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Background and Importance: Stereotactic biopsies or needle aspirations of posterior fossa lesions are technically challenging. Here we report a novel technique for performing these procedures employing the Airo™ intraoperative computed tomographic (CT) scanner and the VarioGuide™ articulated arm (BrainLab, Munich, Germany)., Clinical Presentation: A 62-yr-old woman presented with an irregularly shaped, enhancing lesion of the left pons/middle cerebellar peduncle. Slowed diffusion on magnetic resonance imaging suggested an abscess, but no definitive infectious agent/source could be identified. When the patient deteriorated despite broad-spectrum antibiotic therapy, she was taken to the operating room for stereotactic drainage of the abscess employing the described technique. A specific infectious agent (Eikenella corrodens) was identified from the aspirate, allowing for tailored antibiotic therapy. The procedure was well tolerated and the patient made a full recovery with minimal neurological sequelae., Conclusion: The combination of the Airo™ intraoperative CT and the Varioguide™ articulated arm allows for safe, accurate, and efficient targeting of posterior fossa lesions.

Background and Importance: Intracranial pressure (ICP) monitoring is a mainstay in the management of traumatic brain injury. Large investigations have validated the safety and efficacy of ICP monitors in comatose patients. Clinically relevant infections are extremely rare and cerebral abscess has never been reported with the Camino device. We describe an exceptional case of a life-threatening intracerebral abscess from an intraparenchymal ICP monitor., Clinical Presentation: A 35-month-old child required 7 days of ICP monitoring after a fall from a 2-story window. His hospital course was complicated by severe airway edema treated, in part, with high-dose corticosteroid therapy for a total of 10 days. Two weeks later, the patient deteriorated acutely owing to a large intracerebral abscess under the previous ICP monitor site. Urgent craniotomy with evacuation of the abscess was performed on 2 separate occasions. Cultures grew methicillin-sensitive Staphylococcus aureus, which was treated with long-term antibiotics. At the 3-month follow-up, the patient was meeting age-appropriate milestones without focal deficits., Conclusion: To the best of our knowledge, this is the first report describing an intracerebral abscess as a complication from an intraparenchymal pressure monitor. Corticosteroid therapy may have constituted an independent risk factor for the ICP monitor--associated infection, as well as reinsertion of the ICP monitoring device at the same site. That this is the first reported parenchymal infectious complication underscores the safety of this device with respect to infection. When reinsertion of a parenchymal monitor is considered, a new site should be chosen.

Background and Importance: We report a unique case of a toddler (the only one reported) successfully operated on for a medulla oblongata abscess and comment on the influence of neuroimaging modalities in the preoperative planning of the surgical approach., Clinical Presentation: We report a case of a 20-month-old child with a solitary medulla oblongata abscess. The abscess appeared to be in close proximity to the anterior medulla oblongata, but preoperative planning based on diffusion tensor imaging (DTI) tractography motivated us to try to remove this lesion through a midline suboccipital approach. The ventral medulla oblongata abscess was surgically removed via a telovelar approach. At the anterior wall of the 4th ventricle, a fenestration was made with pus release and evacuation of the cavity. The child was discharged 1 week later with an uneventful and full recovery., Conclusion: Modern imaging modalities of the nervous system can be very helpful in preoperative planning. Functional visualization of the nervous system provided by modern imaging techniques, such as the DTI tractography, can alter the classic topographic concept of surgical approach. In the case presented, approaching an anterior medulla oblongata abscess based on DTI tractography data, through a suboccipital midline transventricular approach, proved to be an effective and safe technique.

Objective: Tuberculous brainstem abscess is a clinically rare condition with potentially high mortality and morbidity. We present this report to draw attention to the importance of early recognition and adequate treatment of tuberculous brainstem abscess., Clinical Presentation: A 24-year-old man complained of longstanding fever, headache, and weakness followed by development of progressive slurred speech and hemiparesis of the right extremities. Magnetic resonance imaging revealed a large thick-walled cystic lesion lying within the brainstem., Intervention: The patient demonstrated a remarkable clinical recovery after microsurgery combined with a course of antituberculous therapy. Microbiological and histological findings confirmed the diagnosis of a tuberculous abscess., Conclusion: Despite its rarity, the tuberculous brainstem abscess must be considered in the differential diagnosis of cystic brainstem mass lesions in vulnerable patients. When confronted with progressing neurological deterioration and poor response to antituberculous therapy, stereotactic or microsurgical management should be considered. Microsurgical excision combined with a complete course of antituberculous therapy in our patient led to a good outcome.

Objective: Brain abscesses (BA) are life threatening, even in immunocompetent patients, in part because microbiological diagnosis is often lacking and management is empirical. Recent epidemiological changes make it all the more important to have a precise microbiological diagnosis. Our purpose was to evaluate the efficacy of a strategy aimed at obtaining a microbiological diagnosis in immunocompetent patients presenting with suspected BAs., Methods: We conducted a cohort study including all consecutive patients suspected of having BAs according to clinical, biological, and radiological findings. Severely immunocompromised patients were excluded. Aspiration was performed free-hand in patients with superficial abscesses (<1 cm depth from the cortical surface) and under stereotactic guidance in patients with deep-seated abscesses. Microbiological diagnosis was optimized, using the best aerobic and anaerobic growth conditions, blood culture bottles inoculated in the operating room, and molecular biology techniques if necessary. Antibiotic treatment was adapted according to the findings., Results: Twenty-six patients were suspected of having BAs during the study period. Twenty-four patients benefited from aspiration (stereotactic puncture in 3 cases), which was safe, confirmed the diagnosis of BAs, and yielded microbiological diagnosis in all cases, even in those patients who had previously received antibiotics (n = 8; 33%). In 10 patients (42%), microbiological results led to a different choice in antibiotic therapy than the recommended empirical regimen., Conclusion: Microbiological diagnosis can be obtained in all cases of BA. This is achieved by the conjunction of rapid needle aspiration and the optimization of microbiological diagnosis resulting from fast management of the surgical specimen, good anaerobic culture conditions, and the use of blood culture bottles and molecular biology techniques when appropriate. Moreover, it is of clinical and therapeutic interest when BAs are suspected in immunocompetent patients.

Objective: Infection involving the cerebrum is a true neurosurgical emergency that requires rapid diagnosis and appropriate surgical and medical intervention to achieve good clinical outcome., Methods: Because of the potential for devastating neurological sequelae, it is imperative that neurosurgeons be involved in the diagnosis and management of these serious conditions once an infection is suspected. With the advent of computed tomography and magnetic resonance imaging, it is now possible to detect an infectious process early in its course and follow the response to therapy. Although significantly more effective than in the past, antimicrobial therapy alone is insufficient to eradicate most intracranial infections, especially in the presence of compression or displacement of the cerebrum. Surgery remains an essential part of the management of intracranial infection because of its ability to provide immediate relief from pressure on neural structures and thereby result in clinical improvement., Results: The most common infections affecting the brain, namely, cranial epidural abscess, subdural empyema, brain abscess, viral infection, tuberculosis, and neurocysticercosis, can each be associated with significant mass effect on the cerebrum that is greatly reduced through surgery. This relief, in combination with newer antimicrobial agents that have an improved ability to cross the blood brain barrier, has led to a reduction in the infection-related morbidity and mortality rates associated with intracranial infections., Conclusion: Combining advanced imaging and surgical techniques in the form of intraoperative magnetic resonance image-guided neurosurgery may further enhance clinical outcomes in these once uniformly fatal diseases.

Objective: Despite the aggressive infection of soft tissue caused by Clostridium perfringens (gas gangrene-necrotizing fasciitis), a brain abscess with this bacteria treated by early surgical excision, debridement of necrotic tissue, and antibiotic coverage may be expected to have a good recovery. Long-term follow-up has not been well established in this group of patients. We report this case to show the outcome at 3 years post surgical and antibiotic treatment for C. perfringens brain abscess and stress the need for urgent intervention to achieve good outcome. We also present a literature review of Clostridial brain abscesses since the 1960s., Clinical Presentation: A 53-year-old man was brought to the emergency room after having a witnessed seizure status postassault 3 days before admission. On presentation, he was febrile, disoriented, lethargic, and demonstrated right upper extremity weakness. A computed tomographic scan of the head showed a left frontoparietal depressed cranial fracture complicated with gas and intraparenchymal air fluid level cavity., Intervention: Emergent surgery for debridement and excision of necrotic tissue was performed. Empiric intravenous antibiotic therapy was started and penicillin G was added for 6 weeks after C. perfringens was demonstrated., Conclusion: Despite the severe infection and effect of C. perfringens in soft tissues in the brain, it appears that emergent surgical debridement and antibiotic coverage will yield an excellent outcome for these patients.

IN 1891, Dr. Cemil Topuzlu operated on a brain abscess that originated as a complication of a depression fracture of the cranial inner table. The patient presented with Jacksonian seizures on his left side after a sharp trauma resulting in a 15 cm-long scalp laceration and underlying linear cranial fracture in the right parietal bone. Dr. Topuzlu attributed Jacksonian epilepsy to the fracture irritating the motor area in the right hemisphere and attempted a craniotomy based on his measurements to localize the Rolandic fissure. The operation was complicated by a brain abscess, and Dr. Topuzlu reoperated to drain the abscess. He successfully treated the brain abscess and Jacksonian seizures and then presented this case in the Royal Society of Medicine of the Ottoman Empire and in the International Surgery Congress in Lyon in 1894. The case report was published in his surgery book in 1905. The case was not only the first case of brain abscess to be treated successfully with surgical intervention in the Ottoman Empire, it was also one of the first cases of neurological surgery performed using contemporary anesthesiological and surgical techniques, which reveals the importance of neurological examination and cerebral localization techniques in the era before x-rays. Dr. Topuzlu was the founder of modern surgery in the Ottoman Empire and deserves to be credited for his novel applications in the 19th century.

Objective and Importance: This is the second report of a Citrobacter-associated brain abscess in an adult and the first report of its association with an intradural tumor. Excluding those associated with trauma, neurosurgical procedures, and proximity to the skull base, only seven other cases of abscesses associated with intracranial tumors have been published. Five of seven tumor-associated abscesses with a microbiological diagnosis involved gram-negative bacteria, a finding that may indicate a predilection of these microorganisms for intracranial tumors., Clinical Presentation: A 78-year-old female patient presented with a 6-month history of confusion and personality changes. Her medical history included paroxysmal atrial fibrillation and a 10-day course of high-dose dexamethasone but no other predisposing conditions for sepsis. She was afebrile, had no focal neurological deficits, and had no systemic abnormalities on examination. Computed tomographic imaging revealed a noncalcified, homogeneously enhancing, 3-cm-diameter, extra-axial tumor associated with the right anterior falx cerebri. The tumor did not extend to the skull base., Intervention: At craniotomy, 10 to 20 ml of thick pus was found around the posteroinferior surface of the tumor. On extended culture, this material demonstrated Citrobacter koseri growth, which was effectively treated with ceftriaxone followed by meropenem and one repeated abscess aspiration. No systemic source of the infection was found., Conclusion: The characteristic endothelial invasiveness of Citrobacter and related gram-negative bacteria may predispose to the formation of abscesses in association with intracranial tumors.

Objective: To report our experience in treating multiloculated pyogenic brain abscess and determine whether there are differences in the bacteriology, predisposing factors, treatment choices, and outcomes between multiloculated and uniloculated brain abscesses., Methods: We studied clinical data collected during a 16-year period from 124 patients with pyogenic brain abscess, including 25 cases of multiloculated abscess., Results: The incidence of multiloculated brain abscess was 20%. In these 25 patients, hematogenous spread from a remote infectious focus was the most common cause of infection, as it was for the cases of uniloculated abscess. Headache and hemiparesis were the most common symptoms in patients with multiloculated abscess. In patients with uniloculated abscess, fever was the most common symptom. Viridans streptococci were the most commonly isolated pathogens. Bacteroides fragilis was the most common anaerobe in multiloculated abscess, and aerobic gram-negative bacilli were the most common pathogens in patients with uniloculated abscess. Of the patients with multiloculated abscess, 21 were treated surgically and 4 were treated with antibiotics only. Overall, eight patients (38%) needed another operation because of abscess recurrence after the initial operation. In uniloculated abscess, the rate of abscess recurrence after initial surgery was 13.1%. Mortality was 16% in multiloculated abscess and 17.1% in uniloculated abscess., Conclusion: Multiloculated abscesses accounted for 20% of our patients with pyogenic brain abscess. Excision seems to be the more appropriate surgical choice in multiloculated abscess. Prognosis for patients with multiloculated abscess can be as good as that for patients with uniloculated abscess. However, clinicians must carefully monitor these patients because the possibility of recurrence after surgery is significantly higher in patients with multiloculated abscess than in those with uniloculated abscess.

Objective: Nocardial brain abscesses are associated with significant morbidity and mortality rates. The optimal management remains unclear. We reviewed the surgical outcomes of patients treated with a relatively uniform policy at a single institution., Methods: Eleven patients were treated at the Royal Adelaide Hospital between 1970 and 2001. Their clinical presentations, surgical treatment, and outcomes were reviewed., Results: Clinical presentations most frequently involved focal neurological deficits (91%). Predisposing factors were identified for 63% of the patients. Nine patients were treated only with aspiration and long-term chemotherapy. Two patients underwent craniotomy and lesion excision. The majority of patients required either one or two procedures. There were no deaths in this series. Management complications were observed for three patients. Abscess aspiration was complicated by parenchymal hemorrhage and ventriculitis for one patient and temporary worsening of hemiparesis for two patients., Conclusion: Our results suggest that aspiration alone (repeated as clinically indicated) is a safe, efficacious treatment for the majority of patients with nocardial brain abscesses.

Objective and Importance: An unusual, but not unique, case of cerebellar aspergillosis associated with autologous peripheral blood stem cell transplantation for breast cancer is presented., Clinical Presentation: A 45-year-old woman with breast cancer underwent chemotherapy and radiotherapy as well as autologous peripheral blood stem cell transplantation. She developed a cerebellar aspergillosis abscess that was treated successfully with two surgical resections., Intervention: After removal of pus and the abscess wall, the patient received local application of amphotericin B (AmB). She received AmB 1 mg/kg/d for 3 months and itraconazole 100 mg/kg/d for 1 year. After 3 months of AmB treatment, magnetic resonance imaging revealed that disease had not recurred., Conclusion: In cases of central nervous system aspergillosis, to increase the therapeutic efficiency, AmB can also be applied to the abscess cavity. Computed tomographic and contrast-enhanced magnetic resonance imaging scans play an important role in establishing early diagnosis in high-risk, immunocompromised patients.

Objective and Importance: Patent foramen ovale (PFO) has been suggested as a potential source of paradoxical embolism. A higher prevalence of PFO in ischemic stroke of unexplained cause has been recognized. Brain abscesses are commonly associated with a contiguous focus of infection, hematogenous spread from a distant focus, or cranial trauma. However, no predisposing factors, including a distant focus with unknown cause, are identified in approximately 15 to 30% of reported cases., Clinical Presentation: We encountered two patients with brain abscess presumably caused by dental infections. Both patients displayed PFO, through which right-to-left atrial contrast shunting was revealed by transesophageal echocardiography. Although the radiological location of the abscesses suggested hematogenous spread as a cause, the patients had no arteriovenous shunting other than the PFO, despite exhaustive investigations for a potential infectious route. The patients displayed no definite focal orofacial inflammatory signs during the postoperative course despite diagnosis of pyorrhea alveolaris or periodontitis., Intervention: In Patient 1, the abscess was aspirated stereotactically, and in Patient 2, the abscess disappeared radiologically after high-dose antibiotic treatment., Conclusion: The mechanism of brain abscess formation putatively related to PFO should be different from that related to common dental sepsis. Analysis of these cases suggested that infectious embolism from a latent or even identifiable focus through the PFO may be an underrecognized cause of brain abscess, in contrast to simple seeding of the brain via transit of the infecting bacteria through the valveless emissary veins.

Objective: To elucidate prodromal signs and clinical factors influencing the prognosis in patients with intraventricular rupture of brain abscess (IVROBA) to prevent and manage this catastrophic condition., Methods: In this study, 33 consecutive patients with IVROBA diagnosed by computed tomography (CT) were treated. Basic and therapeutic parameters were evaluated as independent predictive factors of a poor prognosis by using univariate analysis. The factors were statistically analyzed based on the interval between initial symptoms and IVROBA., Results: Patients with a good outcome were younger (<21 yr old) (P < 0.003) and had fewer complications after IVROBA (P < 0.03). For the most part, these patients had undergone aspiration for brain abscess with ventricular drainage combined with the immediate administration of appropriate intravenous and intrathecal antibiotics (P < 0.02). In just a short time, abscesses located in the parieto-occipital region ruptured into the ventricle (P < 0.004), and those with nonsterile cultures (P < 0.01) developed into IVROBA. Just before IVROBA, patients had severe headaches, signs of meningeal irritation, and a rapidly deteriorating clinical condition within 10 days after the signs of meningeal irritation developed. A CT scan obtained before IVROBA ascertained localized enhancement of the ventricular wall adjacent to the abscess., Conclusion: Our findings suggest that signs of meningeal irritation and localized enhancement of the ventricular wall adjacent to the abscess, as observed on CT scans, preceded IVROBA. To decrease the mortality rate associated with purulent brain abscesses, signs forewarning of IVROBA should be recognized, and aggressive management of IVROBA should be initiated. Aggressive CT-guided aspiration of deep-seated abscesses, particularly in the parieto-occipital region, at the time forewarning signs of IVROBA are observed lead to the prevention of IVROBA and an improvement in outcome.

Objective and Importance: We present a case report of a patient with a left frontal brain abscess. Cultures obtained from the abscess at the time of surgery were identified as dental flora known to establish a synergistic relationship in polymicrobial infections. This type of synergistic relationship makes the clearance of an infection more difficult for an intact immune system. A serum immunoglobulin (Ig) Type A deficiency was identified postoperatively. This immunodeficiency may have contributed to the development of the abscess., Clinical Presentation: The patient presented with headaches and photophobia. Computed tomography of the head performed with intravenously administered contrast demonstrated a left frontal brain abscess., Intervention: The patient was operated on through a left frontal approach, carefully avoiding the frontal sinus. The abscess was aspirated, and the patient was treated with intravenous antibiotics for several weeks. Postoperatively, the patient did well. There were no signs of enhancement on follow-up computed tomographic scans at 7 and 12 months postoperatively., Conclusion: Through a comprehensive immunological workup, an IgA deficiency was identified postoperatively. Although the deficiency of a single type of Ig may be asymptomatic, complications from recurrent or chronic bacterial infections may occur. The deficiency of IgA, combined with a synergistic polymicrobial infection, contributed to the development of an intracranial abscess. A patient presenting with a brain abscess without any predisposing medical history should be evaluated for an underlying immune deficiency.

Objective and Importance: A case of a cerebral abscess, occurring in a patient who had undergone bone marrow transplant, caused by a new pathogen, Chaetomium atrobrunneum, and a review of the literature are presented. Although Aspergillus species are by far the most common fungi found in cerebral abscesses in immunocompromised patients, an increasing number of fungi commonly found in nature but not usually associated with infections in humans have been isolated from cerebral abscesses in these patients., Clinical Presentation: A 31-year-old male patient, who had undergone a recent bone marrow transplantation for multiple myeloma, presented 3 months after transplantation with right-sided hemiplegia caused by a left parietal hemorrhagic lesion., Intervention: A biopsy guided by computed tomography showed that the abscess contained the fungus C. atrobrunneum. The final identification of the organism was based on cultures, scanning electron microscopic studies, and consultation with the Fungus Testing Laboratory at the University of Texas Health Science Center, San Antonio, TX. The patient was treated with several antifungal medications but developed uncontrolled cerebral edema, which led to further neurological deterioration and eventual death., Conclusion: Cerebral abscesses in the immunocompromised patient may no longer be assumed to be caused solely by Aspergillus species. The literature reveals several rare cases of uncommon fungi found in these abscesses. Only four cases of cerebral infections caused by the genus Chaetomium have been reported. The case presented represents the first time a patient who had undergone a bone marrow transplant with a cerebral abscess was found to be caused by the pathogen C. atrobrunneum.

Objective: Cerebral Nocardia abscesses are rare, accounting for approximately 1 to 2% of all cerebral abscesses. Prompt aggressive surgical treatment involving craniotomy and excision of these lesions has been advocated by many authors, because these lesions have significantly higher morbidity and mortality rates than do most other cerebral abscesses. We report an atypical presentation of cerebral nocardiosis localized to the choroid plexus of the lateral ventricle., Clinical Presentation: A 56-year-old man presented with a 3-week history of fever, cough, and progressive headache and an ensuing 3-day history of progressive lethargy, confusion, and gait ataxia. Radiographic studies demonstrated a loculated contrast-enhancing left lateral ventricular lesion with significant perilesional parenchymal edema that was thought preoperatively to be a neoplasm., Intervention: The patient underwent a craniotomy for resection of the lesion. Intraoperatively, a reddish gray lesion with purulent exudate was encountered within the left lateral ventricle intimately adherent to the choroid plexus as well as to the ependyma and subependymal veins. A frozen section demonstrated an organizing abscess wall. The lesion was resected in its entirety, and multiple cultures were sent for analysis., Conclusion: Microbiology cultures grew Nocardia asteroides. A course of intravenous antibiotics was started, which included trimethoprim-sulfamethoxazole, amikacin, and ceftriaxone. Two weeks after surgery, at the time of discharge, the patient's neurological status had improved considerably. Although Nocardia abscesses have been documented to occur throughout the central nervous system, the presentation of a lesion confined to the choroid plexus of the lateral ventricle with significant parenchymal edema is unusual and demonstrates that Nocardia abscesses must be considered in the differential diagnosis of a contrast-enhancing intraventricular mass lesion involving the choroid plexus.

Importance: Rhinocerebral mucormycosis is extremely difficult to treat. Approximately 70% of patients are poorly controlled diabetics, and many of the remainder are immunocompromised as a consequence of cytotoxic drugs, burn injuries, or end-stage renal disease. Despite standard treatment consisting of surgical debridement and the intravenous administration of amphotericin B, rhinocerebral mucormycosis is usually a fatal disease., Clinical Presentation: We describe the case of a 16-year-old male patient with juvenile onset diabetes mellitus who presented with fever, right-sided hemiparesis, and dysarthria. Axial view computed tomography revealed abscess formation in the left basal ganglia and frontal lobe, which was proven by stereotactic biopsy to contain Rhizopus oryzae., Intervention: Intravenous administration of amphotericin B (30-280 mg/dose) was begun on the day of admission. On hospital Day 20, after the occurrence of frank abscess formation, the lesion was aggressively debrided. Despite these therapies, there was neurological deterioration characterized by the development of hemiplegia and aphasia. Sequential computed tomographic scans enhanced with contrast medium demonstrated progressively enlarging lesions. Ommaya reservoirs were placed into the abscess cavity and the frontal horn of the contralateral lateral ventricle. The patient was then treated with intracavitary/interstitial injections of amphotericin B during the course of 80 days and three doses of intraventricular amphotericin B. Clinical and radiographic improvement was achieved after treatment. Two years after the initial diagnosis, magnetic resonance imaging of the brain showed no evidence of disease and an examination revealed a neurologically intact and fully functional patient., Conclusion: We conclude that with an infection as morbid as rhinocerebral mucormycosis, it is advisable to use surgical debridement and all available routes for delivering amphotericin B to infected cerebral parenchyma, which include intravenous, intracavitary/interstitial, and cerebrospinal fluid perfusion pathways.

Objective: In vivo proton magnetic resonance spectroscopy was performed for 24 patients with pyogenic brain abscesses, to examine the consistency of the spectral patterns and to observe the changes in metabolites with treatment., Methods: Localized proton spectra were obtained from 4- to 8-ml volumes in the abscesses, using stimulated echo acquisition mode and spin echo sequences. Twenty-two patients were treated with combined surgical and medical therapy, and two patients were treated conservatively. High-resolution magnetic resonance spectroscopy was performed for 15 samples of abscesses obtained from these patients, to confirm the assignments of resonances seen in vivo. Postaspiration studies were performed for 12 patients treated with combined medical and surgical therapy and 2 patients treated medically., Results: Lactate and amino acids were seen in spectra for all patients, irrespective of the time of spectroscopy after the onset of combined medical and surgical therapy. Acetate and pyruvate disappeared after 1 week of combined treatment., Conclusion: It was concluded that spectral patterns for brain abscesses are consistent and specific and can assist in the noninvasive diagnosis of abscesses. Responses to combined treatment could be monitored by showing the changes in metabolite patterns in serial spectroscopic studies.

Objective: Cerebellar abscesses that are often ominously silent have a significant mortality. Sudden total occlusion of cerebrospinal fluid (CSF) pathways makes an aggressive surgical approach mandatory. Our neurosurgical unit at Wentworth Hospital, Durban, South Africa, prospectively instituted a protocol for patients with cerebellar abscesses with reference to CSF diversion with the aim of improving outcome. Our 13-year experience with this approach to cerebellar abscesses is presented., Methods: Since 1983, patients with cerebellar abscesses have been managed according to a standard protocol. In 1987, a policy of aggressive CSF diversion was prospectively instituted. This involved immediate CSF diversion in any patient with over or incipient hydrocephalus, even if fully conscious. The associated hydrocephalus was diagnosed on initial computed tomographic scans. CSF diversion was performed by means of a ventricular drain, inserted in the reception area under local anesthesia. The period from January 1983 to December 1995 was analyzed, and the impact of aggressive CSF diversion on patient outcome was evaluated., Results: Seventy-seven patients with cerebellar abscesses during the 13-year period under review were studied. Thirty-four patients were treated before the introduction of the policy of aggressive CSF diversion. Of these patients, 10 died, resulting in a mortality of 29% and a morbidity of 21%. Forty-three patients were treated after the institution of the new policy of CSF diversion. Of these patients, five died, resulting in a mortality rate of 11.6% and a morbidity rate of 14%., Conclusion: Although surgical drainage of a cerebellar abscess and eradication of the primary septic source and appropriate antibiotic coverage are necessary, the management of hydrocephalus, or even incipient hydrocephalus, is of paramount importance.

Objective and Importance: Gas-containing brain abscesses are rare, and the vast majority are caused by Clostridium perfringens. Significant simultaneous fungal infection in a bacterial abscess is even rarer. We present such a case and review the literature., Clinical Presentation: A 21-month-old male patient sustained a penetrating head injury in a barnyard, developed a gas-containing left parietal brain abscess, and presented with high fever, galeal swelling, and seizure., Intervention: The patient initially underwent debridement of his wound and then repeated aspirations. The initial cultures revealed pure growth of Clostridium perfringens. Despite appropriate antibiotic therapy, serial neuroimaging did not demonstrate a decrease in the size of the cavity. An excision had to be undertaken 6 weeks after the injury. The culture from the excised specimen revealed an unexpected growth of a saprophytic and opportunistic fungus, Myceliophthora thermophila. Antifungal treatment consisting of the administration of liposomal amphotericin B and itraconazole was then performed. The child was well and neurologically intact 6 months after the excision., Conclusion: Our review revealed 38 cases of clostridial brain abscess in the literature. Despite the reputation of the organism, the outcome with clostridial brain abscesses was relatively benign. The main characteristics of clostridial brain abscesses are highlighted, with reference to their optimal treatment. Our review also revealed that fungal infection after a penetrating head injury is extremely rare and often fatal. Our case seems to be the first in the medical literature with growth of M. thermophila as a causative agent for intracranial suppuration.

Objective and Importance: There are increasing reports of nasal sinus mucopyoceles eroding the base of the cranium and causing the rapid onset of neurological complications. Uncommon presentations can mimic tumors, but the infectious nature mandates an urgent surgical decompression. It is important to document these uncommon presentations. CLINICIAL PRESENTATION: A mucopyocele of the clivus is reported in a patient with a frequent history of sinusitis. Diplopia caused by an acute sixth nerve palsy prompted the radiological diagnosis with computed tomography and magnetic resonance imaging., Intervention: Transsphenoidal drainage of the lesion lead to marked improvement in the patient., Conclusion: This is the third reported case of a clival mucocele. Mucoceles of nasal sinuses can erode intracranially, causing neurological sequalae, and clival involvement is extremely rare. Early drainage leads to marked improvement.

Invasive aspergillosis of the central nervous system is a rare but well-described disease. There have been only a few reported survivors, and mortality exceeds 95% in the immunosuppressed host. We present a 2-year-old boy with acute lymphatic leukemia and multiple Aspergillus brain abscesses who was successfully treated with liposomal amphotericin B, itraconazole, and surgical excision of the abscesses. Liposomal amphotericin B is a new preparation that safely allows the attainment of significantly higher tissue levels with less toxicity than standard amphotericin B. The treatment of patients with invasive central nervous system aspergillosis is reviewed.

The mortality of patients with brain abscesses has decreased significantly from 38% in the 1950s to 25% in the 1980s (P = 0.003, Fisher's exact test by decade of report; asymptotic P values based on chi 2 distribution with 3 degrees of freedom, 28 series, 2825 total patients). This decrease in mortality has been attributed to improved diagnostic imaging, the evolution of neurosurgical techniques and understanding of intracranial pressure pathophysiology, greater critical care understanding, and newer antibiotics. However, the mortality associated with the intraventricular rupture of brain abscesses (IVROBA) remained consistently high (at or above 80% once IVROBA was identified) throughout these decades. Although 129 cases (84.5% mortality, 20 survivors) of IVROBA were located in these series and an additional six case reports of survival after IVROBA were found in the literature, treatment advice and detailed clinical description of these surviving cases are sparse or absent. A case of IVROBA with good quality of survival is presented along with the aggressive five-component therapeutic plan used. The five components are: 1) open craniotomy with debridement of abscess cavity, 2) lavage of the ventricular system, 3) 6 weeks of intravenous antibiotics, 4) intraventricular gentamicin twice daily for 6 weeks, and 5) intraventricular drainage for 6 weeks.

Bacterial brain abscesses occur in approximately 1500 to 2500 patients each year in the United States. Multiple abscesses have been noted in 10 to 50% of these patients. The goal of this study was to better define the roles of surgery and medical management in patients harboring multiple brain abscesses and to develop an algorithmic approach to the treatment of these complex patients. Between 1976 and 1992, 16 patients with multiple brain abscesses were treated by a single physician (M.L.R.). The ages of the patients ranged from 1.5 to 73 years (median, 47 yr). In all patients, a diagnosis of multiple abscesses was made by computed tomography (15 patients) or magnetic resonance imaging (1 patient) brain scans. The number of abscesses per patient ranged from 2 to 30, and the abscesses were located in all regions of the brain. Thirteen received a combination of antibiotics and surgical drainage, and three received antibiotics only. Surgery was performed on abscesses larger than 2.5 cm or on those situated in critical areas of the brain or causing significant mass effect. Excision and open aspiration via craniotomy and stereotactic aspiration were analyzed on the basis of the location of the lesion and infecting organism. Any abscess that enlarged after 2 weeks of antibiotics or that failed to shrink after 3 to 4 weeks of antibiotics was again aspirated or excised. Forty-three surgical procedures were performed in 13 patients, and 8 (62%) of the patients operated on required more than one surgical procedure. No significant morbidity was observed in any of the surgical procedures. Antibiotics were administered intravenously for an average of 6 to 8 weeks and were adjusted according to organism type and sensitivity to antibiotics. One patient (6%) died, and the remaining 15 patients had resolution of all abscesses and good neurological recovery within 6 months. On the basis of these results, we propose a combined surgical and medical approach to the treatment of patients with multiple brain abscesses. We recommend the aggressive surgical drainage of all abscesses larger than 2.5 cm in diameter, combined with 6 to 8 weeks of intravenous antibiotics. Biweekly computed tomography or magnetic resonance imaging is necessary to closely monitor patients for evidence of abscess growth or failure to resolve despite antibiotics, prompting another operation. The application of this combined approach should yield cure rates of more than 90% in patients with multiple brain abscesses, a result similar to that expected when treating patients with solitary lesions.

The successful management of nocardial brain abscess remains problematic. The authors report 11 cases of nocardial brain abscess treated between 1971 and 1993 and review 120 cases reported since 1950. The clinical findings included focal deficits in 55 patients (42%), nonfocal findings in 36 (27%), and seizures in 39 (30%). Extraneural nocardiae were present in 66% of the cases; pulmonary (38%) and cutaneous/subcutaneous (20%) locations were the most frequent. The abscesses were single in 54% of the patients, multiple in 38%, and of unknown number in 8%. Forty-four of 131 patients (34%) were immunocompromised; since 1975, 18 of 40 immunocompromised patients (45%) were transplant recipients and six (15%) had human immunodeficiency virus. The mortality rate was 24% after initial craniotomy and excision (11/45), 50% after aspiration/drainage (17/34), and 30% after nonoperative therapy (7/23); 29 cases (22%) were diagnosed at autopsy. The mortality rate was 33% in patients with single abscesses and 66% in those with multiple abscesses (P < 0.0003). There was no difference in the mortality rates of immunocompromised and nonimmunocompromised patients treated before computed tomography (CT) was available; since the advent of CT, however, the mortality rate has been significantly higher in immunocompromised patients (55% vs. 20%, P < 0.05). Although the mortality rate for nocardial brain abscesses has dropped almost 50% since the advent of CT, it has remained virtually unchanged in immunocompromised patients and is three times higher than that of other bacterial brain abscesses (30% vs. 10%). The authors recommend image-directed stereotactic aspiration for diagnosis; however, craniotomy and total excision are necessary in most cases, because nocardial abscesses are usually multiloculated. Patients with minimal neurological deficits or small abscesses may be treated initially with antibiotics alone. Sulfonamides, alone or in combination with trimethoprim, are most effective and should be continued for at least 1 year. Minocycline, imipenem, or aminoglycoside in combination with a third-generation cephalosporin may be used with reasonably good success as second-line agents in cases of allergy or nonresponsiveness to sulfa agents.

The authors report the case of a 17-year-old patient with an osteoma of the frontoethmoidal sinus who had a secondary abscess of the frontal lobe and an intracranial mucocele. Clinical, radiological, and surgical correlates of this triad are presented.

Neurosurgical operations have traditionally been classified along the lines of general surgical procedures. A prospective study, during an 18-month period, was undertaken in 2249 patients undergoing neurosurgical procedures to establish and evaluate a method of classifying surgical cases by the use of specific neurosurgical criteria. Patients were placed in one of five categories according to the level and type of contamination at the time of surgery. Infection included all abnormal wounds and was documented as deep when infection occurred beneath the galea (subgaleal pus, osteitis, abscess/empyema, ventriculomeningitis) and as superficial if only the scalp (including wound erythema) was involved. A statistically significant difference in the sepsis rate was found in the different categories (P < 0.0001). Of the 342 "dirty cases," 9.1% of patients developed further wound sepsis. Concomitant cerebrospinal fluid fistulae (44%), second operations (11.8%), and patients with penetrating injuries (9.2%) were the major factors implicated in sepsis in the "contaminated" category (9.7%). In the "clean contaminated" category, a sepsis rate of 6.8% was found. Prolonged surgery (longer than 4 hours) was also implicated in higher infection rates (13.4%). This study strongly supports the separation of patients who have foreign materials implanted (sepsis rate = 6.0%) from "clean" patients, essentially cases categorized as having no known risk factors that may affect sepsis, in whom a sepsis rate of 0.8% was found (P < 0.001). Importantly, surgery for the repair of so-called "clean" neural tube defects in neonates requires separate consideration. An infection rate of 14.8% existed in this subgroup. A uniform system of reporting wound abnormalities is also proposed.

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.

Cerebral mucormycosis (without associated involvement of and invasion from the nasal sinuses and turbinates) is an extremely rare opportunistic infection of the central nervous system. We report the case of an intravenous drug abuser (who was negative for the human immunodeficiency virus) who presented with hemiparesis on the right side, slurred speech, altered mental status, and an unsteady gait. Imaging studies revealed a large left-side basal ganglia lesion. A stereotactic biopsy obtained a tissue sample that revealed wide, nonseptated hyphal fragments with granulomatous inflammation. The patient was treated with 3 gm of amphotericin B during a 5-month period. The patient had no residual neurological dysfunction after treatment. Open surgical resection was not employed. This case suggests that stereotactic biopsy followed by long-term amphotericin B therapy, in lieu of open surgical resection, represents a viable treatment option for this rare disorder.

A 14-year-old girl with a rare form of fungal brain abscess involving the dura and brain parenchyma is reported. No portal of entry of the infection was found. Histological findings and fungal culture both indicated that the causative agent was Xylohypha bantiana, an uncommon dematiaceous fungus. A review of the literature suggests that this infection, which affects primarily young male patients, exhibits distinct neurotropism. Despite therapy, the prognosis is generally poor.

INTRA-ABSCESS CONCENTRATIONS OF the intravenously administered latamoxef (LMOX, moxalactam in the United States) and cefotetan (CTT), were studied in 11 patients with intracranial abscess. None of these patients underwent surgical ablation of the abscess. In all cases, the abscess was aspirated, and multiple aspirations were required in five patients. Antibiotic concentrations in 18 aspirates were, therefore, determined by the agar well method. LMOX concentrations in 16 aspirates drawn from nine brain abscess cases ranged from 0 to 10.9 micrograms/ml, with a mean (standard deviation) of 4.18 (3.04) micrograms/ml. The CTT concentration in one patient with a brain abscess was 8.51 micrograms/ml, and the LMOX concentration in the one remaining patient with subdural empyema was 5.20 micrograms/ml. In one patient, the serum-to-pus penetration rate of LMOX was estimated to be 0.11 against the peak value of the concentration in serum or 0.44 against the simultaneously obtained level in serum. Significantly higher concentrations of LMOX were produced in abscess cavities with multiple-dose administration or by prior drainage of pus. More-advanced stages of local inflammation, as demonstrated by computed tomography, correlated with higher concentrations. However, the routine indexes of systemic inflammation, such as body temperature, white blood cell count, and level of C-reactive protein in serum, cannot be used to predict the concentration present in intracerebral pus. A tendency for LMOX concentrations in pus obtained after single dose-administration to decrease with increasing duration from symptom onset to sampling was observed but was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Aspergillus brain abscess is often a fatal disease, regardless of the mode of therapy. Most often seen in the compromised host, it is notoriously refractory to systemic antifungal agents and intrathecal antimycotics. Even with radical surgical debridement, only 13 patients, including the present case, have survived longer than 3 months after being treated for aspergillus brain abscess or granuloma. Studies have shown poor penetration of amphotericin B into the brain and cerebrospinal fluid. One way to achieve therapeutic levels of the agent near the abscess is through the direct introduction of the agent into the abscess site via an indwelling catheter. In the present case, a woman with an aspergillus abscess of the left temporal lobe was treated by a combination of systemic agents, radical debridement, and local therapy, resulting in a cure with a follow-up of 6 years. This is the first reported instance of the use of long-term, local antifungal therapy delivered to the area of the abscess cavity, using a closed reservoir system, and this patient is only the second renal transplant patient reported to have survived aspergillus brain abscess. This form of treatment produced no untoward long-term side effects or neurological sequelae. Local irrigation with antifungal agents should be considered in conjunction with systemic antifungal drugs and drainage and/or debridement in cases of fungal intracerebral aspergilloma. This technique may also prove useful with other fungal brain lesions.

Because subdural empyema (SDE) is an unusual central nervous system infection, recognition is not always prompt. Consequently delays can allow a serious but curable infection to become irreparably damaging or even fatal. This condition, particularly in the early stages, is relatively easy to treat. Personal experience with six patients during the past 3 years promoted us to review the data from UCLA and its affiliated hospitals. Among the 23 cases of SDE reviewed, the predisposing factor in 16 was sinusitis, mastoiditis, or otitis media. The clinical presentation, encompassing a systemic febrile illness, headache, and neurological deficit, was monotonously uniform. The high incidence of paranasal sinus involvement in the adult, middle ear infections in infants, and seizures in 15 patients comprised further clinical clues suggesting the diagnosis. Although usually diagnosed as an intracranial inflammatory process, an initial failure to suspect a purulent collection in the subdural compartment was typical. Although the findings of definitive diagnostic studies (computed tomography or angiography) are strikingly positive in advanced cases, in the earlier stages of this disorder they may be subtly abnormal. Because the mortality and morbidity rates, in some measure, depend on the stage at which the process is arrested, the real challenge lies in making a prompt diagnosis. The most favorable results are associated with early, decisive surgical treatment.

The author reviews the methods of surgical treatment of brain abscess. All methods are grouped into the following six categories: tube drainage, marsupialization, the migration method of Kahn, tapping only, aspiration, and excision. At present, only two methods are used: aspiration and excision. Antibiotics and computed tomographic (CT) scanning play important roles in the surgical treatment of a brain abscess. The use of CT scanning is invaluable in the management of brain abscess for early and exact localization, assessment of the adequacy of operation, and sequential follow-up.

A 56-year-old man developed an abscess within a right parietal cystic anaplastic astrocytoma 3 days after removal of iodine-125 sources placed 9 days earlier for interstitial radiation therapy. After treatment with cephalosporin antibiotics proved unsuccessful, the patient was treated with intravenous vancomycin and intermittent percutaneous drainage of the abscess. Vancomycin levels obtained from the brain abscess fluid, both before and during later operative removal of the abscess, were 15 and 18 micrograms/ml, respectively; the serum vancomycin level was 21 micrograms/ml. This is the first report of the excellent penetration of vancomycin into brain abscess fluid.

Aspergillus species are second only to Cryptococcus neoformans as the most common cause of fungal infections of the central nervous system in immunocompromised patients. Survival following treatment of Aspergillus brain abscess has been reported only 4 times. In each case, craniotomy was performed for abscess drainage. We present a case of long-term survival following stereotactic drainage of a bilateral Aspergillus brain abscess. In all reported cases, including the present one, histological examination of the abscess contents established the correct diagnosis. Amphotericin B was used in combination with operation in 4 of the 5 cases of long-term survival.

Seizures complicate many neurosurgical diseases and, in many situations, their prevention is desirable. In an attempt to arrive at a rational approach to the purely prophylactic administration of anticonvulsants, existing data pertaining to four topics were examined: the danger posed by a single seizure, the incidence of seizures in a given disease state, the ability of anticonvulsant medication to prevent seizures, and the risks and benefits associated with pharmacological intervention. In general, where the risk of seizure exceeds 10 to 15% or where a single seizure may have disastrous consequences, anticonvulsant prophylaxis is recommended.

The importance of stereotactic aspiration to the successful management of three cases of brain stem abscess is discussed with special reference to the advantages offered over medical treatment alone. Stereotactic aspiration allows evacuation of pus, accurate bacteriological diagnosis, selection of an optimal antibiotic regimen, and instillation of antibiotics directly into the abscess cavity. In two of the three cases described here, the abscess reaccumulated after initial aspiration despite appropriate maximal medical therapy. A repeat aspiration was required before resolution occurred. We conclude that medical management alone is not adequate for some cases of brain stem abscess. There was no morbidity that could be attributed to the procedure, suggesting that the risk of stereotactic aspiration is probably quite low and is likely to be less than the risk of incorrect diagnosis, suboptimal choice of antibiotics, or progression of the lesion despite appropriate maximal medical therapy.

We present a case of multiple brain lesions in which the preoperative computerized tomographic (CT) scan suggested the presence of brain abscesses rather than metastatic tumors. The patient presented with symptoms of left frontal and right cerebellar mass lesions, confirmed by carotid and vertebral arteriography and a radionuclide brain scan. A CT scan revealed multiple contiguous ring-enhancing lesions of various sizes at both sites. With the exception of a prior mild pulmonary infection, no findings suggested underlying malignancy, immunosuppression, or medical illness. We based our decision to administer antibiotics preoperatively on the presumed presence of abscess. We found and totally removed two multiloculated abscesses during one operation and initiated sulfa drug therapy (sulfisoxazole) immediately after identification of the Nocardia organism. The patient experienced no postoperative complications and at 6-months follow-up is clinically free of disease.

A 27 year-old Vietnamese male immigrant to Canada developed a hemispheric cerebellar abscess. The patient presented at the hospital with osteomyelitis of the 5th finger of the left hand. He complained of lassitude, weight loss, and early morning headache, nausea, and vomiting, and he developed a left facial weakness. A computed tomographic scan demonstrated the distinctive appearance of an abscess of the left cerebellar hemisphere. Aspiration of the abscess afforded immediate relief of obstructive hydrocephalus and provided pus from which Mycobacterium tuberculosis was grown, thus permitting specific antituberculous chemotherapy. The cerebrospinal fluid obtained at the time of operation was sterile. The patient recovered fully. A primary site of infection was not conclusively identified.

Multiple cerebral abscesses have been recognized with increasing frequency because of the use of computed tomography and have been the subject of various therapeutic proposals. Their prognosis has been considerably improved thanks to high dose antibiotic therapy. However, diagnostic and therapeutic problems persist.

The records of 102 patients with brain abscesses treated over 17 years were analyzed. In recent years, cardiac and pulmonary causes were less frequent, the abscesses were smaller, and fewer patients were in poor neurological condition. There has been no significant change in the type or number of infective organisms or in the number of abscesses during the study period. Computed tomographic brain scanning was the most important factor in reducing the mortality rate from 41% to 4%. The patients were grouped according to the treatment received: excision (n = 46), aspiration (n = 33), or nonsurgical therapy (n = 17). Patients treated nonsurgically were more likely to have smaller abscesses and multiple lesions than were patients in the other two groups. There were no significant differences in the morbidity or mortality rates between treatment groups. Patients whose abscesses were excised had a significantly shorter course of antibiotics than the other patients. Organisms were identified in 85% of the cultures from surgical specimens. The use of preoperative antibiotics was significantly associated with sterile cultures; 30% of patients who received antibiotics preoperatively had sterile cultures, compared with only 4% of patients who did not receive such treatment. The mortality rate among all treated patients (the diagnosis of brain abscess was missed in 6 patients before computed tomographic scanning became routine) was significantly related to the initial neurological grade and the size of the lesion but not to age, sex, or the number of abscesses. Four of the 8 treated patients who died had congenital cyanotic heart disease; an aggressive surgical approach is recommended for such patients.(ABSTRACT TRUNCATED AT 250 WORDS)

An unusual complication of brain abscess in cyanotic heart disease is presented. This patient, who was suffering from recurring brain abscesses at different sites was diagnosed on regular follow-up, and a metrizamide computed tomographic ventriculogram confirmed the diagnosis of foramen of Monro obstruction ipsilateral to the abscess.

A case of moxalactam-induced coagulopathy is reported. The authors think that this coagulopathy is caused by an effect on platelet aggregation and not by inhibition of vitamin K-dependent clotting factors. It is recommended that bleeding times be routinely checked preoperatively in patients being treated with moxalactam.

Intracranial aspergillosis is rare and often fatal. The authors report the successful treatment of a right temporal intracerebral aspergillus abscess.

We describe a man who developed a gliosarcoma at the site of a previously surgically decompressed frontal Actinomyces israelii brain abscess. We review the clinical profile of gliosarcoma and the possible role of the abscess and operation in the induction of this malignancy.

A case is presented and 10 cases are reviewed in which abscess formation developed in an intrasellar tumor. The diagnosis was made preoperatively or before autopsy in only 1 patient. The mortality rate was greater than 50%. The most common presentation was headache, fever, and visual disturbances with an abnormal sella and sterile cerebrospinal fluid (CSF). Nonconstant findings included meningeal signs and leukocytosis of the CSF. Trans-sphenoidal removal of the tumor and drainage of the abscess with appropriate antibiotic therapy is recommended. (Neurosurgery, 5: 718--722, 1979).