Successful treatment of brainstem abscess with stereotactic aspiration

doi:10.1016/S0090-3019(99)00146-9

Surgical Neurology

Volume 52, Issue 5, November 1999, Pages 445-448

https://doi.org/10.1016/S0090-3019(99)00146-9 Get rights and content

Abstract

BACKGROUND

Brainstem abscess is an uncommon condition associated with a high mortality. We report a case of brainstem abscess in a 51-year-old female with a pulmonary arteriovenous fistula that was cured after appropriate antibiotic therapy following stereotactic aspiration. The value of stereotactic aspiration in the management of brainstem abscess is documented with a review of the relevant literature.

CASE REPORT

A 51-year-old female with a pulmonary arteriovenous fistula suffered fever, diplopia and weakness on the right side. Magnetic resonance (MR) imaging of the brain showed a large cystic mass with ring-like enhancement in the brainstem. A diagnosis of brainstem abscess as a complication of pulmonary arteriovenous fistula was made. MR imaging-guided stereotactic exploration was carried out via the suboccipital transcerebellar approach and the pathogen of the brainstem abscess was identified. The brainstem abscess was cured after treatment employing antibiotics to which the pathogen was sensitive.

CONCLUSIONS

Stereotactic aspiration is an effective procedure for brainstem abscesses. This procedure is less invasive than open surgery and can be performed even in patients in poor general condition.

Section snippets

Case report

A 51-year-old female was admitted to our hospital with a 1-week history of fever, a 2-day history of diplopia, and weakness on the right side. She had undergone surgery for an atrial septal defect at the age of 18 years and had been diagnosed as having liver cirrhosis due to hepatitis C virus after a blood transfusion at the age of 40 years. Two years before the present event, she was found to have a pulmonary arteriovenous fistula. On examination she was febrile and her general condition was

Discussion

In the face of infectious disease, we must first identify the pathogen. Lumbar puncture is hazardous to the patient with brain abscess [14], and the pathogen often cannot be determined from cerebrospinal fluid 2, 6, 7, 19, 24, 26. Therefore, we believe that surgical treatment is necessary to identify the pathogen.

Twenty-five cases, including ours, of successful treatment of brainstem abscess have been reported 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 15, 16, 17, 18, 19, 20, 22, 23, 24, 26. Nine

References (26)

S. Kashiwagi et al.
Brainstem abscess
Surg Neurol
(1987)
D. Kondziolka et al.
Results and expectations with image-integrated brainstem stereotactic biopsy
Surg Neurol
(1995)
E. Rossitch et al.
The use of computed tomography–guided stereotactic techniques in the treatment of brainstem abscesses
Clin Neurol Neurosurg
(1988)
J. Steck et al.
Stereotactic biopsy of brainstem mass lesions
Surg Neurol
(1995)
C.D. Abernathey et al.
Stereotaxic suboccipital transcerebellar biopsy of pontine mass lesions
J Neurosurg
(1989)
J. Adachi et al.
Diagnosis of brainstem abscess in the cerebritis stage by magnetic resonance imaging
Neurol Med Chir (Tokyo)
(1995)
M.D. Dake et al.
Pyogenic abscess of the medulla oblongata
Neurosurgery
(1986)
J. Danziger et al.
Brain–stem abscess in childhoodcase report
J Neurosurg
(1974)
H. Fujino et al.
Cure of a man with solitary abscess of the brain-stem
J Neurol
(1990)
J.R. Fulgham et al.
Cure of a solitary brainstem abscess with antibiotic therapycase report
Neurology
(1996)

J.C. Garcia–Monco et al.

Resolution of a brainstem abscess through antituberculous therapy

Neurology

(1997)

F.H. Harvey et al.

Brainstem abscess and the syndrome of acute tegmental encephalitis

Ann Neurol

(1980)

H. Imai et al.

Diagnosis and treatment of brainstem abscess using magnetic resonance imaging and microsurgical aspirationcase report

Neurol Med Chir (Tokyo)

(1995)

Cited by (31)

Functional Preservation after Planned Partial Resection Followed by Gamma Knife Radiosurgery for Large Vestibular Schwannomas
2015, World Neurosurgery
Citation Excerpt :
All of these patients underwent partial removal for functional preservation and were then followed for 24–60 months (median 45 months) after the salvage surgery. The tumor size decreased in 3 patients, was unchanged in 1, and 1 patient experienced cyst enlargement at the dorsal portion of the tumor (stereotactic cyst aspiration was performed via the transcerebellar approach 54 months after salvage surgery) (33). We observed 3 complications associated with the surgical resection: 1 patient (2.5%) experienced a lung abscess due to aspiration pneumonia, 1 (2.5%) experienced aseptic meningitis and was treated with steroids, and 1 (2.5%) experienced a pulmonary embolism, but none of these complications were critical to the overall treatment.
The treatment goal for vestibular schwannomas (VS) has been changed from total removal of the tumor to functional preservation with long-term tumor growth control. The small- to medium-sized VS can be treated by stereotactic radiosurgery, but large VS require surgical decompression for the relief of cerebellar dysfunction and increased intracranial pressure. We have been performing planned partial surgical resections followed by gamma knife radiosurgery (GKS) for large VS. Here, we evaluate a recent series of such cases from the standpoint of functional outcomes.
From January 2000 to May 2013, we treated 40 patients with large unilateral VS (maximum tumor diameter at least 25 mm) with planned partial tumor removal followed by GKS for functional preservation. The median maximum diameter of the tumors was 32.5 mm (range 25–52 mm). All patients underwent surgery via the retrosigmoid approach, and tumors situated on the ventral and in the internal auditory canal intentionally were not removed, thus preserving cranial nerve functions. GKS was performed 1–12 months after surgical resection (median interval 3 months). The median tumor volume at GKS was 3.3 cm³ (range 0.4–10.4 cm³) and the median prescribed dose was 12 Gy (range 10–12 Gy). The median follow-up period after GKS was 65 months (18–156 months).
At the final follow-up, facial nerve preservation (House-Brackmann grade I–II) was achieved in 38 patients (95%; House-Brackmann grade I: 92.5%, II: 2.5%). Among the 14 patients with preoperative pure tone average (PTA) less than 50 dB, 6 of them (42.9%) maintained PTA less than 50 dB at the last follow-up. Two patients improved from severe hearing loss to PTA less than 50 dB (1 patient after surgery and 1 patient one and half years after GKS). Five- and 10-year tumor growth control occurred in 86% of patients. Four patients (10%) required salvage surgery; the predictive factor was tumor volume greater than 6 cm³ at GKS (P = 0.01).
Planned partial removal of large VS followed by GKS achieved a high rate of facial nerve and hearing preservation. To achieve long-term tumor growth control, the tumor volume at GKS after planned partial surgical resection should be smaller than 6 cm³. Our results revealed that patients with hearing preservation postoperatively have a chance of maintaining hearing function, even though the possibility exists of deterioration by long-term follow-up after surgical intervention and GKS. Furthermore, some patients with severe hearing loss before treatment have the chance of hearing improvement, even those with large VS.
Recurrent brain abscess induced by pulmonary arteriovenous fistula
2011, Journal of Infection and Chemotherapy
Brain abscess associated with an arteriovenous fistula (AVF) is sometimes difficult to diagnose and tends to recur. We report a case of recurrent brain abscess due to a pulmonary AVF (PAVF). A 69-year-old woman with a mass in the left cerebral peduncle had taken a progressively worse and shown decorticate rigidity. After an intravenous antibiotic for fever of unknown origin was changed, her condition gradually improved. She was discharged with the help of a cane. Thirty-one months later, she suffered left hemiparesis. Magnetic resonance imaging revealed a cystic mass in the right lateral frontal lobe. At surgery, we confirmed pus in the cyst. A PAVF was detected and was treated with coil embolization. The left hemiparesis improved and the postoperative course was uneventful. Exhaustive study is absolutely necessary to detect the etiology of recurrent brain abscess and to achieve a cure.
Brainstem abscess caused by Haemophilus influenza and Peptostreptococcus species
2011, Journal of Clinical Neuroscience
Citation Excerpt :
After excluding the items published before 1984, a total of 35 articles on the relevant topic of solitary brainstem abscess were accepted for this review. The results have been presented in Supplementary Tables 1 and 2.8–42 Overall, 39 patients with solitary brainstem abcesses were reported in 35 articles.
We present a patient with a solitary brainstem abscess caused by Haemophilus influenza type b (Hib) and Peptostreptococcus species. This is the first report of a Hib brainstem abscess in the English literature. Hib has been mainly associated with respiratory or nasal infections, and a few cases of intracerebral abscesses, but no brainstem abscesses have been described. The literature on solitary brainstem abscesses was reviewed and an overview of the literature between January 1984 and May 2009 is presented.
Pediatric brainstem abscess successfully treated with stereotactic aspiration: illustrative case
2023, Journal of Neurosurgery: Case Lessons
Microsurgical anatomy of safe entry zones on the ventrolateral brainstem: a morphometric study
2022, Neurosurgical Review
Microsurgical Anatomy of Safe Entry Zones on the Ventrolateral Brainstem: A Morphometric Study
2021, Research Square

View all citing articles on Scopus

View full text

InfectionsSuccessful treatment of brainstem abscess with stereotactic aspiration

Abstract

Section snippets

Case report

Discussion

Surg Neurol

Surg Neurol

Clin Neurol Neurosurg

Surg Neurol

Stereotaxic suboccipital transcerebellar biopsy of pontine mass lesions

J Neurosurg

Diagnosis of brainstem abscess in the cerebritis stage by magnetic resonance imaging

Neurol Med Chir (Tokyo)

Pyogenic abscess of the medulla oblongata

Neurosurgery

Brain–stem abscess in childhoodcase report

J Neurosurg

Cure of a man with solitary abscess of the brain-stem

J Neurol

Cure of a solitary brainstem abscess with antibiotic therapycase report

Neurology

Resolution of a brainstem abscess through antituberculous therapy

Neurology

Brainstem abscess and the syndrome of acute tegmental encephalitis

Ann Neurol

Diagnosis and treatment of brainstem abscess using magnetic resonance imaging and microsurgical aspirationcase report

Neurol Med Chir (Tokyo)

Infections
Successful treatment of brainstem abscess with stereotactic aspiration