Brain abscess as a complication of stroke

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.

Brain abscess – A rare complication of endovascular treatment for acute ischemic stroke

Background:

Brain abscess is a neurosurgical emergency, which can arise through direct bacterial seeding or hematogenous spread. Rarely, brain abscess formation has been reported following ischemic stroke. An increasingly utilized therapy for stroke is mechanical thrombectomy, and within this report, we present a case of brain abscess formation following this procedure.

Case Description:

A 78-year-old female presented to our center with a right total anterior circulation stroke (TACS) secondary to terminal internal carotid artery occlusion. An emergent mechanical thrombectomy was performed and the patient’s initial postoperative recovery was good. In the 3^rd week after the procedure, however, the patient became more confused and following the onset of fever, an MRI brain was performed, which demonstrated an extensive multiloculated right-sided brain abscess. Burr hole drainage of the abscess was subsequently undertaken and pus samples obtained grew Proteus mirabilis, presumed secondary to a urinary tract infection, and the patient was started on prolonged antibiotic therapy. To date, the infection has been eradicated and the patient survives albeit with persistent neurological deficits.

Conclusion:

To the best of our knowledge, this is the first reported UK case of brain abscess following mechanical thrombectomy for stroke. Endovascular interventions can lead to increased incidence of ischemia-reperfusion injury in stroke with increased blood–brain barrier damage and risk of microbial seeding. This case highlights the need for rigorous asepsis and proactive treatment of systemic infections in the acute phase following endovascular treatment and consideration of brain abscess in all patients who present with new-onset confusion and unexplained fever following stroke.

Brain abscess complicating ischemic embolic stroke in a patient with cardiac papillary fibroelastoma - Case report and literature review

A 72-year-old man without obvious risk factors initially presented with acute ischemic stroke and fever, without concomitant infection. Broad spectrum antibiotic therapy was initiated. Transthoracic and Transesophageal echocardiography, and cardiac MRI revealed a 20 mm round mass attached to the anterior mitral valve leaflet, suggesting the diagnosis of a benign cardiac tumor or a vegetation. At the site of infarction an abscess of 11 mm in diameter developed 30 days later. The patient underwent surgical valve repair for the prevention of further embolic complications. Histology revealed a cardiac papillary fibroelastoma (PFE). He made complete clinical recovery. Secondary abscess formation after ischemic stroke is rare: 11 other cases have been reported. Because they develop at the site of a previous ischemic infarct, these abscesses usually do not manifest by additional neurologic deficits, making difficult their diagnosis. In most cases a concomitant infection cannot be individualized. Even if these abscesses are a rare entity, patients with cerebral infarct presenting with fever must be closely follow-up with cerebral imaging. Even if PFE is a rare cardiac source of embolic stroke, it should be considered in the differential diagnosis of stroke in a patient where an alternative etiology has not been established.

Cerebral Abscess Following Endovascular Treatment of Aneurysm: Report of 2 Cases and Review of the Literature

INTRODUCTION

Endovascular treatment is growing in popularity globally as an important treatment option for intracranial aneurysms. Cerebral infection as a complication of endovascular treatment of aneurysms is sufficiently rare that only 6 isolated cerebral abscess cases have been reported thus far.

CASE REPORT

In this report, we present 2 cerebral abscesses from 3 institutions, which developed after coil embolization of anterior communicating artery and middle cerebral artery aneurysms.

CONCLUSION

This report was written to discuss the possible mechanisms underlying cerebral abscess after endovascular treatment of aneurysms and to suggest potential treatment and prevention methods.

Cerebral abscesses after endovascular coiling of a paraophthalmic aneurysm: Case report and review of the literature

Background:

Intracranial infections are a rare complication of therapeutic neuroendovascular procedures.

Case Description:

We present a case of a 72-year-old female with multiple unilateral cerebral hemisphere abscesses after endovascular embolization of a right paraophthalmic aneurysm and also provide a comprehensive review of the literature on cerebral abscesses following neurovascular embolization.

Conclusion:

Infection following coil embolization of cerebral aneurysm is rare. However, it is likely to increase in the setting of increased used of neuroendovascular techniques in the future. Therefore, we suggest that extreme care is taken to ensure proper asepsis during embolization, and a high index of suspicion is maintained in patients with predisposing characteristics (large hemorrhage, ischemia, recurrent endovascular procedures, right-to-left shunt, and concomitant infection). Given the fact that the majority of abscesses occurred in patients who have had ruptured aneurysms, we suggest consideration is given to prophylactic intraprocedural intravenous antibiotics use as seen with open aneurysm treatment.

Cerebral Abscess following Mechanical Thrombectomy for Ischemic Stroke: Report of a Case and Review of Literature

Cerebral infections have been reported after endovascular interventions such as embolization and coiling. Such complications are extremely rare and only one other case has been reported in a patient who underwent an endovascular therapy for ischemic stroke. We report a 32-year-old woman, who presented to our hospital with headaches lasting four weeks after an endovascular intervention for ischemic stroke via mechanical thrombectomy. Further investigations revealed a cerebral abscess in the area of the infarct. She was effectively treated with antibiotics in combination with stereotactic drainage and was discharged after she made a good recovery. A review of literature on cerebral abscesses after minimally invasive procedures such as endovascular intervention was also done and is being presented in this paper. A cerebral abscess can occur rarely after endovascular interventions. A high degree of suspicion is important in identifying patients with an abscess and appropriate treatment can prevent significant morbidity or even death.

Bacterial brain abscess formation in post-irradiated patients: What is the possible pathogenesis?

BACKGROUND

Until recently, post-radiotherapy brain abscess was considered rare, but it has become an increasingly important aetiology. Discussions of the relationship between bacterial brain abscess and radiotherapy (RT) are rare in the literature. Our clinical study was conducted to analyse the role of RT in the pathogenesis of bacterial brain abscess.

METHODS

For our retrospective study, 146 patients with bacterial brain abscess were recruited. Ten patients with a history of RT before brain abscess formation were reviewed.

RESULTS

Eight of these patients underwent RT treatment for nasopharyngeal carcinoma, one for olfactory neuroblastoma, and another for nasal plasmacytoma. Three showed presence of temporal lobe radiation necrosis neighbouring abscess. Eight patients were shown to have the evidence of tumour invasion. Seven had evidence of nasal infection or otitis media. Statistically significant differences between the RT and non-RT patients were observed for radionecrosis, bone defects between the middle fossa/sphenoid sinus, and the presence of nasal infection/otitis media. The mortality rate was 30%.

CONCLUSION

This study shows possible pathogenesis of bacterial brain abscess formation in post-irradiated patients, which is complicated by both radiation effects and tumour effects. Skull base deficits (either from tumour erosion or osteonecrosis) and nasal/ear infection were significantly different in patients who received radiation vs. those who did not. Radiation-related temporal lobe necrosis was also a predisposing factor. Further study based on a proper patient cohort is warranted.

An Intracranial Petri Dish? Formation of Abscess in Prior Large Stroke After Decompressive Hemicraniectomy

OBJECTIVE

Development of brain abscess after an infarction is a rare clinical condition. There have been 11 cases in the literature. Many patients were treated with potent antibiotics only and did not survive. We present 2 cases in which patients received aggressive surgical resection of brain abscess and survived. The analysis of the literature confirmed our finding that surgical intervention of brain abscess in patients after stroke is advisable.

METHODS

A 58-year-old man was transferred to our institution with left hemiparesis, hemisensory loss, neglect, and hemianopsia. The computed tomography angiography demonstrated large volume right hemispheric infarct. He underwent decompressive hemicraniectomy but developed fevers and swollen fontanelle 6 weeks later, which did not improve with antibiotics. The magnetic resonance imaging demonstrated progression of ring-enhancement of the old infarct and abscess formation was suspected. In another case, a 42-year-old woman was admitted to our institution with aphasia and weakness on the right side. The computed tomography angiography showed left middle cerebral artery territory infarction and decompressive hemicraniectomy was performed. Patient recovered well but a brain abscess was suspected during a routine preoperative computed tomography before cranioplasty.

RESULTS

In the first case, patient was then taken to the operating room for resection of the infarcted brain tissue involved. The patient's consciousness improved, and he was discharged with antibiotic treatment. The patient subsequently underwent cranioplasty with synthetic graft with no complications. In the second case, the suspected abscess was resected surgically and culture of abscess grew Pantoea agglomerans and Bacillus macerans. The patient underwent synthetic cranioplasty 1 month later and remained in good condition.

CONCLUSIONS

Secondary abscess formation after significant ischemic stroke is a rare condition that carries potential for high morbidity/mortality. The limited body of literature with the addition of our 2 cases supports aggressive management with surgical evacuation of brain abscess to increase survival.

Brain abscess potentially secondary to odontogenic infection: case report

Odontogenic infections are rarely implicated in the causes of brain abscess formation. As such, there are very few reports of brain abscesses secondary to odontogenic infections in the literature. This is due partly to the relative rarity of brain abscesses but also to the difficulty in matching the causative organisms of a brain abscess to an odontogenic source. The authors report a case of a 50-year-old woman whose brain abscess may potentially have been secondary to an odontogenic infection. The patient's early diagnosis, supported by imaging and microbiologic assessment, along with early minicraniotomy and extraction of infected dentition followed by a course of cephalosporins and metronidazole, contributed to a successful outcome.

Toll-like receptors in brain abscess

Brain abscesses arise from a localized parenchymal infection, typically elicited by pyogenic bacteria such as Staphylococcus aureus. Despite improvements in detection and treatment strategies, brain abscesses continue to occur, with an increased prevalence in developing countries and immune-compromised patients. Adding to the seriousness of these infections is the recent emergence of antibiotic-resistant strains of bacteria, which are becoming more commonly associated with brain abscesses. Recent studies using a mouse experimental brain abscess model have revealed a complex role for Toll-like receptors (TLRs) in disease pathogenesis. Interestingly, TLR2 has limited impact on the innate immune response during the acute stage of brain abscess formation induced by S. aureus but influences adaptive immunity. In contrast, mice deficient in MyD88, a central adapter molecule for the majority of TLRs in addition to the IL-1R and IL-18R, demonstrate severe defects in innate immunity coupled with exaggerated tissue destruction. It is envisioned that understanding the roles for TLRs in both resident CNS glia as well as infiltrating immune cells will provide insights into how the immune response to bacterial infection can be tailored to achieve effective pathogen destruction without inducing excessive bystander damage of surrounding noninfected brain parenchyma. A discussion of recent findings in this field is presented along with outstanding questions and the concept of a pathogen-necrosis-autoantigen triad for the amplification of TLR signaling is introduced.

Brain abscess formation at the site of intracerebral hemorrhage secondary to central nervous system vasculitis

✓ Brain abscess is a rare but very dangerous neurosurgical lesion. Prompt diagnosis and emergency surgical evacuation are the hallmarks of therapy. Brain abscess following ischemic and hemorrhagic stroke is a rare entity. These cases are often preceded by episodes of bacteremia, sepsis, and local infection. The authors report the case of a 30-year-old woman who presented with a cerebral abscess at the site of a recent intraparenchymal hemorrhage.

Brain abscess following intracerebral haemorrhage

A 79-year old male patient developed a brain abscess as infective transformation of a preceding intracerebral haemorrhage after urinary tract infection. The awareness of brain abscess formation at the site of intracerebral haemorrhage is crucial for early diagnosis and treatment of this rare but potentially fatal complication.

Cerebral abscess of odontogenic origin

INTRODUCTION

Cerebral abscess is a rare but serious and life-threatening infection. Dental infections have occasionally been reported as the source of bacteria for such an abcess.

PATIENT AND METHODS

A 54-year-old man was admitted with a right hemiparesis and epileptic fits. After clinical, laboratory and imaging examination, the diagnosis of a cerebral abscess of the left parietal lobe was made. The intraoral clinical examination as well as a panoramic radiograph confirmed the presence of generalized periodontal disease, multiple dental caries, and periapical pathology. The treatment included: (i) Immediate administration of high-dose intravenous antibiotics and (ii) surgical procedures consisting of craniotomy and resection of the abscess cavity first, and secondly removal of the periodontal, decayed and periapically involved teeth of the patient, in an effort to eradicate all the possible septic foci, presuming the cerebral abscess to be of odontogenic infection.

RESULTS

The patient made an uneventful recovery, and 29 months postoperatively he had completely recovered from the hemiparesis.

Brain abscess following intracerebral haemorrhage

We report two cases of brain abscess, which developed at the site of an intracerebral haemorrhage (ICH) in a 75-year-old man and a 32-year-old-man. The patients recovered after surgical treatment and systemic antibiotic therapy. The route of infection could not be detected in either case. The literature contains only 13 reported cases of brain abscess as a complication of ICH. Although the interval from initial ICH to abscess formation ranged from 4 to 20 weeks, almost all patients had episodes of high fever, indicating the presence of systemic infection and bacterial seeding, 0-14 days after the onset of their ICH. Therefore, abscess formation appears to be caused by haematogenous seeding of infection in patients with ICH. Abscess formation should be considered when a patient deteriorates clinically with a febrile episode after an ICH.

Pyogenic brain abscess following haematogenous seeding of a thalamic haemorrhage

We report the rare occurrence of a pyogenic brain abscess at the site of a preceding intracerebral haemorrhage in a 58-year-old man. The diagnosis was based on clinical observations, isolation of Staphylococcus aureus from blood cultures, and characteristic cerebrospinal fluid and cerebral computed tomography findings. The patient had a favourable response to antibiotic therapy.

Nocardia brain abscess misinterpreted as cerebral infarction

We present the case of a non-immunocompromised man with right-sided hemiparesis and aphasia thought to be caused by cerebral infarction, but which in the later clinical course evolved to be a nocardia brain abscess that needed surgical intervention. Misinterpretation of imaging combined with the absence of clinical signs of infection led to inadequate primary treatment

Are dental infections a cause of brain abscess? Case report and review of the literature

Dental pathology and/or treatment have been linked to a small number of brain abscesses as possible sources of infection. A further case is presented, in which a dental site is implicated. A review of the evidence was undertaken. A wide range of dental procedures had been implicated. In some cases the brain isolate was not of dental origin. In many, the diagnosis was one of exclusion. In order to confirm the role of odontogenic infection in the pathogenesis of brain abscess, modern sampling techniques should be used to precisely identify the isolates. The causal organism should be identified in both oral and cranial sites.

Detection of an intense resonance at 2.4 ppm in 1H MR spectra of patients with severe late-delayed, radiation-induced brain injuries

Proton MRS and MRI were used to monitor the progression of severe cerebral radiation injuries in 10 patients over a period of 18 months. An unknown resonance (Px) in the 2.37-2.40 ppm region was consistently detected in the affected temporal lobes of four patients. The detection of Px was only confined to spectra with lactate (Lac) and in patients with the highest severity grading of radiation injury. The incidence of Px in Lac-positive spectra was 42.8% (15/35) and in lesions with highest injury grading was 46.8% (15/32). Lesions with Px had significantly higher Lac/creatine (Cr) ratios and more extensive mass effect changes when compared to lesions without Px. The probable identity of Px was examined in the context of anaerobic glycolysis producing pyruvate (2.37 ppm) and the model of metabolic changes in brain abscess formation implicating succinate (2.40 ppm).

Cerebral abscess as an unusual complication of coil embolization in a dural arteriovenous fistula. Case report

This 63-year-old man presented with a right temporoparietal cortical infarction. A dural arteriovenous fistula involving the right transverse sinus was diagnosed on cerebral angiography. Transvenous embolization using detachable coils was performed; however, postembolization angiograms demonstrated retrograde filling of a cortical draining vein that was not seen on initial angiography. The patient subsequently developed a cerebral abscess in the region of the previous cortical infarction 2 months after the embolization. The abscess was successfully treated with drainage and antibiotic therapy. The authors report this case to illustrate an unusual complication associated with this procedure and the possible contribution of the cortical draining vein in the pathogenesis of the cerebral abscess.

Cerebral abscess as an unusual complication of coil embolization in a dural arteriovenous fistula

This 63-year-old man presented with a right temporoparietal cortical infarction. A dural arteriovenous fistula involving the right transverse sinus was diagnosed on cerebral angiography. Transvenous embolization using detachable coils was performed; however, postembolization angiograms demonstrated retrograde filling of a cortical draining vein that was not seen on initial angiography. The patient subsequently developed a cerebral abscess in the region of the previous cortical infarction 2 months after the embolization. The abscess was successfully treated with drainage and antibiotic therapy. The authors report this case to illustrate an unusual complication associated with this procedure and the possible contribution of the cortical draining vein in the pathogenesis of the cerebral abscess.