identified. The brainstem abscess was cured after treatment employing antibiotics to which the pathogen was sensitive.

CONCLUSIONS

Stereotactic aspiration is an effective procedure for brainstem abscesses. This procedure is less invasive than open surgery and can be performed even in patients in poor general condition.

Successful stereotactic management of a large cardiogenic brain stem abscess

The brain stem is an unusual location for a pyogenic abscess. We report a case of a brain stem abscess in a 5-year-old boy with tetralogy of Fallot that was refractory to conservative medical therapy but was cured after a single computed tomographic-guided stereotactic aspiration and appropriate antibiotic therapy. The remarkable features in this case were the extremely large size of the abscess (3.2 cm in diameter), occupying the full vertical extent of the brain stem and containing 15 ml of pus. We believe this is the first report of a favorable outcome in a cardiogenic brain stem abscess. The value of computed tomographic-guided stereotactic surgery in the management of this lethal condition is documented with a review of the relevant literature.

Stereotactic aspiration of brain abscesses: is this the treatment of choice?

Despite a reduction in the mortality of patients with brain abscess since the introduction of the computed tomography (CT) scanner, controversy persists as to the preferred method of treatment for this condition. Eleven patients were treated by CT guided stereotactic aspiration of pus and appropriate antibiotic therapy. A total of 14 aspirations were performed. Ten abscesses were supratentorial and one was in the posterior fossa. In 9 patients a bacterial cause was identified while in 2 a fungus was identified. A good outcome was achieved in 7 patients but 3 patients died. Another elderly patient remains disabled at home. The deaths occurred in severely systemically ill patients with poor conscious levels on admission. Only one patient has epilepsy, controlled with anticonvulsants while another has not had further seizures since abscess treatment a year ago. Stereotactic aspiration should be considered the treatment of choice in all but the most superficial and largest cerebral abscesses, although the mortality of this condition in the severely ill remains high.

Medical cure of a brainstem abscess and serial brainstem auditory evoked potentials

The brainstem abscess of a nine-year-old girl with tetralogy of Fallot was cured after six weeks of parenteral antibiotic therapy, without surgical intervention. Serial studies of brainstem auditory evoked potentials were undertaken until the patient was clinically normal. To the authors' knowledge, this is only the second medically cured case reported in the literature, and it is the first case studied with serial brainstem auditory evoked potentials. If the clinical status allows, medical treatment of a brainstem abscess with appropriate antibiotics could be tried before surgical intervention such as stereotactic aspiration for reducing the mass.

Solitary brainstem abscess successfully treated by microsurgical aspiration

A case of pyogenic pontine abscess detected by computerized tomography scan in a 10-year-old boy is presented. While on broad-spectrum antimicrobial treatment, he deteriorated and developed new symptoms of respiratory distress. Microsurgical exposure of the abscess and aspiration of pus resulted in rapid improvement in his neurological state and radiological resolution of the lesion. The aim of this article is to emphasize the importance of prompt diagnosis and the role of surgical drainage of pus in the management of brainstem abscesses.