Microsurgical fenestration and cystoperitoneal shunt through preauricular subtemporal keyhole craniotomy for the treatment of symptomatic middle fossa arachnoid cysts in children.

INTRODUCTION: The optimal surgical treatment for symptomatic middle fossa arachnoid cyst is still controversial. The most leading therapeutic options include cyst shunting and fenestration (endoscopic, microsurgical). We present our experience on surgical treatments of arachnoid cysts. PATIENTS AND METHODS: A retrospective data review of 16 children who underwent keyhole craniotomy for microsurgical fenestration and shunting of middle fossa arachnoid cysts between 1999 and 2012 was performed after institutional review board approval. The average patient age was 6.1 years. The average follow-up period was 36.5 months. There were ten male and six female patients in the series. Indications for surgery included intractable headaches (50%), increasing in cyst size (18.75%), and seizures (31.25%). All patient records were reviewed for their clinical presentation, classification, cyst resolution, symptom resolution, and cyst outcomes. After surgery, all patients underwent assessments of clinical and radiological improvement. RESULTS: Postoperative complications were observed in two cases: progressively resolving monoparesia in one case and resolving epileptic seizure with monotherapy in the other. All patients had a satisfactory clinical outcome, and in 87.5%, there was either a decrease in the size or a complete disappearance of the MFAC. Nevertheless, three (18.75%) of all patients needed shunt revision because of shunt dysfunction. Complication related to surgical technique was cerebrospinal fluid leak which spontaneously resolved in one patient. CONCLUSION: Microsurgical fenestration with keyhole craniotomy to provide passage between cysts to basal cisterns together with cystoperitoneal shunting during the same operation is still an effective and safe method in cases with symptomatic middle fossa arachnoid cysts in children.

A Simple Technique for Bone Storage after Decompressive Craniectomy in Children.

Cranial vault reconstruction in the pediatric population is a specialized procedure, which requires additional considerations. Generally, inherent difficulties of bone storage and cranioplasty are neglected in the literature. We present a simple method of bone storage and autologous cranioplasty in a small child with severe head injury. The child underwent surgical treatment with decompressive craniectomy. A bone flap was transversally divided into two pieces and stored under the galea. Bone storage and reconstruction of the cranial vault with our surgical technique is a safe, easy and cost-effective choice excluding the surgical trauma to obtain a new subcutanous pocket for bone storage in pediatric decompressive craniectomy patients.

Microsurgical management of non-neurofibromatosis spinal schwannoma.

INTRODUCTION: The aim of this study is to assess the clinical properties and surgical results of patients diagnosed with spinal schwannomas without neurofibromatosis (NF) properties. PATIENTS AND METHODS: The data obtained from 35 patients who underwent resection of spinal schwannomas were analyzed. All cases with neurofibromas and those with a known diagnosis of NF Type 1 or 2 were excluded. 35 patients underwent surgery for spinal schwannoma at our institution between January 1997 and 2010. The data were gathered retrospectively from medical records and included clinical presentation, tumor location and post-operative complications. All cases were surgically excised, and they were confirmed to be schwannomas by pathologists with histopathological sections in paraffin stained with hematoxylin-eosin. RESULT: We treated 35 (20 males and 15 females) patients with spinal schwannomas. The mean age of the patients was 47.2 (between 13 and 76) years. Of the cases, six schwannomas were located in the cervical spine, four in the thoracic spine, two in cervico-thoracic area, 10 in the thoraco-lumbar area and 13 in the lumbar spine. Two patients had malignant schwannomas that were recurrent. Of the 35 cases, the schwannomas were intradural-extramedullary in 30 cases (86%), intradural-intramedullar in 2 cases (6%), and extradural in 3 cases (9%). CONCLUSION: Spinal schwannomas may occur at any level of the spinal axis and are most frequently intradural-extramedullary. The most common clinical presentation is pain. Most of the spinal schwannomas in non-NF patients can be resected completely without or with minor post-operative deficits. This knowledge may help us to create a strategy for total resection of a spinal schwannomas.

The effect of polymorphisms in the promoter region of the MMP-1 gene on the occurrence and invasiveness of hypophyseal adenoma.

BACKGROUND: The matrix metalloproteinase-1 enzyme (MMP-1, also called collagenase 1) plays a key role in turnover of collagen fibers in the intercellular matrix. Insertion of a guanine residue was found within the promoter region of the MMP-1 gene. We found that MMP-1 levels increased approximately twofold over normal when this insertion was present, enabling MMP-1 to facilitate tumor invasion and metastasis. MMP-1 is also believed to play a role in tumor development. The aim of our study is to investigate the effect of polymorphisms in the promoter region of the MMP-1 gene on the development of benign and invasive hypophyseal adenomas. PATIENTS AND METHODS: Thirty patients with hypophyseal adenomas diagnosed by radiological examination underwent surgical removal, and the diagnosis was confirmed using immunohistochemical staining of the pathology specimens. We found that ten of these patients had invasive adenomas confirmed by radiological examination and immunohistochemical staining. DNA isolation was performed on all specimens, and 5-cc venous blood samples were obtained from all patients as well as 30 volunteers using the Qiagen QIAquick kit. Promoter regions of MMP-1 genes from the DNA samples were amplified using polymerase chain reaction (PCR) and primers designed for the site-directed mutation method. Following PCR, a guanine residue within the promoter region of the MMP-1 gene was identified using the restriction fragment length polymorphism method and the ALU I restriction enzyme. Three genotypes were detected in a genotyping assay: 2G/2G, 1G/2G, and 1G/1G. RESULTS: Of the surgically treated patients, 36.6% had the 2G/2G genotype, 46.6% had the 1G/2G genotype, and 16.6% had the 1G/1G genotype. The 2G allele frequency was found to be 83.4%. In 90% of cases of invasive adenoma, a homozygous 2G/2G genotype was detected. DISCUSSION: The risk for development of hypophyseal adenoma may be greater in patients with the 2G allele. In cases of existing hypophyseal adenoma, those with the homozygous 2G allele tend to be invasive.

Giant craniofacial immature teratoma with primary intracranial lesions.

Teratomas can occur in almost any region of the body and are the most common extragonadal germ cell childhood tumors. Immature teratomas in the head and neck region cause severe deformity and threat life because of several reasons. Imaging investigation (ultrasonography, computed tomography, magnetic resonance imaging) is of outmost importance for the diagnosis and preoperative planning, considering that the total surgical resection of the teratoma constitutes the treatment of choice. Untreated teratomas have mortality rates of 80% to 100%. In this study, a giant craniofacial immature teratoma having both intracranial and extracranial primary lesions is reported. As a conclusion, intracranial primary lesions should be kept in mind in extracranial head and neck immature teratoma cases.

Successful surgical treatment of a hemophiliac infant with nontraumatic acute subdural hematoma.

BACKGROUND: The moderate hemophiliacs usually have no spontaneous bleeding, but bleed after minor or major trauma. The proper management of intracranial hemorrhage in hemophiliac children is a challenge. CASE DESCRIPTION: An 18-month-old male infant with moderate hemophilia A was admitted with fever, vomiting, and hypersomnia. There was no history of trauma or seizure. The CT scans showed an acute subdural hematoma in the right temporoparietooccipital region with midline shift and a coincidental right cerebellar arachnoid cyst. After bolus factor VIII replacement, a right temporoparietal craniotomy was performed, and the subdural hematoma was evacuated. The postoperative CT scans demonstrated no hematoma. CONCLUSIONS: The possibility of intracranial hemorrhage in a moderate hemophiliac infant should be considered even if the patient has no history of trauma. The surgical treatment results in a successful outcome in hemophiliac children with subdural hematomas provided that an aggressive factor replacement therapy is initiated before surgery.

Dipyrone attenuates cerebral vasospasm after experimental subarachnoid hemorrhage in rabbits.

BACKGROUND: The purpose of this study was to evaluate the effect of the systemic administration of dipyrone in a triple subarachnoid hemorrhage (SAH) model of cerebral vasospasm in rabbits. METHODS: Experimental subarachnoid hemorrhage was induced in rabbits by injecting autologous arterial blood into the cisterna magna. Digital subtraction angiographies (DSA) were performed before and after the first experimental SAH, and at 30, 45, 60 minutes and 72 hours after the first drug administration to measure the diameter of basilar artery. Intracisternal blood injections were repeated 24 and 48 hours after the first injection. Dipyrone (N.=20) or 0.9% NaCl (N.=20) was administered intravenously after initial SAH induction and repeated at 8-hour intervals intramuscularly. After sacrificing by perfusion-fixation, basilar arteries were removed and sectioned for transmission electron microscopic (TEM) examination. RESULTS: The average basilar artery diameter measured by DSA was 724±19 µm in the control, and 686±29 µm in treatment group before SAH. After SAH, mean basilar artery diameters decreased to 71% and 68% of their basal values, respectively. Dipyrone significantly attenuated the basilar artery diameter at one and 72 hours after the first drug administration, in comparison to the control group. TEM studies showed more edema in the endothelial cells of the basilar arteries of the control group when compared to the treatment group. CONCLUSIONS: Dipyrone showed a beneficial effect in autologous blood-induced basilar artery vasospasm in rabbits. These data support the idea that dipyrone can be a potential candidate drug to be tested in patients suffering from cerebral vasospasm secondary to subarachnoid hemorrhage.

Management of Failed Cranioplasty.

AIM: Failed cranioplasty attempts may lead to numerous complications in a broad spectrum including cosmetic problems, infection, neurological deterioration and even death. Selection of the most appropriate surgical technique for second and further surgical attempts for these patients still remains a debate. We aimed to share our experience and technical pitfalls on management of failed cranioplasty, particularly for patients with large cranial defects. MATERIAL AND METHODS: A retrospective data analysis of cranioplasty cases in our series was performed including the time period between 2002 and 2012. Patients required recurrent cranioplasty were analyzed in detail. RESULTS: Totally, 101 patients underwent cranioplasty for bony defect. Of 101 patients, eleven required a revision surgery due to infection or spontaneous resorption of the bone flap. All patients underwent revision cranioplasty with pre-surgical plaster cast mold technique modified from previous studies and/or tissue expansion technique. Polymethyl-metacrylate (PMMA) was used as substitute for reconstructions. Mean follow-up was 36 months. Two out of eleven cases (18.1%) developed major complications, which led to further revision. At the end, a satisfactory reconstruction was achieved for all patients. CONCLUSION: Our modified molded plaster cast technique is a safe and cost-effective approach for the revision of failed cranioplasty. We believe that the tissue expanding techniques have also great contribution to achieve successful results.

Relation of apparent diffusion coefficient with Ki-67 proliferation index in meningiomas.

OBJECTIVE: The purpose of this study was to investigate the relationship between Ki-67 proliferation indexes and apparent diffusion coefficient (ADC) values of low-grade and atypical/anaplastic (high-grade) meningiomas. METHODS: Pre-operative diffusion-weighted imaging and histopathological evaluation of 44 patients with meningiomas were performed retrospectively. Regions of interest (ROIs) were manually drawn on the ADC images. In total six ROI measurements were taken in three consecutive slices, and the average of the mean ADC value was used. The relationship between the ADC and Ki-67 values was investigated, and the ADC values of the low-grade and high-grade meningiomas were compared. RESULTS: 31 (70%) patients had low-grade the meningiomas. 10 (23%) patients had atypical and 3 (7%) had anaplastic meningiomas. ADC values of the low-grade and high-grade meningiomas were 0.81 ± 0.12 × 10(-3) and 0.66 ± 0.08 × 10(-3) mm(2) s(-1), respectively. Ki-67 proliferation indexes were 2.19% ± 1.14% for low-grade and 11.20% ± 9.80% for high-grade meningiomas. A statistically significant negative correlation between Ki-67 proliferation index and ADC values of the low-grade and high-grade meningiomas was detected (r(2) = 0.326, p < 0.001). High-grade meningiomas had lower ADC values than that of low-grade meningiomas. There was statistically significant difference between the ADC values of the low-grade and high-grade meningiomas (p < 0.001). CONCLUSION: Our data provide an inverse correlation between the ADC and Ki-67 proliferation index values of meningiomas. ADC values can be used for histopathological characterization of the meningiomas and pre-surgical planning. ADVANCES IN KNOWLEDGE: The purpose of this study was to investigate the relationship between Ki-67 proliferation indexes and ADC values of low-grade and atypical/anaplastic (high-grade) meningiomas. In addition, we compared the ADC and Ki-67 proliferative index values of the low-grade and atypical/anaplastic (high-grade) meningiomas. We concluded that there was an inverse correlation between the ADC and Ki-67 proliferation index values in meningiomas, and we have found statistically significant difference between the ADC values of the low-grade and high-grade meningiomas. ADC values can be used for histopathological characterization of the meningiomas and pre-surgical planning.

Relationship of dorsal root ganglion to intervertebral foramen in lumbar region: an anatomical study and review of literature.

BACKGROUND: The purpose of this study was to clarify the morphologic features, location and variations of the dorsal root ganglion (DRG). METHODS: Fifteen formalin fixed cadavers for the current study were included. Total of 150 DRGs were examined from L1 to L5. The relationships of the nerve root DRGs to the intervertebral foramen were noted. Position of the DRG was classified by the location of the ganglia in relation to the pedicle. The relationship of the DRG to the intervertebral foramen was evaluated. RESULTS: The distance between the midpoint of the DRG to the cross section of the root with the medial border of the pedicle gradually increased from L1 to L5. The medial border of the foramen distances along the nerve root were L1, 1.77 mm; L2, 2.79 mm; L3, 3.23 mm; L4, 7.28 mm and L5, 8.31 mm. The mean width of the lumbar DRGs were L1, 4.36 mm; L2, 4.56 mm; L3, 4.99 mm; L4, 5.22 mm and L5, 5.82 mm. The mean length of DRGs were as follows: L1, 5.39 mm; L2, 5.83 mm; L3, 7.24 mm; L4, 7.97 mm and L5, 10.83 mm. The mean width and length of DRGs gradually increased from L1 to L5. CONCLUSIONS: The DRG in the lumbar region play a key role in the occurence of low-back pain and sciatica; therefore, it is important to understand the anatomy of DRG. The accurate anatomic information about the position of DRGs would be useful to perform a safe surgical intervention in the lumbar foraminal region.

Relationship of intraoperative ultrasound characteristics with pathological grades and Ki-67 proliferation index in intracranial gliomas.

OBJECTIVE: The purpose of the present study was to investigate the relationship between the intraoperative ultrasonographic appearances and the histopathological characteristics of glial tumors using the pathological grading system and the Ki-67 proliferation index. MATERIALS AND METHODS: Patients with glial tumors who underwent surgery with the aid of intraoperative ultrasonography (IOUS) between September 2013 and August 2014 were included in the study. The lesions' IOUS characteristics were analyzed and compared with the results of surgical histopathological characteristics. Lesions were classified as low-grade gliomas (grade I-II, LGG) and high-grade gliomas (grade III-IV, HGG). The glioblastoma multiforme (grade IV, GBM) group was classified according to the Ki-67 values for further evaluation. The Chi square test (Fisher's exact test) was used for comparing the ultrasonographic characteristics of the low-grade and high-grade gliomas; HGG with different Ki-proliferation indexes. A value of P < 0.05 was considered statistically significant. RESULTS: A total of 41 patients were included. The histopathological findings revealed 15 LGG and 26 HGG. Twenty of the 26 HGG were GBM. Differences were found between the intraoperative ultrasonographic characteristics of the low-grade and high-grade glial tumors. The majority of LGGs were mildly hyperechoic and homogeneous, with distinct margins and a regular contour. HGGs were mostly highly hyperechoic, with indistinct margins, irregular contours, and a heterogeneous internal texture. Surrounding edema was seen more often in HGGs. The differences in the echogenicity of the solid parts, the internal echo patterns, margins, contours, and peripheral edema (P < 0.05) were statistically significant, but the difference in the presence of cysts (P > 0.05) was not significant. In the GBM group, all of the lesions with distinct margins and regular contours had Ki-67 values ≤15 %. We compared the intraoperative ultrasonographic characteristics of the Ki-67 > 15 % group with those of the Ki-67 ≤ 15 % group for statistical significance. The difference between the echogenicity of the solid parts, margins, and contours was statistically significant between the groups (P < 0.05). The difference in the internal echo pattern, presence of cyst, and peripheral edema was insignificant (P > 0.05). CONCLUSIONS: IOUS is a very useful imaging technique not only in defining the borders but also in characterizing the tumoral tissue. The IOUS characteristics of the glial tumors were a valuable tool in differentiating the grades of the glial tumors and might have a relationship with the Ki-67 proliferation index. We think this theory requires further investigation in more detailed comparative studies with larger numbers of patients.

Focal megalencephaly: intraoperative ultrasound imaging in epilepsy surgery.

Hemimegalencephaly is a rare neuronal migration disorder that can be defined as abnormal neural and glial proliferation localized to all or part of a cerebral hemisphere. Most patients demonstrate intractable epilepsy, with early onset before 1 year of age. Surgical resection is one of the treatment options. In recent years, many advanced intraoperative techniques have been used for brain surgery for various pathologies. Intraoperative ultrasonography is a time-saving and noninvasive method for intraoperative imaging. In this report, we present the use of intraoperative ultrasonography in a patient with focal megalencephaly as an anatomical navigation with the functional navigation system, electrocorticography. In this report, we present the use of intraoperative ultrasonography in a patient with focal megalencephaly as an anatomical navigation with the functional navigation system, electrocorticography.

Concurrent repair of orbital shallowness with craniosynostosis surgery: two late cases of simultaneous orbital decompression.

Early closure of cranial sutures results in various types of cranial vault deformities, named craniosynostosis. Although mostly associated with syndromic cases, bony orbit deformities such as exorbitism can be seen with various types of craniosynostosis. This condition can be associated with papilledema and besides its effect on the patient's appearance can cause subluxation of the globe, lagophthalmos or keratitis resulting in corneal ulcers and ultimately loss of vision. Various techniques have been proposed for repair or exorbitism such as fronto-orbital advancement procedures, orbital wall decompression, periosteum scoring and tissue excision. Orbital periosteal scoring covering the globe can be extremely efficient for orbital fat decompression when combined with other orbital volume expanding procedures. We hereby present two late cases of craniosynostosis associated with bilateral exorbitism due to orbital shallowness for which cranial vault reconstruction was performed simultaneously with combinations of fronto-orbital advancement, orbital decompression and periosteal scoring. The late referral of these patients at ages older than the usual time of operation indication made the surgical procedure for craniosynostosis repair and exorbitism treatment challenging. The combined and simultaneous use of bone advancement, orbital wall decompression and specially periosteum scoring can be highly efficient in the treatment of exorbitism associated with craniosynostosis.

Diagnosis and management of pituitary abscess: a case series and review of the literature.

AIM: Pituitary abscess is a disorder characterized with central nervous system (CNS) infection, mass effect, and endocrine dysfunction. These abscesses generally occur due to hematogenous spread in conditions such as paranasal sinusitis, sepsis, and where the blood brain barrier breaks down. This paper aims to discuss four cases of preoperatively diagnosed pituitary abscess in the light of the literature. MATERIAL AND METHODS: Following detailed clinical and hormonal examinations and imaging tests, 210 cases of pituitary adenoma and other sellar pathologies were operated on at the Neurosurgery clinic of Göztepe Training and Research Hospital. RESULTS: All the patients showed fever, systemic signs of toxemia and endocrine dysfunction at the time of diagnosis. In these cases, a preoperative diagnosis of the disease was made thanks to characteristic MRI findings. The four cases were operated by the transnasal transsphenoidal approach and histopathological and microbiological studies were performed for surgical specimens. CONCLUSION: Pituitary abscesses are rare disorders responsible for a high mortality risk. Mortality and morbidity can be reduced by early surgical drainage and appropriate antibiotic treatments. Additionally, these cases should be closely followed-up in terms of pituitary insufficiency, surgical complications and infection.

Investigation of ACE genome insertion/deletion correlation with immunohistochemical profile in pituitary adenomas.

AIM: The deletion polymorphism of the angiotensin-converting enzyme (ACE) genome causes neoplastic development in several organs by increasing the angiotensin 2 (A2) formation. In this study, we aimed to identify the ACE genome insertion/deletion polymorphism in pituitary adenomas and to compare it with the control group. MATERIAL AND METHODS: Patients operated for pituitary adenomas were included in the study. Genomic DNA was extracted from tumoral tissues and peripheral blood samples of the patients by using the Miller method. Primary sequence was selected via targeting the polymorphic region of intron 16 of ACE genome 17q23. DNA samples were multiplied by PCR using HACE3s and HACE3as primers. RESULTS: Twenty-one operated cases were studied. In the study group; 44 % of the patients were identified as D/D, 33% of them as I/D and 23% of them as I/I. In 60%, D allele was identified. According to immunohistochemical investigation, we found that 100% of the patients with Cushing adenoma were D/D alleles. CONCLUSION: Presence of high rate of ACE genome deletion in patients with pituitary adenoma and grade 3-4 patients suggest that ACE genome polymorphism can be a risk factor for the development of pituitary adenomas.

Noninvasive estimation of cerebral perfusion pressure with transcranial Doppler ultrasonography in traumatic brain injury.

AIM: In traumatic brain injury (TBI) patients, to overcome the secondary insults, cerebral perfusion pressure (CPP) oriented therapy is recommended. The study is assigned to estimate CPP values with middle cerebral artery (MCA) flow velocities measured noninvasively using transcranial Doppler ultrasonography (TCD). MATERIAL AND METHODS: Forty-seven TBI patients were studied. Intracranial pressure (ICP), mean arterial pressure (MAP) and MCA flow velocities of the patients were monitored. Invasive CPP was calculated as the difference between MAP and ICP. The formula : 'MAP x FVd/FVm +14' was used to estimate CPP noninvasively. Correlation of the noninvasive and invasive values were analysed. RESULTS: The mean values of noninvasive CPP and invasive CPP were 66.10 ± 10.55 mmHg and 65.40 ± 10.03 mmHg respectively. The correlation between noninvasive and invasive CPP measurements was strongly significant (p < 0.001) with a correlation coefficient of r = 0.920. CONCLUSION: With ICP monitoring systems, CPP is calculated and the therapy is guided according to these values. As it is recognized that brain perfusion can be assessed with TCD waveforms, noninvasive CPP estimation with MCA flow velocities may help to observe the trends in CPP values.

Anatomy of Meckel's cave and the trigeminal ganglion: anatomical landmarks for a safer approach to them.

AIM: Surgical approaches to Meckel's cave (MC) are often technically difficult and sometimes associated with postoperative morbidity. The relationship of surgical landmarks to relevant anatomy is important. Therefore, we attempted to delineate quantitatively their anatomy and the relationships between MC and surrounding structures. MATERIAL AND METHODS: With the aid of a surgical microscope, MC and its contents were studied in 15 formalin-fixed cadaver head specimens. Measurements were made and their relationships were observed. RESULTS: The distance from the zygomatic arch and the lateral end of the petrous ridge to MC was 26.5 and 34.4 mm, respectively. The distance from the arcuate eminence, the facial nerve hiatus, and the foramen spinosum to MC was 16.6, 12.8 and 7.46 mm respectively. The TG lay 5.81 mm posterior to the foramen ovale. The distance from the abducens, trochlear and oculomotor nerves to the trigeminal ganglion was 1.87, 5.53 and 6.57 mm respectively. The distance from the posterior and the anterior walls of the sigmoid sinus to the trigeminal porus was 43.6 and 33.1 mm respectively. The trigeminal porus was on average 7.19 mm from the anterior wall of the internal acoustic meatus. CONCLUSION: The anatomical landmarks as presented herein regarding MC may be used for a safer skull base approach to the region.

The surgical treatment of plagiocephaly.

AIM: Anterior plagiocephaly usually occurs with premature synostosis of the ipsilateral half of the coronal suture. The forehead is flattened on the affected side, with a backward and upward displacement of the affected orbit. The bulging of the calvaria may occur in the contralateral parietal area. MATERIAL AND METHODS: This article presents the surgical techniques used over 7 years to treat plagiocephalic children. Eleven patients with unilateral coronal synostosis treated during 2003-2010 were analyzed retrospectively. The study included reviews of pre and postoperative computed tomography scans, operative techniques, clinical outcomes and complications. Unilateral orbital advancement with "tongue in groove" was performed in 5, and bilateral orbital advancement in 6 cases. Pre and postoperative anthropometric measurements were used to document the amount of advancement of the elevated and recessed orbita, and the amount of withdrawal of the contralateral side. RESULTS: The mean age of the patients at time of surgery was 11 months. The preoperative values of the orbital height and retrusion were 0.68 cm and 1.87 cm, respectively. They were recorded as -0.1cm and 0,63 cm, postoperatively. Mean follow-up was 36 months, neither neurological sequelae nor other significant complications were encountered. CONCLUSION: The surgical corrections have resulted in significant improvements in skull shape and high patient/parent satisfaction.

Nocardial cerebral abscess associated with mycetoma, pneumonia, and membranoproliferative glomerulonephritis.

Nocardial brain abscesses remain a clinical challenge. We successfully treated a patient with nocardial brain abscess, mycetoma, pneumonia, and glomerulonephritis. Nocardial soft tissue involvement, mycetoma, is well known. However, the fact that actinomycetoma can metastasize may not be as well appreciated. The association between nocardiosis and glomerulonephritis should be better clarified.