Aspiration Surgery with Appropriate Antibiotic Treatment Yields Favorable Outcomes for Bacterial Brain Abscess

Brain abscess mimicking a brain tumor only realized during surgery: A case report in a resource strained environment

Background

Diagnosis of brain tumors increased in sub-Saharan Africa since the advent of computed tomography (CT)-scans and magnetic resonance imaging (MRI) in these regions, enabling easy diagnosis. However, some histological types of brain tumors can be confusing, especially on CT-scan, simulating other pathologies such as inflammatory granulomas or pyogenic abscesses. MRI, in this instance, with its diffusion-weighted imaging, susceptibility weighted imaging, or perfusion imaging, is important to help with accurate diagnosis. The down side of these imaging facilities, however, is that less and less importance is accorded to proper and detailed history taking. Such a care-free attitude to history taking can be costly, especially in resource strained environments.

Case Description

We report the case of a 06-year-old child who presented with seizures associated with headaches and vomiting. In this case, proper history taking following the surgical intervention revealed a history of head trauma after a fall with a scalp wound, which was suppurated but later progressed well. The CT scan showed a solid cystic lesion. The first component is a ring enhanced portion (hyperdense ring with the hypodense center, surrounded by edema) with central calcification located in the frontal region, and the second component is a cystic portion located in the temporal region. This lesion with dual component was more suggestive of a tumoral lesion on imaging than an abscess. The child did not benefit from further imaging due to unavailability in the region as well as the socioeconomic status of the family making them incapable of going elsewhere to do it. A decision to surgically excise the lesion was made, and during surgery, we found a well-circumscribed yellowish lesion associated with an arachnoid cyst. The capsule of the lesion was very thick, and after opening it, the content was pus combined with debris. The child did well on antibiotic therapy post-surgery. The follow-up was unremarkable.

Conclusion

Brain MRI is essential to differentiate some pyogenic brain abscesses from tumors. However, meticulous history taking is important to gather as much information as possible about any medical pathology, which would then be corroborated with the physical examination findings and imaging to increase diagnostic accuracy and minimize misdiagnosis.

Effectiveness of Surgical Excision in Preventing Recurrence of Multilocular Brain Abscess

Background Despite advances in surgical treatment and antimicrobial therapy reducing mortality and recurrence rates of brain abscesses, many patients still face a challenging clinical course. To assess whether selecting an appropriate surgical approach influences patient outcomes, we retrospectively analyzed cases at our hospital, with a particular focus on abscess morphology. Methods We retrospectively analyzed 20 patients who underwent surgery for brain abscesses at our hospital between March 2005 and April 2022. Brain abscesses were classified as either simple or multilocular. Recurrence was defined as an increase in abscess size on postoperative contrast-enhanced imaging, while a poor outcome was defined as a >1-point increase in the modified Rankin Scale score at discharge. Results Of the 20 patients, 18 were included in the analysis. The mean patient age was 67 ± 15 years, and 17 were men. Among the 18 abscesses, 16 were classified as simple and two as multilocular. A total of 22 surgeries were performed, including 18 as initial treatments, three for recurrence, and one for a second recurrence. The procedures consisted of two excisions, 14 aspirations, five external ventricular drainage (EVD) procedures, and one aspiration combined with EVD. In cases treated with aspiration, the recurrence rate was significantly higher in the multilocular abscess group than in the simple abscess group (75% vs. 9.1%), with an OR of 24.0 (95% CI, 1.26-63.82; p = 0.011). Conclusions In patients with multilocular brain abscesses, our findings suggest that aspiration is associated with a higher recurrence rate, while surgical excision may be a more effective treatment approach. However, further studies are needed to confirm this benefit.

Clinical outcomes of neuroendoscopic resection of brain abscess guided by electromagnetic navigation among patients presenting at Jieyang People's Hospital in China

Background

The treatment of brain abscesses presents certain difficulties. How to enhance the surgical effect and the positive rate of bacterial culture has always been our objective.

Aim

This study explored the surgical outcome of neuroendoscopic resection of brain abscess under the guidance of electromagnetic navigation and how to increase the positive rate of bacterial culture.

Methods

From June 2018 to December 2023, a total of 5 cases of neuroendoscopic resection of brain abscess under the guidance of electromagnetic navigation were conducted in our hospital. After admission, enhanced head MR layer scans were carried out. The imaging data were imported into the neuronavigation system. After successful registration, the abscess wall was cauterized with bipolar under the guidance of electromagnetic navigation, and the abscess wall was taken for bacterial culture and drug sensitivity test. We calculated the positive rate of bacterial culture, that is, the positive rate of bacterial culture is the number of positive cases of bacterial culture divided by the total number of cases sent for culture. After the operation, sensitive antibiotics were intravenously administered according to the bacterial culture and drug sensitivity test.

Results

The headache symptoms of the 5 patients were significantly alleviated, and there was no residual limb dysfunction. Reexamination of the head MR indicated that the abscess was significantly reduced. Five cases were all subjected to bacterial culture, among which bacteria were cultured in three cases, and the positive rate of bacterial culture was 60 %. The abscess clearance rate after the operation was all greater than 80 %.

Conclusion

Neuroendoscopic resection of brain abscess under the guidance of electromagnetic navigation has a favorable effect.This surgical method increases the positive rate of bacterial culture and holds significant reference significance for the subsequent intravenous administration of antibacterial drugs.

Update and approach to patients with brain abscess

PURPOSE OF REVIEW

The epidemiology of brain abscess has changed in recent decades. Moreover, acute and long-term management remains challenging with high risks of mortality and neurological sequelae. This review describes recent advances in epidemiology, diagnosis, and treatment of brain abscess.

RECENT FINDINGS

The incidence of brain abscess is increasing, especially among elderly individuals. Important predisposing conditions include dental and ear-nose-throat infections, immuno-compromise, and previous neurosurgery. Molecular-based diagnostics have improved our understanding of the involved microorganisms and oral cavity bacteria including anaerobes are the predominant pathogens. The diagnosis relies upon a combination of magnetic resonance imaging, neurosurgical aspiration or excision, and careful microbiological examinations. Local source control by aspiration or excision of brain abscess combined with long-term antimicrobials are cornerstones of treatment. Long-term management remains important and should address neurological deficits including epilepsy, timely diagnosis and management of comorbidities, and potential affective disorders.

SUMMARY

A multidisciplinary approach to acute and long-term management of brain abscess remains crucial and source control of brain abscess by neurosurgery should be pursued whenever possible. Numerous aspects regarding diagnosis and treatment need clarification. Nonetheless, our understanding of this complicated infection is rapidly evolving.

Pulmonary arteriovenous malformations in patients with previous brain abscess: a cross-sectional population-based study

BACKGROUND AND PURPOSE

Pulmonary arteriovenous malformations (PAVMs) may cause recurrent brain abscess. The primary aim was to determine the prevalence of PAVM amongst survivors of brain abscess. The proportion with cardiac right-to-left shunts was also assessed post hoc.

METHODS

This was a cross-sectional population-based study of adult (≥18 years) survivors of cryptogenic bacterial brain abscess in Denmark from 2007 through 2016. Patients were invited for bubble-echocardiography to detect vascular right-to-left shunting and, if abnormal, subsequent computed tomography thorax for diagnosis of PAVM. Data are presented as n/N (%) or median with interquartile range (IQR).

RESULTS

Study participation was accepted by 47/157 (30%) eligible patients amongst whom two did not appear for scheduled bubble-echocardiography. The median age of participants was 54 years (IQR 45-62) and 19/57 (33%) were females compared with 59 years (IQR 48-68, p = 0.05) and 41/85 females (48%, p = 0.22) in non-participants. Bubble-echocardiography was suggestive of shunt in 10/45 (22%) participants and PAVM was subsequently confirmed by computed tomography in one patient with grade 1 shunting. The corresponding prevalence of PAVM was 2% (95% confidence interval 0.06-11.8) amongst all examined participants. Another 9/45 (20%) were diagnosed with patent in persistent foramen ovale (n = 8) or atrial septum defect (n = 1), which is comparable with the overall prevalence of 25% amongst adults in the Danish background population.

CONCLUSIONS

Undiagnosed PAVM amongst adult survivors of cryptogenic bacterial brain abscess is rare but may be considered in select patients. The prevalence of cardiac right-to-left shunts amongst brain abscess patients corresponds to the prevalence in the general population.

European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults

SCOPE

These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended for clinicians involved in diagnosis and treatment of brain abscess in children and adults.

METHODS

Key questions were developed, and a systematic review was carried out of all studies published since 1 January 1996, using the search terms 'brain abscess' OR 'cerebral abscess' as Mesh terms or text in electronic databases of PubMed, Embase, and the Cochrane registry. The search was updated on 29 September 2022. Exclusion criteria were a sample size <10 patients or publication in non-English language. Extracted data was summarized as narrative reviews and tables. Meta-analysis was carried out using a random effects model and heterogeneity was examined by I2 tests as well as funnel and Galbraith plots. Risk of bias was assessed using Risk Of Bias in Non-randomised Studies - of Interventions (ROBINS-I) (observational studies) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (diagnostic studies). The Grading of Recommendations Assessment, Development and Evaluation approach was applied to classify strength of recommendations (strong or conditional) and quality of evidence (high, moderate, low, or very low).

QUESTIONS ADDRESSED BY THE GUIDELINES AND RECOMMENDATIONS

Magnetic resonance imaging is recommended for diagnosis of brain abscess (strong and high). Antimicrobials may be withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time, preferably within 24 hours (conditional and low). Molecular-based diagnostics are recommended, if available, in patients with negative cultures (conditional and moderate). Aspiration or excision of brain abscess is recommended whenever feasible, except for cases with toxoplasmosis (strong and low). Recommended empirical antimicrobial treatment for community-acquired brain abscess in immuno-competent individuals is a 3rd-generation cephalosporin and metronidazole (strong and moderate) with the addition of trimethoprim-sulfamethoxazole and voriconazole in patients with severe immuno-compromise (conditional and low). Recommended empirical treatment of post-neurosurgical brain abscess is a carbapenem combined with vancomycin or linezolid (conditional and low). The recommended duration of antimicrobial treatment is 6-8 weeks (conditional and low). No recommendation is offered for early transition to oral antimicrobials because of a lack of data, and oral consolidation treatment after ≥6 weeks of intravenous antimicrobials is not routinely recommended (conditional and very low). Adjunctive glucocorticoid treatment is recommended for treatment of severe symptoms because of perifocal oedema or impending herniation (strong and low). Primary prophylaxis with antiepileptics is not recommended (conditional and very low). Research needs are addressed.