Brain abscess: an overview

Intracranial dissemination of Klebsiella pneumoniae originating from pulmonary infection: a case report

BACKGROUND

Metastatic brain abscesses caused by Klebsiella pneumoniae are extremely rare but life-threatening conditions. To depict a unique case of the middle-aged hypertensive man with an unusual presentation of metastatic brain abscesses originating from a pleural abscess caused by Klebsiella pneumoniae and subsequently leading to loss of consciousness (LOC).

CASE REPORT

A 52-year-old Iranian man with a history of hypertension presented to the emergency department with a five-day history of worsening cough, high-grade fever, shortness of breath, chest pain, fatigue, and a productive cough. Laboratory tests revealed leukocytosis, elevated C-reactive protein, and respiratory alkalosis. A chest computed tomography scan confirmed pneumonia, and a brain scan revealed multiple hypodense lesions. Despite antibiotic therapy, the patient's condition worsened, leading to confusion, disorientation, and loss of consciousness. Magnetic resonance imaging revealed multiple ring-enhancing lesions, suggesting an abscess formation. Bronchial washings and BAL samples confirmed a lower respiratory tract infection. Cultures from the bronchial washings grew Klebsiella pneumoniae.

CONCLUSIONS

Metastatic brain abscesses caused by Klebsiella pneumoniae are exceedingly rare but life-threatening conditions. Timely diagnosis and effective antimicrobial treatment are critical for patient outcomes. This case underscores the significance of recognizing atypical presentations of bacterial infections, as early detection and appropriate management can significantly impact patient outcomes.

Comparison of surgical outcomes between primary and secondary brain abscess

Brain abscess (BA) constitutes 1-8% of intra-cerebral tumors, and thus the present study aimed to compare the surgical outcomes of patients with primary and secondary BA. The present retrospective study examined 32 of cases BA who underwent surgery in a local institution between February, 2013 and December, 2023. All patients received intravenous antibiotic therapy according to the antibiogram for antimicrobial susceptibility. In total, 32 patients were separated into two groups as follows: Group A (16 patients, 50%) with primary abscess and group B (16 patients, 50%) with secondary abscess. Of the 32 patients included in the study, 23 (71.8%) were males, and the median age was 55.3 years. On the whole, the present study demonstrates that a multidisciplinary approach involving a combination of often multiple surgical procedures and prolonged antibiotic medication may improve the functional outcome if the underlying pathology allows for a functional outcome.

Polymicrobial brain abscesses: A complex condition with diagnostic and therapeutic challenges

Brain abscesses (BA) are focal parenchymal infections that remain life-threatening conditions. Polymicrobial BAs (PBAs) are complex coinfections of bacteria or bacterial and nonbacterial pathogens such as fungi or parasites, with diagnostic and therapeutic challenges. In this article, we comprehensively review the prevalence, pathogenesis, clinical manifestations, and microbiological, histopathological, and radiological features of PBAs, as well as treatment and prognosis. While PBAs and monomicrobial BAs have some similarities such as nonspecific clinical presentations, PBAs are more complex in their pathogenesis, pathological, and imaging presentations. The diagnostic challenges of PBAs include nonspecific imaging features at early stages and difficulties in identification of some pathogens by routine techniques without the use of molecular analysis. Imaging of late-stage PBAs demonstrates increased heterogeneity within lesions, which corresponds to variable histopathological features depending on the dominant pathogen-induced changes in different areas. This heterogeneity is particularly marked in cases of coinfections with nonbacterial pathogens such as Toxoplasma gondii. Therapeutic challenges in the management of PBAs include initial medical therapy for possibly underrecognized coinfections prior to identification of multiple pathogens and subsequent broad-spectrum antimicrobial therapy to eradicate identified pathogens. PBAs deserve more awareness to facilitate prompt and appropriate treatment.

Overdose Risk and Brain Injury (Traumatic Brain Injury/Acquired Brain Injury), A Commentary

OBJECTIVE

This commentary seeks to evaluate existing knowledge about the relationship between brain injury (BI) and overdose (OD), to unify distant bodies of literature, and to enhance prevention and treatment for opioid OD among individuals with BI.

BACKGROUND

There is a hidden epidemic of undiagnosed BI in the United States. Due to lack of screening, the vast majority of BI sufferers do not know they have a BI. Not only are those with BI at elevated risk for opioid use, misuse, and opioid use disorder, but also they are at elevated risk for OD. Conversely, those with OUD and those who experienced an OD, are more likely to sustain BI. Key Findings/Conclusions: The existing literature suggests that primary strategies to reduce ABI (Acquired Brain Injury)/TBI (Traumatic Brain Injury) harms involve addressing: screening, stigma, racial disparities, and popular misconceptions about OD. The association between TBI and OD is an underexamined public health issue, exacerbated by the bidirectional nature of the relationship. Not only is TBI a risk factor for opioid OD; opioid OD was also found to be a major cause of ABI, which can have lifelong effects similar to Alzheimer's disease. Screening tools for BI were underutilized and inconsistently implemented across reviewed studies. Enhanced screening population wide is a promising intervention, complemented with expanded treatment and research. Black individuals face worse outcomes in BI and treatment outcomes. Anti-racist strategies must fight inequity while addressing social and structural drivers of overdose and BI within the opioid and opioid overdose crises.

Delayed brain abscess as a complication of cerebral infarction: A rare case report and review of the literature

INTRODUCTION

Systemic infections are a common complication of cerebral stroke, while the development of a cerebral abscess on the background of infarcted brain tissue is an extremely rare occurrence. Here, we present a new case alongside a literature review.

CASE PRESENTATION

A previously healthy 37-year-old man presented with sudden right-sided weakness and speech difficulties, progressing to complete aphasia. Initial tests showed no abnormalities, but subsequent CT scans revealed left basal ganglia infarction. Despite treatment and improvement, three months later, his condition worsened, leading to surgical intervention to excision of a cerebral abscess caused by Staphylococcus aureus. Following successful surgery and treatment, the patient showed improvement and was discharged for regular follow-up care.

DISCUSSION

The convergence of stroke and brain abscess poses serious clinical challenges, requiring prompt diagnosis and treatment to mitigate catastrophic consequences. Brain abscess, stemming from cerebral infection, may arise from various sources, including contiguous spread, hematogenous dissemination, or traumatic injury. Diagnosis is complicated by nonspecific radiological findings, which often lead to misdiagnosis. Risk factors include age, immunocompromised states, and certain medical conditions. Despite challenges, early detection and appropriate management, involving surgical drainage and antimicrobial therapy, are crucial for favorable outcomes.

CONCLUSION

Cerebral abscess following cerebral infarction is rare but should be suspected in patients with prior stroke or hemorrhage, experiencing worsening focal deficits and consciousness. Advanced age and comorbidities increase clinical suspicion.

Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

Otogenic Cerebellar Abscess with Polymicrobial Anaerobic Infection in a Young Female- A Rare Presentation

Brain abscess is a serious clinical condition caused by a localized collection of pus within the brain tissue. This typically occurs as a result of an infection that originates from a nearby area, such as an ear, sinus, or dental infection, or an infection in the bloodstream. Streptococcus and Staphylococcus species are the most common organisms implicated in brain abscesses. Apart from aerobic growth, cases of mixed infections of both aerobic and anaerobic organisms are also commonly reported in the literature. Herein we report a 23-year-old immunocompetent female with chronic otitis media who presented with cerebellar abscess where the aerobic growth was sterile and anaerobic culture revealed pure growth of dual anaerobes viz… Peptostreptococcus and Bacteroides thetaiotaomicron. This case highlights the importance of prompt diagnosis and management of polymicrobial anaerobic infection in cases of brain abscess.

Listeria monocytogenes Brain Abscess Presenting With Stroke-Like Symptoms: A Case Report

We present a case of Listeria monocytogenes brain abscess in an immunocompromised patient admitted for stroke-like symptoms of headache and aphasia. Computerized tomography of the head revealed a 1.7 x 1.3 cm left frontal lobe lesion with surrounding edema, secondary to stroke, tumor, or abscess. Magnetic resonance imaging brain revealed a ring-enhancing lesion and a small contralateral area of restricted diffusion. Two of the two blood cultures grew an organism identified as L. monocytogenes using matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Treatment with ampicillin and trimethoprim-sulfa yielded marked symptomatic improvement. A brain biopsy was consistent with bacterial abscess. The patient's clinical course was favorable, with improved aphasia and negative follow-up blood cultures. A literature review found a limited number of L. monocytogenes abscess cases and none had clear guidelines for diagnosis. Recent studies have proposed five criteria for diagnosis. Our patient fulfilled three of these proposed guidelines.

Esophageal Perforation Presenting Initially as Multiple Brain Abscesses Secondary to Streptococcus intermedius

Brain abscess is a life-threatening infection that can occur secondary to contiguous or hematogenous spread. Several underlying conditions can lead to brain abscesses, such as dental infection, otitis media, sinusitis, and immunosuppression. Esophageal perforation leading to brain abscesses is extremely rare. We report a rare case of a 32-year-old man who presented to the emergency department with progressive headaches and upper-extremity weakness. Upon further evaluation, computed tomography (CT) revealed multiple brain abscesses secondary to Streptococcus intermedius infection. The patient eventually underwent esophagogastroduodenoscopy (EGD), which showed a perforation in the middle third of the esophagus. This case highlights the importance of considering esophageal perforation as a predisposing condition for brain abscesses.

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.

Clinical characteristics and outcomes of children with non-sinogenic Brain infections

BACKGROUND

Central Nervous System (CNS) suppurative infections are serious but rare conditions in the paediatric population. Data on long-term neurocognitive and quality of life outcomes in children recovering from these infections are lacking.

METHODS

A retrospective cohort review of children <16 years with non-sinogenic infections undergoing neurosurgery was conducted. Data for patients admitted to Children's Health Ireland at Temple St between 2008-2021 were analysed for clinical and microbiological profiles. Follow-up reviews evaluating neurological and academic sequelae and quality of life were performed. Categorical variables were analysed for unfavourable outcome with a p < 0.05 significance value.

RESULTS

Forty patients were included with a mean age of 4.5 years and equal gender distribution. Fever (68%) and vomiting (58%) were the most common presenting complaints. Only fourteen (35%) patients presented with the classic triad of fever, headache, and focal neurological deficit. Meningitis/Encephalitis was the most common cause of suppurative infection (40%). Predisposing factors included congenital heart disease (18%), prematurity (15%) and immunocompromised status (10%). More patients received an initial Burr hole aspiration (73%) than Craniotomy (27%). The re-operation rate was higher in the craniotomy group (45%) compared to the burr hole group (34%), but this was not statistically significant (p = 0.522). Four patients died (10%) including two intra-hospital deaths (5%). Male gender (p = 0.047) and multiple abscesses (p = 0.041) were associated with unfavourable outcome at discharge. Mobility impairment was the most affected determinant of quality of life.

CONCLUSION

CNS suppurative infections are associated with long-term neurocognitive sequelae in children. Multiple abscesses and male gender are associated with unfavourable GOS on discharge. Children are still left with mobility impairment (25%), personality changes (23%) and intellectual disability (18%) at an average of 5 years. Long-term follow up with multidisciplinary input is required. Further research should focus on evaluating long-term HRQoL in children.

Streptococcus intermedius: From a Normal Oral Commensal to a Life-Threatening Organism

Subdural empyema is a collection of pus in the subdural space between the dura mater and the arachnoid. It carries very high morbidity and mortality as it can spread anywhere in the brain; however, the risk can be mitigated with appropriate surgical and medical intervention. Being protected by the skull, cranial infections are usually preceded by a significant risk factor, either an external invader such as skull fractures secondary to trauma, penetrating injury, prior surgery, or, more commonly, in more than 50% of cases, due to spread of an internal infection such as ear or sinus infections. Anaerobic and aerobic bacteria can cause subdural empyema. Both gram-positive and gram-negative bacteria are notorious for developing this kind of infection; for example, different groups of gram-positive streptococci and staphylococci, gram-negative Haemophilus influenza, and other gram-negative bacilli can cause subdural empyema. While streptococci are more frequent with sinus infection causing subdural empyema, staphylococci are associated with skin invasion secondary to either head trauma or cranial surgery. Streptococcus intermedius is a gram-positive alpha-hemolytic pathogen belonging to the larger Streptococcus anginosus group that itself is a subgroup from viridans streptococci, aka Streptococcus milleri. Streptococcus intermedius is an oral commensal flora and is considered to be a low-virulence bacteria in immunocompetent patients but can be associated with significant morbidity and mortality. Subdural empyema tends to occur more often in immunocompromised patients such as diabetic patients, those with human immunodeficiency virus infection, and those using immunosuppressive medications. The clinical course ranges from indolent to fulminant. The size and location of the abscess play a role in clinical presentation. Headache is the most common presenting symptom, but patients can also present with fever, nausea, seizure, or altered mental status. Diagnosis can be obtained with CT and MRI scans of the brain. Prompt drainage of the abscess and lengthy antibiotics improve the prognosis significantly. Our case highlights a rare origin of subdural empyema from the direct spread of a skin abscess.

Brain Abscesses in the Tropics

Purpose of Review

This review aims to elucidate the etiologies of brain abscesses in the tropics. Despite the similarities in causes of brain abscesses across global regions, tropical settings manifest distinguishing characteristics, prominently observed on computed tomography or magnetic resonance imaging.

Recent Findings

In tropical climates, the leading conditions predisposing individuals to brain abscesses are polymicrobial bacterial infections originating from paranasal sinuses, dental sources, and otitis media. However, the tropics present unique etiologies to be aware of, including Trypanosoma cruzi (Chagas disease), free-living amoebas like Balamuthia mandrillaris, infections from Burkholderia pseudomallei (melioidosis), fungi such as Talaromyces marneffei, and Mycobacterium tuberculosis. Given the differential diagnoses, which include neoplastic, inflammatory, and demyelinating diseases, a stereotactic biopsy coupled with a microbiological assessment remains valuable for accurate diagnosis.

Summary

In tropical regions, brain abscesses are a concern when confronted with mass-occupying or other types of brain lesions. Successful clinical management of brain abscesses typically combines surgical intervention and extended anti-microbial treatment. However, specific parasitic invasions like Chagas disease, free-living amoebas, and Entamoeba histolytica necessitate targeted anti-parasitic therapies. Furthermore, international policy efforts should focus on prevention measures in resource limited regions with heightened risks and disease burden.

Comparison of endoscopic sinus sampling versus intracranial sampling for microbiological diagnosis of intracranial infection in children: a case series and literature review

INTRODUCTION

Intracranial infection is often associated with contiguous sinus infection, with Streptococcus intermedius being the most common pathogen. Microbiological assessment is possible via sinus or intracranial sampling. While a sinus approach is minimally invasive, it is not clear whether this yields definitive microbiological diagnosis leading to optimized antimicrobial therapy and avoidance of intracranial surgery.

METHODS

A retrospective review of a prospectively collected electronic departmental database identified patients between 2019 and 2022. Further demographic and microbiological information was obtained from electronic patient records and laboratory management systems.

RESULTS

Thirty-one patients were identified with intracranial subdural and/or epidural empyema and concurrent sinus involvement during the 3-year study period. The median age of onset was 10 years with a slight male predominance (55%). All patients had intracranial sampling with 15 patients undergoing sinus sampling in addition. Only 1 patient (7%) demonstrated identical organism(s) grown from both samples. Streptococcus intermedius was the most common pathogen in intracranial samples. Thirteen patients (42%) had mixed organisms from their intracranial cultures and 57% of samples undergoing bacterial PCR identified additional organisms, predominantly anaerobes. Sinus samples had a significant addition of nasal flora and Staphylococcus aureus which was rarely grown from intracranial samples. Of concern, 7/14 (50%) of sinus samples did not identify the main intracranial pathogen diagnosed on intracranial culture and additional PCR. Literature review identified 21 studies where sinus drainage was used to treat intracranial empyemas, with only 6 authors reporting concurrent microbiology results. This confirmed our cohort to be the largest comparative study in the current literature. No center has observed a greater than 50% concordance in microbiological diagnoses.

CONCLUSION

Endoscopic sinus surgery may have therapeutic benefit, but it is not an appropriate approach for microbiological diagnosis in pediatric subdural empyemas. High rates of contaminating nasal flora can lead to misdiagnosis and inappropriate treatment. Routine addition of 16S rRNA PCR to intracranial samples is recommended.

Brain abscess caused by Porphyromonas gingivalis and Eubacterium nodatum mimicking acute stroke

We described a case of a 65-year-old man with a brain abscess caused by Porphyromonas gingivalis and Eubacterium nodatum. The patient presented right central facial nerve palsy, mutism and right hemiparesis at the examination. The patient underwent a left frontal craniotomy with evacuation of the brain abscess. Specimens were collected for microbiological analysis and intravenous treatment was started with levetiracetam, dexamethasone, meropenem (1 g/8 h) and linezolid (600 mg/12 h). After identification of anaerobic bacteria the antibiotic treatment was changed to piperacillin/tazobactam (4 g/0,5 g/8 h), fulfilling 8 weeks of antibiotic with good clinical and radiological evolution.

Management of cerebral abscess with large ventricular septal defect in rural area: a case report

Cerebral abscess is an uncommon complication of cyanotic heart disease. However, it has a high case fatality rate, and its management requires a multidisciplinary approach. Earlier diagnosis would result in a better outcome. In this report, we presented a case of a 6-year-old boy with a cerebral abscess and a large ventricular septal defect, which was treated surgically in a rural area with a limited resources facility.

Orbital fibrous capsule formation with abscess found 3 years after penetrating injury from a wooden chopstick

Intraorbital wooden foreign bodies are sometimes difficult to diagnose because of nonspecific clinical manifestations and diversity of imaging characteristics. We herein report a case involving a 72-year-old woman with a history of trauma induced by a coated wooden chopstick 3 years prior. Two years after the incident, computed tomography (CT) scan revealed an intraorbital mass that was initially diagnosed as an intraorbital hemangioma. The patient presented with hyperemia, impairment of ocular movement, and optic neuropathy in her right eye. Magnetic resonance imaging (MRI) showed granulation tissue and an abscess around a foreign body, which was compressing the eyeball. Surgical extraction of the foreign body was performed, leading to resolution of symptoms. The depiction of wooden foreign bodies by imaging is complicated and affected by several factors, increasing the risk of delayed diagnosis. To avoid permanent sequelae, MRI might be helpful because its imaging capabilities are superior to those of CT.

Multiparametric imaging in the evaluation of intracerebral abscesses

Cerebral abscesses are uncommon space occupying lesions; they are associated with high morbidity and mortality, though are potentially treatable. Patients often present with non-specific symptoms and may have few clinical signs. Routine clinical imaging may not give a definite diagnosis, as the findings can be indistinguishable from those of other intracranial mass lesions. We review the role of advanced MR techniques to characterise brain abscesses and discuss the role of imaging in monitoring their response to the treatment.

Pertinence of Streptococcus anginosus group in intracerebral abscesses in the era of extended antibiotic resistance

AIMS

• To study the incidence of Streptococcus anginosus group (SAG) in pyogenic or community acquired intra cerebral abscess. • To understand the risk factors for the same. • To analyze the specific radiological features and clinical outcome after surgery and antibiotic therapy.

METHODS

This is a retrospective observational study of case series over a period of one year. Patients diagnosed with intracerebral abscess were included in the study. Pus collected from were received in the laboratory and processed according to the standard protocols. Data regarding the clinical findings and demographics were collected from medical records.

FINDINGS

A total of 202 samples were studied. 103 were found to be pyogenic. SAG were isolated from 21 samples (20.38%) and all the isolates were sensitive to Penicillin. Age of the patients ranged from 18months to 68years. Male preponderance was noted with male to female ratio of 4:1. Otogenic infections were the most common predisposing factors and focus of infection could not be ascertained in 5 patients. All patients were treated with surgical intervention and antibiotics (Vancomycin, Amikacin and Metronidazole) for 6 weeks and recovery was remarkable. One patient succumbed to the illness.

CONCLUSION

SAG can be an aggressive pathogen with propensity for abscess formation. Chronic Suppurative Otitis Media (CSOM) is still a major cause of intracerebral abscess in developing country like India which is a benign and curable disease and should not be neglected. Injudicious use of antibiotics and negligence regarding the dose and duration of therapy from both patients and health care providers is the major cause for common infections to become more difficult to treat and succumbing to complications.

Multiple Abscesses in the Frontal, Temporal and Brainstem regions in a 4.5-year-Old Girl- An Illustrative Case Report

Background

Brainstem located abscesses are rare in the pediatric population. Diagnosis of brain abscess can be challenging as patients may present with nonspecific symptoms and the classical triad of headache, fever, and focal neurological deficit is not always present. Treatment can be conservative or a combination of surgical intervention with antimicrobial therapy.

Case Description

We present the first case of a 4.5-year-old girl with acute lymphoblastic leukemia that developed infective endocarditis (IE) and subsequently developed 3 suppurative collections (frontal, temporal, and brainstem). The patient had negative cerebrospinal, blood, and pus culture growth and subsequently underwent burr-hole drainage of the frontal and temporal abscesses with a 6-week course of intravenous antibiotic therapy with an uneventful postoperative course. At 1 year, the patient is left with minor right lower limb hemiplegia and no cognitive sequelae.

Conclusion

The decision to surgically intervene for brainstem abscesses is dependent on surgeon and patient factors including the presence of multiple collections, midline shift, the aim of source identification in sterile cultures, and the patient's neurological condition. Patients with hematological malignancies should be monitored closely for IE which is a risk factor for hematogenous spread of brainstem located abscesses.

Case report on successful treatment for brain abscess in a Japanese monkey (Macaca fuscata)

BACKGROUND

A brain abscess in human beings is a focal infection of the central nervous system frequently characterized by areas of localized cerebritis and central necrosis surrounded by a well vascularized capsule. A brain abscess, although sporadically reported, is relatively rare disease in domestic animals (horses, cattle, goats and alpacas), companion animals (dogs and cats) and laboratory nonhuman primates. Brain abscesses are life threatening disease that needs early and aggressive veterinary therapy.

CASE PRESENTATION

The purpose of this study on a brain abscess in a Japanese monkey was to report the investigational and therapeutic processes including clinical observations, hematological and serum biochemical profiles, and magnetic resonance imaging (MRI) features, probiotic and antibiotic therapy. In clinical observation, the monkey presented with slowly progressive gentle and depressed behavioral change. Hematological findings showed that slightly declined platelet counts gradually increased in the course of the treatment. Serum biochemical profiles revealed initial markedly elevated. A series of chemotherapy provide prominent relief from the influence of the brain abscess. MRI images illustrated that a brain abscess was located in the right frontal lobe and the mass was delineated by a thick rim, indicating the capsule formation stage. The lesion chronologically decreased in size over the course of treatment. Until 11 weeks after treatment of the brain abscess, the size of brain abscess continued to reduce, leaving an organized lesion trace. To the best of my knowledge, this is the first report on successful treatment for a brain abscess in a Japanese monkey (Macaca fuscata).

CONCLUSIONS

Medical management of simian brain abscesses is possible based on the controlled and resolving nature of the lesions as determined by MRI and completion of a of chemical antibiotic treatment presented in this study.

Clinical and radiological characteristics of brain abscess due to different organisms in hospitalized patients: A 6-year retrospective study from China

Background

Brain abscess (BA) is a rare but life-threatening infection. Early identification of the pathogen is helpful to improve the outcomes. This study aimed to describe the clinical and radiological features of patients with BA caused by different organisms.

Methods

A retrospective, observational study of patients with known etiologic diagnosis of BA in Huashan Hospital Affiliated to Fudan University in China between January 2015 and December 2020 was conducted. Data on patient demographics, clinical and radiological presenting features, microbiological results, surgical treatment, and outcomes were collected.

Results

Sixty-five patients (49 male, 16 female) with primary BAs were included. Frequent clinical presentations included headache (64.6%), fever (49.2%) and confusion (27.3%). Streptococcus viridans was associated with thicker wall of abscesses (6.94 ± 8.43 mm for S. viridans versus 3.66 ± 1.74 mm for other organisms, P = 0.031) and larger oedema (89.40 ± 15.70 mm for S. viridans versus 74.72 ± 19.70 mm for other organisms, P = 0.023). The independent factor associated with poor outcome identified by multivariate analysis was confusion (Odds ratio 6.215, 95% confidence interval 1.406-27.466; P = 0.016).

Conclusions

Patients with BAs caused by Streptococcus species had nonspecific clinical signs, but specific radiological features, which might be helpful for early diagnosis.

Convergence of Artificial Intelligence and Neuroscience towards the Diagnosis of Neurological Disorders-A Scoping Review

Artificial intelligence (AI) is a field of computer science that deals with the simulation of human intelligence using machines so that such machines gain problem-solving and decision-making capabilities similar to that of the human brain. Neuroscience is the scientific study of the struczture and cognitive functions of the brain. Neuroscience and AI are mutually interrelated. These two fields help each other in their advancements. The theory of neuroscience has brought many distinct improvisations into the AI field. The biological neural network has led to the realization of complex deep neural network architectures that are used to develop versatile applications, such as text processing, speech recognition, object detection, etc. Additionally, neuroscience helps to validate the existing AI-based models. Reinforcement learning in humans and animals has inspired computer scientists to develop algorithms for reinforcement learning in artificial systems, which enables those systems to learn complex strategies without explicit instruction. Such learning helps in building complex applications, like robot-based surgery, autonomous vehicles, gaming applications, etc. In turn, with its ability to intelligently analyze complex data and extract hidden patterns, AI fits as a perfect choice for analyzing neuroscience data that are very complex. Large-scale AI-based simulations help neuroscientists test their hypotheses. Through an interface with the brain, an AI-based system can extract the brain signals and commands that are generated according to the signals. These commands are fed into devices, such as a robotic arm, which helps in the movement of paralyzed muscles or other human parts. AI has several use cases in analyzing neuroimaging data and reducing the workload of radiologists. The study of neuroscience helps in the early detection and diagnosis of neurological disorders. In the same way, AI can effectively be applied to the prediction and detection of neurological disorders. Thus, in this paper, a scoping review has been carried out on the mutual relationship between AI and neuroscience, emphasizing the convergence between AI and neuroscience in order to detect and predict various neurological disorders.

Retrospective review of the epidemiology, microbiology, management and outcomes of intra-cranial abscesses at a neurosurgical tertiary referral centre, 2018-2020

BACKGROUND

Intracranial abscesses are rare but serious, and are associated with significant morbidity and mortality. Due to both the rarity and severity of these infections, well-controlled trials have not been reported in the literature, and optimal management is a matter for expert opinion. Advances in surgical management have improved outcomes and increased rates of microbiological diagnosis. However, the approach to antimicrobial chemotherapy varies considerably, including the choice of antibiotic, the duration of treatment, and the timing of oral switch.

METHODS

We conducted a retrospective review of 43 cases of intracranial abscesses from a large, tertiary neurosurgical centre in London, UK, between 2018 and 2020, including 29 primary intra-parenchymal abscesses, 11 subdural abscesses and 3 extradural abscesses.

RESULTS

The majority of cases had surgical intervention; 6/43 (14%) required repeat intervention (all intra-parenchymal abscesses). A microbiological diagnosis was made in 83% of cases. Intravenous antibiotics were given for a median of 33 days (IQR 23-44 days), with a variable duration of oral follow-on antibiotics. Total duration of antibiotic treatment ranged from 0 to 467 days. Only three patients from our cohort are known to have died.

CONCLUSION

Shorter courses of intravenous antibiotics for brain abscesses were not associated with increased mortality. In the absence of well-controlled trials, a national registry of intracranial abscesses would provide invaluable data to inform optimal treatment.

Multifocal Brain Abscesses Due to Streptococcus intermedius

Brain abscess is a life-threatening illness that occurs when an intracerebral infection leads to cerebritis and subsequent pus formation within a well-vascularized capsule. While streptococci (aerobic, anaerobic, and microaerophilic) are the most common bacteria isolated, its presentation as multifocal brain abscesses is rarely described. In this report, we describe a 43-year-old male patient who presented to the emergency department due to progressive lethargy and low-grade fever of seven days worsening. Upon further evaluation, the patient was found to have multiple brain abscesses secondary to Streptococcus intermedius, confirmed by the culture of stereotactic aspiration of brain collection. This case underlines the importance of considering Streptococcus intermedius as a cause of multifocal brain abscesses.

Recurrent Nocardial Brain Abscess Developing in an Immunocompetent Patient, A Case Report

Central nervous system nocardiosis is rare but has high morbidity and mortality. Immunocompromised patients who have malignancies such as lymphoma, infections such as human immunodeficiency virus (HIV), and bone marrow or solid organ recipients are particularly vulnerable to infection. However, here, we present a patient who developed nocardiosis and recurrent brain abscesses despite having no immunodeficiency problems. The abscess recurred despite total abscess excision and parenteral therapy. After nocardiosis was diagnosed, intravenous treatment with imipenem and amikacin was initiated. The patient was discharged on oral doxycycline. In our immunocompetent case, the abscess recurred four times, resulting in death.

Surgical aspiration versus excision for intraparenchymal abscess: a systematic review and Meta-analysis

Brain abscesses are associated with considerable morbidity and mortality, requiring timely intervention to achieve favourable outcomes. With the advent of high-resolution computed tomography (CT) imaging, mortality following both aspiration and excision of brain abscesses has improved markedly. As a result, there has been a marked shift in neurosurgical practice with aspiration eclipsing excision as the favoured first-line modality for most abscesses. However, this trend lacks sufficient supporting evidence, and this systematic review and meta-analysis seeks to compare aspiration and excision in the treatment of brain abscess. Twenty-seven studies were included in the systematic review, and seven comparative papers in meta-analysis. Aspiration was the chosen technique for 67.5% of patients. Baseline characteristics from the studies included only in the systematic review demonstrated that abscesses treated by aspiration were typically larger and in a deeper location than those excised. In the meta-analysis, we initially found no significant difference in mortality, re-operation rate, or functional outcome between the two treatment modalities. However, sensitivity analysis revealed that excision results in lower re-operation rate. On average, the included studies were of poor quality with average Methodological Index for Non-Randomized Studies (MINORS) scores of 10.3/16 and 14.43/24 for non-comparative and comparative papers respectively. Our study demonstrates that excision may offer improved re-operation rate as compared to aspiration for those abscesses where there is no prior clinical indication for either modality. However, no differences were found with respect to mortality or functional outcome. Evidence from the literature was deemed low quality, emphasizing the need for further investigation in this field, specifically in the form of large, well-controlled, comparative trials.

Rare brain and pulmonary abscesses caused by oral pathogens started with acute gastroenteritis diagnosed by metagenome next-generation sequencing: A case report and literature review

Odontogenic brain and pulmonary abscesses are extremely rare infectious diseases. It is mainly caused by the upward or downward transmission of local infection or blood-borne spread. In recent years, with the wide application of some novel testing methods in clinical practice, the diagnosis of unexplained infections such as odontogenic abscesses in different organs has gradually become clear. We report a case of a 21-year-old male who was healthy and had not received any oral treatment before onset. He started with acute gastroenteritis-related symptoms, then developed meningitis-related symptoms seven days later with septic shock. No obvious abscess lesions were found on head computed tomography (CT) at admission, and the etiology was not clear by routine examination, which was very easy to misdiagnose as a serious infection caused by intestinal pathogens. But odontogenic pathogens were found both in his blood and cerebrospinal fluid through metagenomic next-generation sequencing (mNGS) analysis. Subsequently, rechecked imaging examination displayed multiple brain and pulmonary abscesses. Finally, it was diagnosed as an odontogenic brain and pulmonary abscess. After an extremely lengthy anti-infection course (13 weeks of intravenous antibiotics plus 2 weeks of oral antibiotics) and surgery, the patient was improved and discharged from the hospital. From this case, we could see that the development of new diagnostic technologies such as mNGS plays an important role in the early and confirmed diagnosis of diseases previously difficult to diagnose such as odontogenic polymicrobial infections and ultimately helps to improve the prognosis of these patients.

Retrospective Review of the Clinical Outcomes of Surgically Managed Patients with Intracranial Abscesses: A Single-Center Review

OBJECTIVE

This study analyzed patient, radiologic, and clinical factors associated with operative brain abscesses and patients' functional outcomes.

METHODS

A retrospective analysis was conducted of neurosurgical cases of brain abscesses from 2009 to 2019 at a Canadian center. Functional outcome was recorded as Modified Rankin Scale score and Extended Glasgow Outcome Scale score. Multivariate analysis was conducted to identify relevant prognostic factors.

RESULTS

We identified 139 patients managed surgically for brain abscesses. Resection alone was performed in 64% of patients, whereas 26.6% underwent aspiration alone. Most were adults (93.2%) and male (68.3%). Immunocompromise risk factors included diabetes (24.5%), cancer (23.7%), and immunosuppressive therapy (11.5%). Likely sources were postoperative (17.3%), systemic spread (16.5%), and poor dentition (12.9%). Microorganisms cultured from abscess samples were mixed growth (28%), Streptococcus anginosus (24.5%), and Staphylococcus aureus (7.9%). Disposition was home (42.4%) or repatriation to a home hospital (50.4%). By Extended Glasgow Outcome Scale, 25.2% had an unfavorable outcome including a mortality of 11.5%. Factors on multivariate analysis associated with poor outcome included diabetes (odds ratio, 2.8; 95% confidence interval [CI], 1.2-5.0) and ventricular rupture (odds ratio, 5.0; 95% CI, 1.7-13.5; hazard ratio, 12; 95% CI, 3.9-37.0). Supratentorial superficial eloquently located abscess was also associated with poor outcome (hazard ratio, 5.5; 95% CI, 1.8-16.7). Outcomes were similar with surgical excision and aspiration.

CONCLUSIONS

Ventricular rupture and diabetes are significant risk factors for poor outcomes in intraparenchymal brain abscesses. No clear difference in outcomes was found between surgical excision or aspiration in our retrospective cohort.

Plasma Microbial Cell-Free DNA (CF-DNA) Next-Generation Sequencing in Diagnosing Intracranial Abscesses: Pathophysiology and a Scoping Review of the Literature

Plasma microbial cell-free DNA (cf-DNA) from next-generation sequencing (NGS) provides improved sensitivity and specificity compared to standard microbial blood cultures. cf-DNA sequencing also has an improved turnaround time (TAT) and allows quicker commencement of antibiotics in life-threatening infections such as a brain abscess. Brain abscesses carry significant morbidity and mortality. Empiric treatment and management are critical in improving functional neurological outcomes. Reported here is the case of a severe central nervous system (CNS) infection with multiple ring-enhancing lesions seen throughout the cerebrum on magnetic resonance imaging (MRI). Standard microbial blood cultures were inconclusive and definitive identification of the pathogen was achieved through microbial cf-DNA NGS. 

Brain abscesses develop in four distinct phases: early cerebritis, late cerebritis, early capsule formation, and late capsule formation. The pathogenesis of cerebral abscess involves direct parenchymal inflammation of the pathogen, the recruitment of inflammatory CNS cell types (microglia, inflammatory astrocytes, etc), and the chemotaxis of immune cells. cf-DNA is released into the bloodstream in response to pathogen opsonization and immune-mediated cell death. A scoping literature review includes cases of intracranial abscesses diagnosed via cf-DNA NGS.

An Eight Year Clinico-Microbiological Retrospective Study on Brain Abscesses in India

Background:

Intracranial abscesses have been a diagnostic and therapeutic challenge since time immemorial for both the microbiologists and the neurosurgeons. There is paucity of detailed studies documenting the infecting organism causing brain abscesses in South India.

Aims:

The study aimed at identifying and assessing the prevalence of aerobic, anaerobic bacteria and fungi associated with brain abscesses at a tertiary care hospital in South India.

Methods and Material:

Eight years data was collected from the records of culture reports from 2007 to 2010 and 2013 to 2018. The corresponding clinical case records were retrieved for the assessment of risk factors. Risk factors of brain abscess development were assessed based on clinical cases records.

Results:

Data from 140 brain abscess cases obtained over a period of 8 years were analyzed. Out of the 140 samples, 66 (47.14%) were culture positive in which 33 (50%) had single aerobic/facultative anaerobic bacteria, 20 (30.3%) had mixture of more than one aerobic/facultative anaerobic bacteria, 12 (18.18%) had single obligate anaerobic bacteria and 1(1.5%) sample had Mycobacterium tuberculosis isolated. Among the total 92 isolates, Pseudomonas aeruginosa (21/92, 23%) and Staphylococcus aureus (20/92, 22%) predominated. Bacteroides fragilis group was the most common obligate anaerobe isolated. There were no fungal isolates. As there were various isolates isolated, hence there is heterogeneity of isolates detected Neuroanatomically, parietal lobe (45/140, 32%) was the most common location. Otogenic infection was the major risk factor for parietal and temporal lobe abscess (P value < .05).

Conclusions:

It has become essential for the microbiologists to be aware of unusual isolates from brain abscess and its complex nature. Obscurity and difficulty in their microbiological diagnosis calls for more such detailed studies.

Klebsiella invasive liver abscess syndrome presenting with a central nervous system manifestation secondary to latent cholecystitis: a case report

Background

Brain abscess is a life-threatening event. Moreover, when Klebsiella pneumoniae is the cause, rapid diagnosis and appropriate treatment are required. Klebsiella invasive liver abscess syndrome, a bloodstream metastatic infection of potentially aggressive nature, has been recognized to cause infection in the central nervous system, and concern for Klebsiella liver abscess syndrome is increasing globally.

Case presentation

A 73-year-old Japanese woman was admitted to the institution complaining of aggravated dysarthria and weakness in the right upper extremities with onset 5 days earlier. Magnetic resonance imaging revealed a brain abscess in the left basal ganglia, and abdominal computed tomography revealed a liver abscess in liver segment 7. The patient’s dysarthria symptoms became increasingly worse over the next few days, so surgical drainage via frontotemporal craniotomy was performed on admission day 3, and subsequent culture from the brain abscess showed growth of Klebsiella pneumoniae. On admission day 9, percutaneous transhepatic drainage of the liver segment 7 abscess was undertaken. The pus culture also showed growth of Klebsiella pneumoniae, thus associating the liver abscess with the brain abscess. Following long-term conservative treatment with antibiotics and abscess drainage, the liver abscess disappeared. However, the patient continuously presented with right upper quadrant pain, and abdominal computed tomography showed swelling of the gallbladder. Consequently, percutaneous transhepatic gallbladder drainage was initially administered, and the bile culture was also positive for Klebsiella pneumoniae. For radical treatment, a laparoscopic cholecystectomy was performed on admission day 99. The postoperative period was complicated by an intraabdominal abscess; however, conservative therapy was successful. She was subsequently discharged, and 12-month follow-up revealed no further sequelae.

Conclusions

We describe a rare case of Klebsiella liver abscess syndrome, which first presented with a central nervous system manifestation. Our patient was successfully treated via an early surgical intervention and subsequent antibiotic therapy. Although surgical drainage remains the cornerstone treatment for brain abscess, when a brain abscess is found, and there is a high index of suspicion for the existence of a liver abscess, Klebsiella liver abscess syndrome should be considered as a possible diagnosis.

Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children

OBJECTIVE

Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention.

METHODS

A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted.

RESULTS

65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%.

CONCLUSION

Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.

Neurosurgical Emergency in an Adult With Single Ventricle Physiology: A Case Report

The anesthetic management of a patient with uncorrected congenital heart disease presenting for noncardiac surgery is quite challenging. When this becomes a neurosurgical emergency, the need to balance cerebral and complex circulatory physiologies tests the anesthesiologist's preparedness. The principal clinical challenges we faced were preventing increases in intracranial pressure while maintaining the circulatory physiology using the "cardiac grid" approach to hemodynamic management in a case of acyanotic double outlet right ventricle with a posterior fossa space-occupying lesion. Point of care preoperative echocardiography enabled us to understand the altered circulatory physiology and successfully manage this patient.

Focused Management of Patients With Severe Acute Brain Injury and ARDS

Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.

Neurological effects of respiratory dysfunction

The respiratory and the nervous systems are closely interconnected and are maintained in a fine balance. Central mechanisms maintain strict control of ventilation due to the high metabolic demands of brain which depends on a continuous supply of oxygenated blood along with glucose. Moreover, brain perfusion is highly sensitive to changes in the partial pressures of carbon dioxide and oxygen in blood, which in turn depend on respiratory function. Ventilatory control is strictly monitored and regulated by the central nervous system through central and peripheral chemoreceptors, baroreceptors, the cardiovascular system, and the autonomic nervous system. Disruption in this delicate control of respiratory function can have subtle to devastating neurological effects as a result of ensuing hypoxia or hypercapnia. In addition, pulmonary circulation receives entire cardiac output and this may act as a conduit to transmit infections and also for metastasis of malignancies to brain resulting in neurological dysfunction. Furthermore, many neurological paraneoplastic syndromes can have underlying lung malignancies resulting in respiratory dysfunction. It is essential to understand the underlying mechanisms and the resulting manifestations in order to prevent and effectively manage the many neurological effects of respiratory dysfunction. This chapter explores the various neurological effects of respiratory dysfunction with focus on their pathophysiology, etiologies, clinical features and long-term neurological sequelae.

Management Strategy of Intracranial Complications of Sinusitis: Our Experience and Review of the Literature

Objective

Sinusitis or rhinosinusitis is a very common disease worldwide, and in some cases, it leads to intracranial complications (ICS). These are more common in immunocompromised patients or with underlying comorbidities, but even healthy individuals, can be affected. Nowadays, ICS have become less common thanks to improved antibiotic therapies, radiological diagnostic methods, surgical techniques and skills. Nonetheless, they can still cause significant morbidity and mortality. For this reason, management of these complications requires a multidisciplinary approach to plan and customize treatment options. This paper presents our strategy in the management of a series of intracranial complications induced by acute sinusitis and compares our experience and outcomes with the literature.

Study design

Single institute experience, retrospective analysis of cases series and literature review.

Methods

Adult and child patients who were treated for ICS in the Department of Otorhinolaryngology at Sion Hospital, in Switzerland from 2016 to 2020 were included. Their symptoms, medical history, clinical and radiological findings, treatment, and outcome were documented.

Results

Eight patients (6 males- 2 females) aged from 14 to 88 y.o., were enrolled. None had any previous history of chronic, or recurrent sinusitis. Moreover, very few presented specific rhinological symptoms, but with neurological or other symptoms. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) were used to confirm the diagnosis of all ICS. All types of known intracranial complications were observed in our cohort with a wide range of extension and severity of sinusitis. A multidisciplinary approach with individual treatments was tailored to each patient. Outcomes were favorable in almost all patients with neither recurrence, nor neurological sequels being observed in the follow-up. Only one patient was lost due to fatal complications of advanced lung cancer.

Conclusion

ICS remain a challenging clinical problem due to substantial associated morbidity and mortality. The incidence of these complications is relatively low. Therapeutical management guidelines are lacking. Early detection and multidisciplinary approach are key to successful treatment.

Cocaine-Induced Pituitary and Subdural Brain Abscesses and the Treatment Challenges

Cocaine is a well-known recreational drug with stimulant effects associated with relevant social, economic, and clinical implications. The most common route of abuse is via snorting. It has high addictive potential. Furthermore, one of the most well-known symptoms of a chronic user is chronic rhinitis. In the medical journals, there are numerous reports of complications, including lesions affecting the nasal septum, nasal sinuses, and even brain abscesses. We came across a 41-year-old male patient with severe manifestations of chronic cocaine use involving nasal, paranasal, and visual symptoms and signs. However, the most devastating was the complication of pituitary abscess, as a sequela to chronic cocaine sniffing. This case highlights the clinical, diagnostic, and management challenges with a multi-disciplinary approach. Last but not least, was the role of patient counselling and education. This ensured compliance towards management with a favourable outcome, which was rewarding for both the patient and the medical team involved in the care of the patient. It would hopefully create more awareness and assist in abstinence. We also hope it would incite more effort towards data collection and analysis, as well as allow us to explore the actual incidence of its use and devastating complications, which to date, for reasons of disguise and denial, remain somewhat ambiguous.

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.

Tuberculosis presenting with seizure and abdominal pain in a young female: A case report

In this case report, a 23-year-old female presented to the Emergency Department with complaints of abdominal pain, weight loss, progressive headaches, and an episode of seizure-like activity. Computerized tomography abdomen/pelvis revealed multilobulated ovarian masses and scattered peritoneal thickening. A brain Magnetic resonance imaging was ordered and demonstrated a peripherally enhancing intracranial mass. The brain lesion was resected and pathology revealed necrotizing granulomatous inflammation. Cultures were positive for acid fast bacilli. The patient was diagnosed with tuberculosis and treated with multidrug therapy. Upon further questioning, the patient had recently traveled to a tuberculosis endemic region. This case highlights the importance of an in-depth history and physical exam as a means to a more complete differential diagnosis considering the age of the patient and the findings on imaging.

Diagnosis, Management, and Outcomes of Brain Abscess due to Gram-Negative Versus Gram-Positive Bacteria: Brain abscess due to Gram-positive vs. Gram-negative bacteria

OBJECTIVES

Differences in management and outcomes of brain abscesses due to Gram-positive (GPB) versus Gram-negative bacteria (GNB) are not well defined.

METHODS

Retrospectively reviewed adult patients with brain abscesses due to monomicrobial infection from 2009 through 2020.

RESULTS

177 had a monomicrobial brain abscess; 143 (80.8%) caused by GPB and 34 (19.2%) by GNB. Patients with GNB had more history of head/neck surgery than those with GPB (58.8% vs. 36.4%; P= 0.02). Pathogens in the GNB group included Pseudomonas aeruginosa (29.4%), Klebsiella species (spp.; 20.6%), and Enterobacter spp. (20.6%); in the GPB group were Staphylococcus aureus (32.2%) and Streptococcus spp. (31.5%). Most patients had combined medical/surgical management (64.7% GNB vs. 63.6% GPB). Median duration of antibiotic therapy was 42 days, and there were no significant differences in infection relapse or 3-month survival rates. Patients with GNB were more likely to have therapeutic failure than did those with GPB (44.1% vs. 22.4%; P= 0.01).

CONCLUSION

Compared with brain abscesses caused by GPB, those due to GNB were more likely to have prior head and neck surgery. No statistically difference in outcomes was observed between groups; however, patients with GNB had a higher therapeutic failure rate than did those with GPB.

Erosion of the sella turcica and pituitary expansion secondary to polymicrobial brain abscesses: a case report

Introduction

Brain abscesses can lead to a diverse array of complications, especially when they are polymicrobial in nature. Multiple underlying pathogens may present with a unique set of clinical symptoms which require an early identification and treatment. Skull base osteomyelitis with sellar floor erosion and pituitary involvement with SIADH are such rare complications of brain abscesses which have never been reported previously in the literature.

Case Presentation

We report the case of an immunocompetent 38-year-old male with altered mental sensorium and left hemiparesis due to polymicrobial brain abscess which required surgical evacuation. The post-operative recovery was complicated by severe hyponatremia secondary to SIADH which was treated uneventfully. Radiological imaging demonstrated pituitary enlargement with herniation through an eroded sella turcica without active CSF leak. Patient responded well to the antibiotic therapy based on microbiological susceptibility testing with a complete resolution of the pituitary enlargement on radiological follow-up.

Conclusion

Conservative treatment with targeted antibiotics can lead to the resolution of pituitary enlargement secondary to a brain abscess. However, a close clinical follow-up is required to look for a CSF leak considering the sellar floor erosion due to osteomyelitis.

Partial oral antibiotic treatment for bacterial brain abscess: an open-label randomized non-inferiority trial (ORAL)

Background

The advised standard treatment for bacterial brain abscess following surgery is 6 to 8 weeks of intravenous (IV) antibiotic treatment, but an early switch to oral antibiotic treatment has been suggested to be equally effective.

Methods

This investigator-initiated, international, multi-center, parallel group, open-label, randomized (1:1 allocation) controlled trial will examine if oral treatment after 2 weeks of IV antibiotic therapy is non-inferior to standard 6–8 weeks of IV antibiotics for bacterial brain abscess in adults (≥ 18 years of age). The study will be conducted at hospitals across Denmark, the Netherlands, France, Australia, and Sweden. Exclusion criteria are severe immunocompromise or impaired gastro-intestinal absorption, pregnancy, device-related brain abscesses, and brain abscess caused by nocardia, tuberculosis, or Pseudomonas spp. The primary objective is a composite endpoint at 6 months after randomization consisting of all-cause mortality, intraventricular rupture of brain abscess, unplanned re-aspiration or excision of brain abscess, relapse, or recurrence. The primary endpoint will be adjudicated by an independent blinded endpoint committee. Secondary outcomes include extended Glasgow Outcome Scale scores and all-cause mortality at end of treatment as well as 3, 6, and 12 months since randomization, completion of assigned treatment, IV catheter associated complications, durations of admission and antibiotic treatment, severe adverse events, quality of life scores, and cognitive evaluations. The planned sample size is 450 patients for a one-sided alpha of 0.025 and a power of 90% to exclude a difference in favor of standard treatment of more than 10%. Date of initiation of first study center was November 3, 2020, with active recruitment for 3 years and follow-up for 1 year of all patients.

Discussion

The results of this study may guide future recommendations for treatment of bacterial brain abscess. If early transition to oral antibiotics proves non-inferior to standard IV treatment, this will provide considerable health and costs benefits.

Trial registration

ClinicalTrials.gov NCT04140903, first registered 28.10.2019. EudraCT number: 2019-002845-39, first registered 03.07.2019