The treatment of nosocomial meningitis and brain abscess by carbapenem-resistant Klebsiella pneumonia.

We report the fourth case of Carbapenem-resistant Klebsiella pneumoniae (CRKP) meningitis and the only one associated with brain abscess formation. A 29-years-old male patient developed septic shock 13 days after a right nasopharyngeal AVM resection. CRKP was grown from CSF with a MIC for meropenem ≥16 mg/L. Intravenous tigecycline and amikacin, combined with intrathecal amikacin and oral sulfamethoxazole were given. CSF culture was sterile on the 23rd day post operation. A right temporal lobe brain abscess formed by day 38 and was drained. Antibiotics were changed to oral sulfamethoxazole and minocycline for four weeks. The patient was cured with no relapse to date. With few cases reported we can only carefully recommend the combinational use of intravenous antibiotics with high dose intrathecal/intraventricular aminoglycosides.

Hyperbaric oxygen for intracranial abscess.

The term "intracranial abscess" (ICA) includes cerebral abscess, subdural empyema, and epidural empyema, which share many diagnostic and therapeutic similarities and, frequently, very similar etiologies. Infection may occur and spread from a contiguous infection such as sinusitis, otitis, mastoiditis, or dental infection; hematogenous seeding; or cranial trauma. In view of the high morbidity and mortality of ICA and the fact that hyperbaric oxygen therapy (HBO2) is relatively non-invasive and carries a low complication rate, the risk-benefit ratio favors adjunct use of HBO2 therapy in selected patients with intracranial abscess.

The concept of "Four Walls, Two Poles" in the lesions of the thalamus and ganglion regions: case report and literature review.

BACKGROUND: There are few articles about the surgical techniques of thalamic glioma and the lesions in the basal ganglia area. According to three existing cases and the literature review (Twelve articles were summarized which mainly described the surgical techniques), we discuss the surgical characteristics of lesions of the thalamus and basal ganglia area and summarize the relevant surgical skills. CASE PRESENTATION: Of the three cases, two were thalamic gliomas and one was brain abscess in basal ganglia. According to the three-dimensional concept of the "Four Walls, Two Poles", lesions of the thalamus and basal ganglia were surgically removed, and the operative effect was analysed by relevant surgical techniques. Surgical resection of the lesions of the thalamus and basal ganglia area according to the three-dimensional concept of the "Four Walls, Two Poles" has achieved good surgical results. Relevant surgical techniques, such as the use of retractors, the use of aspirators, the choice of surgical approaches, and the haemostasis strategy, also played an important role in the operation process. CONCLUSIONS: In the presented three cases the three-dimensional concept of the "Four Walls, Two Poles" allowed for safe surgical resection of lesions of the thalamus and basal ganglia.

[Long course of polymyxin B for the treatment of brain abscess caused by carbapenem resistant Acinetobacter baumannii: a case report].

The clinical efficacy of polymyxins in severe infection caused by carbapenem resistant organism (CRO) has gradually been recognized, and the course of treatment is generally 2 to 4 weeks. The most common complications after intravenous injection are nephrotoxicity and neurotoxicity, however, there are few reports on the efficacy and safety of the long course use of polymyxins. A patient with carbapenem resistant Acinetobacter baumannii (CRAB) infection after neurosurgery was admitted to the department of neurosurgical intensive care unit (NICU) of Lanzhou University Second Hospital. As the family refused the excision of brain abscess and Ommaya reservoir placement, polymyxin B was given intravenous (3.0 mg×kg-1×d-1) combined with intrathecal (5 mg once daily) injection, and high-dose sulbactam (8 g/d) was intravenously injected for anti-infection therapy. Finally, the brain abscess was absorbed and the patient was successfully cured. The total course of polymyxin B was 69 days with a cumulative dosage of 7 500 mg. There were no complications such as polymyxin-related nephrotoxicity and neurotoxicity during the period, and no symptoms of respiratory inhibition or neuromuscular blockage were observed, but polymyxin-related skin pigmentation appeared about 1 month after intravenous administration of polymyxins B, which subsided after drug withdrawal. It is suggested that long course of polymyxins B is safe and effective for intracranial infection caused by CRAB.

Precision diagnosis and therapy of a case of brain abscesses associated with asymptomatic pulmonary arteriovenous fistulas.

BACKGROUND: Brain abscesses, a severe infectious disease of the CNS, are usually caused by a variety of different pathogens, which include Streptococcus intermedius (S. intermedius). Pulmonary arteriovenous fistulas (PAVFs), characterized by abnormal direct communication between pulmonary artery and vein, are a rare underlying cause of brain abscesses. CASE PRESENTATION: The patient was a previous healthy 55-year-old man who presented with 5 days of headache and fever. Cerebral magnetic resonance imaging (MRI) suggested a brain abscess. Thoracic CT scan and angiography demonstrated PAVFs. Aiding by metagenomic next-generation sequencing (mNGS) of the cerebrospinal fluid (CSF) sample which identified S. intermedius as the causative pathogen, the patient was switched to the single therapy of large dose of penicillin G and was cured precisely and economically. CONCLUSIONS: It is an alternative way to perform mNGS to identify causative pathogens in patients with brain abscesses especially when the results of traditional bacterial culture were negative. Further thoracic CT or pulmonary angiography should also be undertaken to rule out PAVFs as the potential cause of brain abscess if the patient without any known premorbid history.

MR Navigation and Tractography-Assisted Transcranial Neuroendoscopic Aspiration of Pediatric Thalamic Abscess.

AIM: Management of thalamic abscess is being considered as a contentious issue in neurosurgery. Regarding these lesions, besides removing the abscess, the most minimal morbidity is targeted during surgery and planning. MATERIAL AND METHOD: A 5-year-old female presented with the symptoms of altered consciousness and left hemiparesis. Her medical history pointed out that she was being followed up for a congenital cardiac anomaly consisting of transposition of the great arteries and a ventricular septal defect. A cranial MRI revealed 2 masses with peripheral contrast enhancement in the right frontal and thalamic regions. She was operated immediately and the right frontal mass, compatible with abscess, was totally excised with frontal mini craniotomy. The patient was hospitalized and followed up under intensive parenteral antibiotics. Control cranial imaging revealed progression in the size of the thalamic abscess, which was corroborative with the increased left hemiparesis. MR tractography was obtained and the patient underwent MR navigation and tractography combined neuronavigation-assisted transcranial neuroendoscopic aspiration of the thalamic abscess. RESULTS: The patient was stable in the early and late postoperative periods and her hemiparesis showed a dramatic recovery with no additional neurological deficits. CONCLUSION: Neuronavigation is considered as one of the techniques that aid the neurosurgeon to augment the success of surgery and minimize the morbidity, especially in critically localized lesions, i.e., eloquent areas. Combining MR navigation with MR tractography images and using them during neuronavigation to assist endoscopic procedures may decrease the surgical morbidity as much as possible.

Methicillin-resistant Staphylococcus aureus intracranial abscess: An analytical series and review on molecular, surgical and medical aspects.

PURPOSE: Intracranial abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) is rare and unexplored. The aim of the present study is to examine the prevalence, clinical and molecular characteristics, treatment options and outcome of MRSA intracranial abscess over a period of 6 years. PATIENTSAND METHODS: A total of 21 patients were included in this retrospective study. The demographic and clinical details of all the patients were collected. Molecular typing including staphylococcal cassette chromosome mec typing, spa typing and polymerase chain reaction of Panton-Valentine leucocidin toxin (PVL) gene for the latter 6 isolates was performed. RESULTS: The paediatric population was the most affected group (33.3%). The primary route of infection was post-operative/trauma in 7 (33.3%) cases. All the patients were treated surgically either by aspiration or excision. Fifteen (71%) patients received anti-MRSA treatment with vancomycin or linezolid, where linezolid-treated patients showed better prognosis. Of the 11 patients who were on follow-up, unfavourable outcome was observed in 3 (27.3%) cases and 8 (72.7%) cases improved. The molecular typing of six isolates revealed four community-associated (CA) MRSA, one each of livestock-associated (LA) and healthcare-associated MRSA with PVL gene noted in all. CONCLUSION: We propose that timely diagnosis, surgical intervention and appropriate anti-MRSA treatment would contribute to better outcome. The occurrence of CA-MRSA and LA-MRSA infection in the central nervous system signifies the threat from the community and livestock reservoir, thus drawing attention towards surveillance and tracking to understand the epidemiology and implement infection control measures.

The Utility of Local Anesthesia for Neurosurgical Interventions in a Low-Resource Setting: A Case Series.

INTRODUCTION: Trauma is a major contributor to global morbidity and mortality, and injury to the central nervous system is the most common cause of death in these patients. While the provision of surgical services is being recognized as essential to global public health efforts, specialty areas such as neurosurgery remain overlooked. METHOD: This is a retrospective case review of patients with operable lesions, such as extra-axial hematomas and unstable depressed skull fractures that underwent neurosurgical interventions under local anesthesia. RESULTS: A total of 13 patients underwent neurosurgical intervention under local anesthesia. Two and three patients with burr hole decompression of epidural and subdural hematomas, respectively; seven patients had elevation of depressed skull fractures and lastly one patient had an aspiration of a brain abscess. All patients survived with and without residual neurological deficits. CONCLUSION: Access to resources and staff required to deliver general anesthesia is challenging in resource-poor settings. We have therefore begun performing emergent interventions under local anesthesia, with or without conscious sedation. While some patients had some minor residual weakness after the procedure, the degree of neurological deficit was improved from that observed before the procedure in all patients.

Successful Treatment of Combined Aspergillus and Cytomegalovirus Abscess in Brain and Lung After Liver Transplant for Toxic Fulminant Hepatitis.

Invasive aspergillosis is one of the most important and fatal complications after liver transplant, especially in patients with involvement of the central nervous system. We present a case of a patient who developed cerebral and pulmonary aspergillosis, coinfected with cytomegalovirus, after liver transplant for toxic fulminant hepatitis. The patient was treated successfully with neurosurgical intervention and voriconazole. Voriconazole is considered more effective in cerebral aspergillosis than other anti-fungal agents due to the greater penetration into central nervous system and higher cerebrospinal fluid and brain tissue levels.

Thalamic abscess caused by a rare pathogen: streptococcus constellatus.

Streptococcus constellatus is a microorganism that lives commensally in the oropharyngeal region, urogenital region, and intestinal tract. However, it can cause infection in patients with certain predisposing factors. Rarely, this microorganism can cause a brain abscess. Thalamic localization of brain abscesses is much rarer than abscesses in other locations of the brain. Brain abscess caused by streptococcus constellatus are very rarely been reported in the literature. We present a rare case of a left-sided thalamic abscess caused by streptococcus constellatus in a 25-year-old male patient who was injured by shrapnel pieces in the head and who was malnourished. The patient was successfully treated by stereotactic aspiration and antibiotherapy.

Safety of transport and hyperbaric oxygen treatment in critically-ill patients from Padua hospitals into a centrally-located, stand-alone hyperbaric facility.

INTRODUCTION: Some patients admitted to the intensive care unit (ICU) might require repetitive hyperbaric oxygen treatment (HBOT) while receiving critical care. In such cases, the presence of a hyperbaric chamber located inside or near an ICU is preferable; however, this set-up is not always possible. In Padua, the "Associazione Tecnici IPerbarici" hyperbaric centre is a stand-alone facility outside of a hospital. Despite this, selected ICU patients receive HBOT at this facility. METHODS: We retrospectively reviewed the medical records from 2003 to 2013 of 75 consecutive, critically-ill patients, 28 of whom were initially intubated and mechanically ventilated whilst undergoing HBOT. We evaluated the methods adopted in Padua to guarantee the safety and continuity of care during transfer for and during HBOT in this specially-equipped multiplace chamber. RESULTS: The 75 patients collectively received 315 HBOT sessions, 192 of which were with the patients intubated and mechanically ventilated. The diagnoses ranged from necrotizing fasciitis to post-surgical sepsis and intracranial abscess. We obtained full recovery for 73 patients. Two deaths were recorded not in close time relation to HBOT. CONCLUSIONS: With meticulous monitoring, efficient transport and well-trained personnel, the risks associated with transportation and HBOT can be acceptable for the referring physician.

Hyperbaric oxygen therapy in spontaneous brain abscess patients: a population-based comparative cohort study.

BACKGROUND: There is a need to improve outcome in patients with brain abscesses and hyperbaric oxygen therapy (HBOT) is a promising treatment modality. The objective of this study was to evaluate HBOT in the treatment of intracranial abscesses. METHOD: This population-based, comparative cohort study included 40 consecutive adult patients with spontaneous brain abscess treated surgically between January 2003 and May 2014 at our institution. Twenty patients received standard therapy with surgery and antibiotics (non-HBOT group), while the remaining 20 patients also received adjuvant HBOT (HBOT group). RESULTS: Resolution of brain abscesses and infection was seen in all patients. Two patients had reoperations after HBOT initiation (10 %), while nine patients (45 %) in the non-HBOT group underwent reoperations (p = 0.03). Of the 26 patients who did not receive HBOT after the first surgery, 15 (58 %) had one or several recurrences that lead to a new treatment: surgery (n = 11), surgery + HBO (n = 5) or just HBO (n = 1). In contrast, recurrences occurred in only 2 of 14 (14 %) who did receive HBOT after the first surgery (p < 0.01). A good outcome (Glasgow Outcome Score [GOS] of 5) was achieved in 16 patients (80 %) in the HBOT cohort versus 9 patients (45 %) in the non-HBOT group (p = 0.04). CONCLUSIONS: HBOT was associated with less treatment failures and need for reoperation and seemingly with improved long-term outcome. Further, HBOT was well tolerated and safe. Prospective studies are warranted to establish the role of HBOT in the treatment of brain abscesses.

Fatal thalamic abscess secondary to dental infection.

We present the case of poor neurological recovery and subsequent death secondary to a thalamic abscess in a 53-year-old man. This patient initially presented with sudden dysarthria and left hemiparesis while driving. Neuroimaging showed a multilobular abscess involving the right thalamus with oedema extending to the basal ganglionic region and brainstem. The source of the abscess was initially unknown and it required draining multiple times while the different causes were being explored. The patient's neurological state along with intubation made for a difficult and inconclusive oral examination. It was only after neuroimaging included tooth-bearing areas that it became evident that this patient had extensive periodontal disease with multiple areas of periapical radiolucencies. The patient underwent complete dental clearance alongside repeated drainage of the abscess. Despite initial postoperative improvement, the patient never recovered from the neurological damage and died 3 weeks later.

[Thalamo-mesencephalic aspergillus abscess in a heart transplant subject: a case report and literature review]. / Ascesso aspergillare talamo-mesencefalico in un soggetto sottoposto a trapianto cardiaco: caso clinico e revisione della letteratura.

Cerebral aspergillosis is a rare and highly fatal infection that mainly affects immunocompromised patients. We report on a case of a heart transplanted Caucasian man, who arrived at our hospital because of the onset of diplopy. We performed a broad diagnostic work-up: the brain MRI showed a single ring-enhancing thalamo-mesencephalic area suggestive of abscess lesion; cerebrospinal fluid (CSF) analysis disclosed galactomannan and beta-D-glucan antigens. Thus the antifungal therapy was immediately started. We decided to discontinue the therapy 16 months later because of severe hepatic toxicity, given that the patient was persistently asymptomatic, brain imaging showed a progressive resolution of the abscess area and CSF antigen analysis was persistently negative. The follow-up at three months was unchanged.

[Neurological complications of infective endocarditis in Burkina Faso. Clinical features, management and evolutionary profile]. / Les complications neurologiques des endocardites infectieuses au Burkina Faso. Caractéristiques cliniques, prise en charge et profil évolutif.

INTRODUCTION: Neurological complications are the most frequent extracardiac complications of infective endocarditis (IE). This study aimed to describe the epidemiological, clinical and paraclinical aspects, and outcome of neurological complications of infective endocarditis in three hospitals in the city of Ouagadougou in Burkina Faso. PATIENTS AND METHOD: From 1 January 2009 to 31 December 2012, we included all patients suffering from IE and selected those in whom a neurological complication was objectified. Neurological involvement was sought on clinical examination but especially CT brain (ischemic infarcts, hemorrhages, aneurysms and abscesses). Blood cultures were systematic. Echocardiography was done for vegetations and characteristics. RESULTS: Among 63 cases of IE, neurological complications were found in 14 patients (22.2%). The average age of patients with neurological complications was 37.4 ± 5.8 years. The sex ratio was 1.3 for women. Neurological damage consisted of nine cases of stroke (64.3%), three cases of hemorrhagic stroke (21.4%) and two cases of brain abscess (14.3%). Neurological complications had already occurred before hospitalization in 4 cases. Blood cultures were positive in 8 cases. Germs found were predominantly Staphylococcus aureus (5 cases) and Streptococcus a- viridans (2 cases). All cases of S. aureus were complicated by stroke. At echocardiography, vegetation was found in all cases. It was found on the mitral in 7 cases, the aorta in 3 cases, the mitral and aortic in 2 cases and the mitral and tricuspid in 2 cases also. The EI had occurred on a native valve in 11 cases, prosthesis in 4 cases (2 mitral and 2 aortic). The vegetations average diameter was 11.2 ± 2.1 mm (6.4 and 1 7.7 mm). Vegetations were mobile in 12 cases. The treatment consisted of antibiotics adapted to the antibiogram, neurological and cardiovascular monitoring. The evolution was marked by seven deaths (50%), including 5 deaths related to cerebral complication (71.4% of deaths). CONCLUSION: This study shows that neurological complications during infective endocarditis are frequent, dominated by stroke with a high mortality.

[FEATURES OF OTOGENIC INTRACRANIAL COMPLICATIONS AT THE PRESENT STAGE].

A retrospective analysis of treatment was made in 127 adult patients with acute and chronic otitis media complicated by suppurative-inflammatory pathology of the brain. Purulent meningitis was revealed in 52 (40.9%) of hospitalized patients. Meningoencephalitis was often diagnosed in the cases of acute otitis media (15.4%) and in cases of chronic otitis (22.7%). The otogenic brain abscess was detected in 13.5% of otitis media cases and it was noted to be twice frequent (33.3%) in cases of purulent otitis media. The patients 124 (97.6%) have been operated. An extended mastoidotomy and antromastoidotomy were performed in the acute purulent otitis media. An extended radical operation on the ear was applied in case of chronic otitis media. Performance of craniotomy and complete removal of the abscess using modern systems of neuronavigation showed a higher clinical efficacy as compared with transtemporal approach during sanitizing intervention on the ear including the opening and abscess drainage in surgery of otogenic abscesses of the brain.

Tumor-like Presentation of Tubercular Brain Abscess: Case Report

A 17-year-old girl presented with complaints of headache and decreasing vision of one month's duration, without any history of fever, weight loss, or any evidence of an immuno-compromised state. Her neurological examination was normal, except for papilledema. Laboratory investigations were within normal limits, except for a slightly increased Erythrocyte Sedimentation Rate (ESR). Non-contrast computerized tomography of her head revealed complex mass in left frontal lobe with a concentric, slightly hyperdense, thickened wall, and moderate perilesional edema with mass effect. Differential diagnoses considered in this case were pilocytic astrocytoma, metastasis and abscess. Magnetic resonance imaging (MRI) obtained in 3.0 Tesla (3.0T) scanner revealed a lobulated outline cystic mass in the left frontal lobe with two concentric layers of T2 hypointense wall, with T2 hyperintensity between the concentric ring. Moderate perilesional edema and mass effect were seen. Post gadolinium study showed a markedly enhancing irregular wall with some enhancing nodular solid component. No restricted diffusion was seen in this mass in diffusion weighted imaging (DWI). Magnetic resonance spectroscopy (MRS) showed increased lactate and lipid peaks in the central part of this mass, although some areas at the wall and perilesional T2 hyperintensity showed an increased choline peak without significant decrease in N-acetylaspartate (NAA) level. Arterial spin labelling (ASL) and dynamic susceptibility contrast (DSC) enhanced perfusion study showed decrease in relative cerebral blood volume at this region. These features in MRI were suggestive of brain abscess. The patient underwent craniotomy with excision of a grayish nodular lesion. Abundant acid fast bacilli (AFB) in acid fast staining, and epithelioid cell granulomas, caseation necrosis and Langhans giant cells in histopathology, were conclusive of tubercular abscess. Tubercular brain abscess is a rare manifestation that simulates malignancy and cause diagnostic dilemma. MRI along with MRS and magnetic resonance perfusion studies, are powerful tools to differentiate lesions in such equivocal cases.