From Sound to Silence: Cerebellar Abscesses and Herniation Due to Cochlear Implant Infection With Escherichia coli and Bacteroides fragilis

This paper is a study of the localizing ophthalmic phenomena disclosed in the cases of intradural suppuration, verified by operation or autopsy, which have come under my care since I have appreciated the importance of repeated examinations of the visual fields. It refers only to those patients whose mental condition at the time of the examination allowed sufficient cooperation to determine properly their visual defects and oculomotor abnormalities. It includes a total of thirteen abscesses in twelve cases, with seven recoveries, as follows: six cerebellar abscesses, with four recoveries and two deaths (one cerebellar abscess being associated with subdural suppuration, with death); five temporosphenoidal lobe abscesses with two recoveries (one with a complicating streptococcus meningitis), and three deaths; one case of combined cerebellar and temporosphenoidal lobe abscess with recovery. It also includes two cases of bulbar cisterna meningitis with death in each, and four cases of edema of the brain

Brain abscess due to Nocardia is a rare condition, usually found in immunosuppressed patients, and previous reports have shown its occurrence mostly in the supratentorial compartment. We have analysed a case of cerebellar Nocardial abscess mimicking an ischaemic stroke with a review of the literature. A case report of a patient with a cerebellar abscess and a literature review were sourced from PubMed from 1990 to the present. We present a case of an elderly patient with chronic myeloid leukaemia (post-imatinib in remission) with nephrotic syndrome presenting with symptoms suggestive of ischaemic stroke. Brain magnetic resonance imaging showed a large loculated cystic lesion in the right cerebellar hemisphere with a mass effect. He underwent surgery, and a pus culture grew Nocardia farcinica, which was sensitive to linezolid and resistant to imipenem. Early diagnosis and appropriate therapy contributed to a successful outcome, as this was a rare case of posterior fossa abscess mimicking ischaemic stroke.

Background This case is reported due to the rarity of immediate postoperative brain herniation following spinal surgery, a potentially catastrophic complication. It highlights the need for heightened awareness of intracranial hemorrhage (ICH) as a rare but severe complication after spinal surgery, which is usually considered routine. To the best of our knowledge, this represents the first reported case of brain herniation occurring immediately postoperatively. We aim to underscore the significance of this potentially catastrophic complication associated with a procedure that is otherwise considered routine. Case presentation A 60-year-old man with a history of hypertension and cervical spondylosis underwent decompression surgery for lumbar spinal stenosis. Intraoperatively, an accidental dural tear occurred during laminectomy, leading to cerebrospinal fluid (CSF) leakage of approximately 100 mL. The surgery lasted about 5.5 h, with stable vital signs. Fifteen minutes postoperatively, the patient could not be awakened. After around 2 h, both pupils were slightly larger than normal. A cranial CT scan one hour and 30 min later revealed an extensive left hemispheric subdural hematoma (SDH) and brain herniation; the estimated blood loss was approximately 75 mL. Due to financial constraints, the patient’s family refused surgical intervention. Despite supportive treatment in the ICU, the patient’s condition worsened, and he passed away 7 days after discharge against medical advice. Conclusion This case underscores the potential risk of SDH and brain herniation due to significant CSF leakage in patients undergoing spinal surgery. It emphasizes the importance of thorough preoperative evaluation, careful intraoperative management of dural tears and CSF leakage, and immediate postoperative neurological assessment. Anesthesiologists, surgeons, and nursing staff should be vigilant about such rare complications to provide safer and more effective care. The case also highlights the challenge of treatment refusal due to financial constraints, suggesting the need for incorporating the management of rare complications into national policy frameworks.

Acute intraoperative cerebral herniation is catastrophic in craniotomy and seriously affects the outcomes of surgery and the prognosis of the patient. Although the probability of its occurrence is low, it can lead to severe disability and high mortality. We describe a rare case of intraoperative cerebral herniation that occurred in a syphilis-positive patient. The patient was diagnosed with both glioma and syphilis. When the glioma was completely removed under the surgical microscope, acute cerebral herniation occurred. An urgent intervention in cerebral herniation identified a collection of colorless, transparent, and protein-rich gelatinous substances rather than a hematoma, which is a more commonly reported cause of intraoperative cerebral herniation in the literature. We have found no previous descriptions of such cerebral herniation during craniotomy in a patient with syphilis and glioma. We suspected that the occurrence of intraoperative cerebral hernia might be related to the patient's infection with syphilis. We considered the likelihood of an intraoperative cerebral herniation to be elevated when a patient had a disease similar to syphilis that could cause increased vascular permeability.

Cerebellar abscess is a serious complication of ear disease. In the present report, a case of cerebellar abscess and thrombosis of the sigmoid sinus, secondary to chronic otitis media is described. A 25-year-old male presented with clinical features suggestive of chronic suppurative otitis media. The patient hospitalized for operation. In postoperative third day the patient began to complain about headache. The patient suddenly began to lose his balance while walking and had difficulty in talking. MRI revealed that there was a cerebellar abscess and operated him for the cerebellar abscess. After 6 weeks antibiotherapy the patient discharged from the hospital as cured. As seen in the literature review; most of the patients having thrombosis of the sigmoid sinus and cerebellar abscess together have showed the symptoms of cerebellar abscess. However, the symptoms of thrombosis of the sigmoid sinus were more prominent than cerebellar abscess in our case unlike many others in the literature.

Background: Posterior fossa dermoid cysts are rare, benign lesions whose diagnosis can be quite challenging because of their slow growth and subsequent paucity of symptoms. We present herein an unusual case of recurrent cerebellar abscesses induced by an adjacent extradural dermoid cyst with a complete occipital dermal sinus. Methods: The authors report the case of a 20-month-old girl who presented with signs of acutely raised intracranial pressure and whose head scans showed a left cerebellar hemisphere abscess associated with obstructive hydrocephalus. The patient was treated initially with an external ventricular drain, followed by burr-hole aspiration of the abscess and long-term antibiotics. Since the cerebellar abscess recurred, a posterior fossa craniotomy was performed and gross total resection of the lesion along with the dermal sinus tract and abscess contents was achieved. Histopathological analysis confirmed a dermoid tumor. Conclusions: The occurrence of recurrent cerebellar abscesses must always rise up the suspicion of an associated dermoid cyst. Neuroradiological scans should be carefully evaluated in search for this lesion. Once the diagnosis is established, radical resection of the cyst, sinus tract and infectious components is the treatment of choice.

Cerebellar abscesses are common neurosurgical emergencies in developing countries, and have a distressingly high mortality rate of 10 to 15% even today. There is still no consensus on the standard approach to these lesions, and controversy persists over whether these lesions should be treated with primary excision or aspiration. The authors retrospectively analyzed 82 cases of cerebellar pyogenic abscesses in children treated at their institution over a period of 10 years. This represents the largest such series being described in literature. All lesions except 1 were otogenic in origin. The clinical and radiological features are discussed. Primary excision was undertaken in 66 patients (80%) and aspiration in 16 patients (20%). Five patients in whom the abscesses were initially treated with aspiration subsequently underwent elective excision. Nine (12.6%) of 71 patients in whom the abscesses were excised had residual abscesses on postoperative imaging; in those who had undergone aspiration as the primary treatment, 6 (54.5%) of 11 patients had recurrent abscesses. There were no deaths among the patients who underwent excision of the abscess. Also, excision of posterior fossa abscesses required fewer repeated procedures with lower recurrence rates, and statistically lower rate of complications. Compared to primary aspiration, the authors found that primary excision is the preferred method for treating cerebellar abscesses.

Sixteen patients with surgical infection of the posterior fossa are presented. There were 14 patients with cerebellar abscess, one patient with a solitary posterior fossa subdural empyema, and another with a combined cerebellar abscess and subdural empyema. Two of the cerebellar abscess patients also had supratentorial infections. The presenting features, aetiology, radiology and bacteriology are discussed with particular reference to differences in abscess re-accumulation, and outcome between those managed by aspiration and excision. We have been unable to show that either method of treatment is superior to the other. An overall mortality rate of 19% was achieved; however, for those with parenchymal cerebellar abscesses this was reduced to 13%. We conclude that burr hole aspiration with regular CT is a satisfactory method of treatment for cerebellar abscess.

Surgical Management of Chronic Suppurative Otitis Media with Intracranial Complications

We report a rare case of cerebellar abscess produced by anaerobic bacteria. A 76-year-old man was admitted to our hospital with a history of fever, vomiting, and dizziness lasting 14 days. Computed tomography(CT)scan and magnetic resonance images showed the presence of a multiloculated cerebellar abscess with a right subdural abscess. The patient underwent aspiration of the abscess through a suboccipital craniotomy. Fusobacterium nucleatum, which is an anaerobic bacteria naturally present in the human oral cavity, was detected in cultures of the aspirated abscess. The patient was administered antibiotic treatment combined with hyperbaric oxygen therapy(HBO). The symptoms were briefly relieved but the cerebellar abscess recurred, which required a second aspiration. The combined treatment with antibiotics and HBO was maintained after the second operation. After 6 weeks of treatment, the cerebellar abscess was completely controlled. We conclude that antibiotic treatment combined with HBO is useful for treatment of cerebellar abscesses caused by infection with anaerobic bacteria.

AimsConventional teaching in neonatology is that open cranial sutures protect newborns from brain herniation secondary to raised intracranial pressure. This case series aims to disseminate observations from a tertiary neonatal...

Objective: We aimed to describe a case of fungal cerebellar abscesses due to Aspergillus in an immunocompetent patient. Methods: This was a case report of a patient who presented at King Abdulaziz University Hospital for management of fungal cerebellar abscess. Results: A 27-year-old Saudi patient presented with signs of cerebellar dysfunction, reduced visual acuity outcome, and hoarseness following medical therapy and neurosurgery for cerebellar aspergillosis. Brain computed tomography and magnetic resonance imaging scans revealed findings that were suggestive of a recurrent or residual abscess. Treatment was initiated with oral corticosteroids and liposomal amphotericin B. Two weeks later, liposomal amphotericin B was substituted for oral voriconazole. An initially planned surgical excision was deferred following the improvement of the patient’s symptoms. Conclusion: Fungal cerebellar abscesses due to Aspergillus are extremely rare, especially in immunocompetent patients. A high index of suspicion coupled with aggressive neurosurgical intervention and medical treatment can lead to a favorable outcome in patients with cerebellar abscesses due to Aspergillus.

In this era of antibiotics the incidence of brain abscess and lateral sinus thrombosis (LST) secondary to chronic suppurative otitis media (CSOM) should not be underestimated and the management still remains a clinical challenge. We review the clinical records of patients who presented with temporal lobe abscess (Case 1), cerebellar and extradural abscess (Case 2) and LST (Case 3) of otogenic origin and discuss the importance of multidisciplinary team approach in the management of these high-risk cases. We review the literature in detail and discuss the epidemiology, clinical presentation, diagnostic modalities, treatment options and controversies in the management of brain abscess and LST.

BackgroundGiant prolactinoma (size > 4 cm) is a rare condition and accounts for less than 1% of pituitary adenomas. In even rarer cases, these lesions may involve craniocervical structures requiring surgical intervention. The present case is the largest reported giant prolactinoma (99 × 72 × 57 mm). It led to cranial settling and significant central herniation at the foramen magnum, causing quadriparesis.Case presentationThe patient was a 39-year-old Iranian man from a village around Hamadan city who presented with quadriparesis and paresthesia as well as loss of libido and impotence. Magnetic resonance imaging and computed tomography showed a huge diffuse avid enhancing infiltrating osteolytic lesion at the skull base. It had spread predominantly extramurally into the skull base resulting in cranial deposition, significant central herniation, myelopathy, and acute exacerbation of quadriparesis. On the basis of the pathology, immunohistochemistry, and elevated serum prolactin levels, the diagnosis of giant prolactinoma was almost definite. In addition to urgent midline suboccipital craniotomy for the central herniation and quadriparesis, he was treated with cabergoline followed by occiput cervical fixation and fusion to control the progressive subsidence.ConclusionProlactinoma that is treatable with dopamine agonists should be considered as a differential diagnosis of skull base lesions, even those that are extradural, diffuse, and infiltrative. Giant prolactinoma can lead to craniocervical settling and central herniation that requires surgery and multidisciplinary management.

This study is a systematic review. Brain death (BD) is a clinical diagnosis, made by documenting absent brainstem functions, including unresponsive coma and apnea. Cervical spinal cord dysfunction would confound clinical diagnosis of BD. Our objective was to determine whether cervical spinal cord dysfunction is common in BD. A case of BD showing cervical cord compression on magnetic resonance imaging prompted a literature review from 1965 to 2008 for any reports of cervical spinal cord injury associated with brain herniation or BD. A total of 12 cases of brain herniation in meningitis occurred shortly after a lumbar puncture with acute respiratory arrest and quadriplegia. In total, nine cases of acute brain herniation from various non-meningitis causes resulted in acute quadriplegia. The cases suggest that direct compression of the cervical spinal cord, or the anterior spinal arteries during cerebellar tonsillar herniation cause ischemic injury to the cord. No case series of brain herniation specifically mentioned spinal cord injury, but many survivors had severe disability including spastic limbs. Only two pathological series of BD examined the spinal cord; 56-100% of cases had upper cervical spinal cord damage, suggesting infarction from direct compression of the cord or its arterial blood supply. Upper cervical spinal cord injury may be common after brain herniation. Cervical spinal cord injury must either be ruled out before clinical testing for BD, or an ancillary test to document lack of brainstem blood flow is required in all cases of suspected BD. BD may not be a purely clinical diagnosis.