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.

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.

Hyperbaric oxygen is effective in early stage of healing of experimental brain abscess in rats.

OBJECTIVES: Current therapy of brain abscess (BA) includes a combined approach that involves antibiotics and minimal invasive surgery, but also hyperbaric oxygen treatment (HBOT) as a supportive measure. Optimum treatment is still a matter of significant controversy. METHODS: The experiment, previously approved by a relevant ethical committee, involved 80 female Wistar rats. BA was experimentally induced by inoculation of Staphylococcus aureus. The animals were randomized into groups and treated either with antibiotics, HBOT, or with a combination of both. RESULTS: Beneficial effect of HBOT was evident in groups treated with HBOT or with a combination of antibiotic+HBOT. It was mainly manifested on days three and five of the experiment and was evident as statistically significant increase of a number of newly formed blood vessels, increase in mean vascular density, and smaller abscess necrotic core. DISCUSSION: Although the results of the present study should be interpreted cautiously, they suggest that HBOT has an important but limited role in the treatment of BA.

[Hyperbaric oxygenation: utility in intensive therapy - part 2]. / Hyperbare Oxygenation - Stellenwert in der Intensivtherapie - Teil 2.

Gangrene, non-clostridial myonecroses and intracranial abscesses are clinical entities for which hyperbaric oxygenation can be used therapeutically. Mortality and invalidity can be reduced by this means. Except for gangrene, HBO is used merely as an adjuvant for these diseases when conventional surgical, antibiotic and intensive therapy measures are not sufficient. The action of HBO is based on several points of attack: it reduces the formation of oedema, inhibits the production of alpha-toxins of the Clostridia, has a bacteriotoxic action, increases the effectivity of antibiotics and improves the immune defense system. An early start is decisive for the success of HBO therapy.

Absceso Cerebral: Estudio clínico terapéutico en un hospital provincial del Perú / Brain Abscess: Clinical therapeutic study in a provincial hospital in Peru

El presente estudio prospectivo, descriptivo reporta seis casos de absceso cerebral piógenos, atendidos en el Servicio de Medicina del Hospital II EsSalud de Cajamarca, Perú, durante el periodo de 1990 al 2006. La edad promedio fue de 42 años, la mínima 9 años y el 66 por ciento fueron mayores de 40 años; 3 casos de sexo masculino y 3 de sexo femenino. Los focos primarios fueron: bronquiectasia, otitis media crónica, absceso dentario, sinusitis crónica, de origen cardiogénico y en 1 caso no se determinó. La desnutrición, VIH positivo, diabetes mellitus y endocarditis bacteriana; en 2 no se determinó enfermedad de fondo y en 1 hubo curetaje de absceso dental. Los síntomas de inicio son: cefalea en 50 por ciento convulsiones 17 por ciento. El síntoma principal: convulsiones en 66 por ciento, la hemiparesia y alteraciones del sensorio. El cuadro clínico estuvo caracterizado por cefalea (83 por ciento) convulsiones (66 por ciento), hemiparesia (66 por ciento), fiebre (66 por ciento), afasia (50 por ciento) edema de papila y vómito (50 por ciento) de alteración de memoria, signos meningeos y signos prefrontales (33 por ciento). Los sindromes clínicos: sindrome de cefalea (33 por ciento), neurológico focal (83 por ciento) epileptico focal (67 por ciento) febril (67 por ciento) de HEC (50 por ciento), meníngeo (33por ciento) de funciones superiores (33 por ciento). La TAC y IRM cerebal reveló 6 casos de absceso cerebral, de localización hemisférica derecha en 5 casos, 3 únicos y 3 múltiples; 2 en el lóculo frontal, 1 frontapariental, 1 frontotemporal y 1 parietal. Dos casos en fase de cerebritis y 4 encapsulados, con edema circundante y efecto de masa. El tratamiento se realizó cocn cefotaxima 1gr c/6 hs. VEV/20 días. 1 caso se prolongó el tratamietnno hasta 60 días con metronidazol por vía oral. Las secuelas fueron: hemiparesia, alteraciones prefrontales, convulsiones, polineuropatía periférica por metronidazol. La evolución clínica y tomográfica fue favorable en ...

Hyperbaric oxygen therapy for the treatment of brain abscess in children.

INTRODUCTION: The treatment of brain abscess remains a challenging topic usually involving a multimodal concept. METHODS: We report our experience with hyperbaric oxygen (HBO) therapy in five children presenting with brain abscesses between 1995 and 2002 at the Department of Neurosurgery, Graz. Mean age was 14.8 (range 11-17 years). All abscesses were located supratentorially. One child had a single abscess and one had multilocated abscesses. Two other patients presented with both subdural empyema and brain abscess, one of them showing an epidural empyema as well. In another child, the brain abscess was associated with meningoencephalitis and subdural empyema. In all of them the underlying condition was spread of infection from the paranasal sinuses, except for one, who was immunocompromised due to cytotoxic chemotherapy for acute lymphocytic leukaemia. RESULTS: One single brain abscess and one of the multiple abscesses were drained. All subdural/epidural empyemas were treated surgically. Antibiotics were administered intravenously for 13 to 22 days (mean 22 days). All patients underwent HBO therapy; the number of treatments ranged from 26 to 45 "dives" (mean 30). Treatments were given once daily at 2.2 atmosphere absolutes for 60 min at 12 m. During the hospital stay all improved their clinical condition, with continued regression of abnormalities on magnetic resonance imaging (MRI). In the following weeks, other interventions were performed to treat the origin of the infections. At 6 months follow-up they were all in good clinical condition, either symptom free or with minor residual symptoms. MRI at this time showed no evidence of disease in three, a residual dural enhancement in one and a residual shrunken collection in the child with multilocated abscesses. No recurrence was observed during a mean follow-up of 21 months (range from 7 to 72 months). CONCLUSION: HBO therapy in children with brain abscesses seems to be safe and effective, even when they are associated with subdural or epidural empyemas. It provides a helpful adjuvant tool in the usual multimodal treatment of cerebral infections and may reduce the intravenous course of antibiotics and, consequently, the duration of hospitalization. Multidisciplinary management is recommended to optimize care for these critically ill children.

Stereotactic aspiration and antibiotic treatment combined with hyperbaric oxygen therapy in the management of bacterial brain abscesses.

OBJECTIVE: Despite advances in surgical techniques in the management of the brain abscess, long-term antibiotics are as crucial to cure as the initial surgical procedure itself. This study was designed to evaluate the effect of adjuvant hyperbaric oxygen (HBO) therapy on the duration of antibiotic treatment. METHODS: Between 1999 and 2004, 13 patients with bacterial brain abscesses treated with stereotactic aspiration combined with HBO and systemic antibiotic therapy. Patients younger than 18 years of age were excluded from this study. Postoperatively, all patients were given a 4-week course of intravenous antibiotics. Additionally, patients received hyperbaric oxygen (HBO, 100% O2 at 2.5 ATA for 60 min) twice daily for five consecutive days, and an additional treatment (100% O2 at 2.5 ATA for 60 min daily) was given for 25 days. RESULTS: There were eight male and five female patients. Their ages ranged between 18 and 71 years, with a mean of 43.9 years. The average duration of follow-up was 9.5 months (range, 8-13 mo). This treatment modality allowed infection control and healing for all 13 patients with 0% recurrence rate. HBO treatment was tolerated well, and there were no adverse effects of pressurization. At the end of the follow-up period, 12 patients had a good outcome: nine are without sequelae, and three have a mild hemiparesis but are capable of self-care. One patient has a moderate hemiparesis. CONCLUSION: Although the number of patients is small, this series represents the largest reported group of brain abscess patients treated with stereotactic aspiration combined with antibiotic and HBO therapy. Our preliminary results indicate that the length of time on antibiotics can be shortened with the use of HBO as an adjunctive treatment.

[Rhino-cerebral fungal infection successfully treated with supplementary hyperbaric oxygen therapy]. / Traitement d'un abcès rhino-cérébral mycotique par adjonction d'oxygénothérapie hyperbare.

Rhino-cerebral fungal infections are rare and difficult disorders to cure. We report the case of a woman presenting a left trigeminal neuralgia complicated by ophthalmoplegia and blindness. MRI demonstrated a lesion of the left orbital apex with extension into the cavernous sinus. Fungal infiltration (aspergillosis or mucormycosis), was seen on biopsy. High-dose liposomal Amphotericin B (5mg/kg/day) for six weeks was unsuccessful. Adjunctant hyperbaric oxygen therapy led to clinical and radiological improvement. Hyperbaric oxygen therapy is discussed in the medical management of rhino-cerebral yeast abscesses.

Rhinocerebral mucormycosis with cerebral extension successfully treated with adjunctive hyperbaric oxygen therapy.

Rhinocerebral mucormycosis is a devastating fungal disease with a high mortality rate. Extensive surgical débridement and amphotericin B are currently the mainstays of therapy. When cerebral extension of the fungus occurs, the disease is almost invariably fatal. Two patients with rhinocerebral mucormycosis had progression of their infection to brain abscesses despite aggressive débridement surgery and amphotericin B therapy. Both patients showed marked clinical improvement with the addition of adjunctive hyperbaric oxygen therapy. Both patients remained free of their disease 21 months after hospital discharge.

Solitary histoplasmoma of the thalamus: case report and literature review.

Only nine cases of solitary thalamic abscess have been reported. All were of bacterial origin, and three were successfully treated by surgical drainage and antibiotic therapy. The authors present the history of a patient with a histoplasmoma of the thalamus. As is often the case with solitary thalamic lesions, this lesion was initially assumed to be a tumor and was first treated with radiotherapy. Despite the sensitive location of the lesion, tissue diagnosis and decompression was safely accomplished with the aid of ultrasonic localization. Appropriate antifungal treatment was given, and the patient made a good recovery.

[Hyperbaric oxygen therapy of anaerobic brain abscesses following tonsillectomy]. / Die hyperbare Sauerstofftherapie bei anaeroben Hirnabszessen nach Tonsillektomie.

This study describes the clinical course of a 31 year old woman who developed multiple anaerobic brain abscesses six days after tonsillectomy, followed by hemoparesis and dysarthria. In spite of craniotomy, repeated punctures and drainage of pus and high dose local and systemic antibiotics, there was an obvious deterioration in the patient's condition. Hyperbaric oxygen therapy was tried as a last resort. The patient improved quickly, and six months after the tonsillectomy seems to be neurologically symptomfree.

Hyperbaric oxygen in the treatment of rhinocerebral mucormycosis.

Hyperbaric oxygen therapy was utilized in a case of fulminant mucormycosis of the maxilla, orbit and temporal bone. The patient had refused radical surgery and death seemed iminent in spite of aggressive medical management of diabetic ketoacidosis, amphotericin B and wide surgical drainage of the maxillary and ethmoid sinuses with orbital decompression. Hyperbaric oxygen was instituted on the following theoretical premises: 1. It would provide oxygenation of tissues distal to occluded arteries, thereby increasing local survival and decreasing acidosis, 2. resultant lessening of acidosis would slow or inhibit rapid growth of the organism, and 3. oxygen in sufficient concentration is fungicidal. The rapid progress of the mucormycosis was arrested. Cultures of tissue prior to hyperbaric oxygen treatment produced heavy growth of Rhizopus, and tissues cultured after therapy grew only bacterial contaminants. The patient survived for 3 mo. only to succumb to Pseudomonas meningitis secondary to necrotic bone and epidural abscess of the middle cranial fossa. Rhinocerebral mucormycosis is a fulminant and frequently fatal disease. No survivors were reported before extensive surgical debridement was utilized. Survival improved to 50% with the addition of amphotericin B. Early diagnosis and correction of underlying acidosis has further improved this to 85%. The response to hyperbaric oxygen in this case report possibly introduces a promising new adjunct to therapy of this serious disease.

Diagnosis and treatment of abscess of the central ganglia.

The authors present four cases of abscess of the thalamus and basal ganglia and review an additional 10 cases from the literature. These abscesses appear to be metastatic and are usually associated with a cardiac septal defect or a preceding intrathoracic infection. Fever, elevated white blood count, and/or meningismus, in combination with angiography demonstrating an avascular mass, help distinguish abscess from tumor in this location. The authors advocate aspiration rather than excision.