Intracranial Abscess Formation Research Articles

Pott's Puffy Tumor: aneed for interdisciplinary diagnosis and treatment. German Version

Der Pott-Puffy-Tumor (PPT) stellt als bakterielle Infektion des Sinus frontalis mit subperiostaler und intrakranieller Abszessbildung eine seltene Erkrankung in der Pädiatrie dar. Nachfolgend präsentieren wir vier Fälle eines PPT, die bei zwei Kindern (6 und 9 Jahre) und bei zwei jungen Erwachsenen (17 und 19 Jahre) auftraten. Alle Patienten wurden interdisziplinär von einem Team aus Neurochirurgie, Pädiatrie, HNO-Heilkunde, Neuroradiologie und Mikrobiologie betreut. Die Antibiotikabehandlung wurde in einem Fall mit einer endoskopischen Nasennebenhöhlenoperation (FESS) und in den anderen drei Fällen zusätzlich mit einem offenen transkraniellen Zugang zur Drainage der intrakraniellen Abszessbildung kombiniert. Da der PPT im Kindesalter mit dem Befund einer intrakraniellen Abszessbildung einhergehen kann, ist eine enge interdisziplinäre Zusammenarbeit für eine erfolgreiche Behandlung dieser seltenen Erkrankung erforderlich.

Pott's puffy tumor: aneed for interdisciplinary diagnosis and treatment.

Pott’s puffy tumor (PPT) is an infection of the frontal sinus with subperiosteal and intracranial abscess formation and one of the rare entities in pediatrics. We present a series of four cases of PPT that occurred in two children (6 and 9 years) and in two young adults (17 and 19 years). All patients were treated by an interdisciplinary team of pediatric, neurosurgical, ENT, radiological, and neuroradiological specialists. Antibiotic treatment was combined with single endoscopic surgery in one case and combined endoscopic sinus surgery with an open transcranial approach to drain intracranial abscess formation in three cases. It is important to be aware that PPT occurs in children with the finding of intracranial abscess formation. Therefore, a close interdisciplinary cooperation for successful treatment is needed in this rare disease.

Single Layer and Double Layer Duraplasty for the Management of Persistent Cerebrospinal Fluid Rhinorrhea Following Frontal Sinus Trauma: A Retrospective Study.

Persistent cerebrospinal fluid (CSF) rhinorrhea is an infrequent complication of frontal sinus trauma. It often require craniotomy for dural repair and obliteration of sinus with well vascularized pericranial flap. The multilayer vascularized techniques have gained popularity over the years owing to low rate of postoperative CSF leaks. The study retrospectively analyzed 25 frontal sinus trauma patients (20 males, 5 females) of mean age 32 ± 10.23 years with persistent CSF rhinorrhea from January 2011 to December 2018. All patients underwent frontal craniotomy and duraplasty was done with pericranial flap alone in 14 patients (Group I) and in combination with fascia lata graft in 11 patients (Group II). The clinical outcomes of single and double layer dural reconstruction techniques in management of CSF leak were analyzed. The size of defects ranged between 3 to 28 mm. Significant association was present between defect size and reconstruction technique with large defects underwent double layer repair. Two patients developed CSF leak following repair with pericranial flap alone. The rate of successful closure of CSF fistula was 100% with double layer reconstruction technique. However, statistically no significant association was noted between postoperative CSF leak and reconstruction technique. There was no evidence of meningitis, subdural hematoma, intracranial abscess, and mucocele formation in all patients during follow-up of 50.7 ± 23.6 months. To conclude, pericranial flap is a reliable reconstruction material for management of post traumatic frontal sinus CSF leaks. Dual flap technique that combine the use of fascia lata provides comprehensive solution of CSF fistula repair.

Intracranial abscess formation in an adult alpaca: a case report

BackgroundIntracranial abscess formation is an extremely rare and sporadically documented disease in South American Camelids (SACs). Herein we report the first case of otogenic brain abscess formation in this species.Case presentationA 4 years old female alpaca was presented to our veterinary hospital with a 6 month history of neurologic disorder symptoms, mainly head tilt to the right and emaciation. A comprehensive workup (ultrasound and computed tomography) revealed irreversible cranial nerve abnormalities, extensive lesions in the region of external, middle and internal right ear including destruction of bony structures (tympanic bulla, parts of temporal bone) and severe brain deformation caused by an intracranial abscess. The lesion was up to 6x7x4 cm and occupying almost 40% of the cranial cavity. No pathological findings were evident in other organs or structures. The late referral of the alpaca at this advanced stage of destructive disease precluded surgical intervention.ConclusionsThis case report describes the clinical signs, diagnostic procedures and pathological findings in an adult female alpaca suffering from cranial nerve abnormalities caused by a massive otogenic brain abscess. Camelids suffering from otitis may not present with clinical signs until the pathology is severe. The importance of considering intracranial abscess formation as differential diagnosis in SACs showing the merest hint of nerve deficits cannot be emphasized enough in order to diagnose such pathological processes at an early and treatable stage.

Prevotella melaninogenica Meningitis and Abscess: A Complication of the Removal of a Midline Dermoid Cyst

Abstract Prevotella species are gram-negative anaerobic commensal bacteria of the oropharynx, which frequently cause periodontal disease but are otherwise rarely implicated in serious bacterial infections. Cranial dermoid cysts are benign neoplasms that grow along the planes of the embryonic neural tube closure. In infants, they most commonly present in frontal locations, including periorbital, nasal, and within the anterior fontanelle. Although dermoid cysts are slow growing, usually uncomplicated, and easily treated definitively with surgical excision, cranial cysts located on the midline are associated with a higher risk for persistent dermal sinus tract with intracranial extension of the tumor. We describe a case of a 10-month-old male patient with an occipital midline dermoid cyst with intracranial extension, infected with Prevotella melaninogenica, and complicated by intracranial abscess formation and meningitis.This case highlights two unusual disease entities: the uncommon occipital location of a dermoid cyst, and complications of that cyst caused by a serious bacterial infection with a normal oral flora. We discuss the recommendation for neuroimaging prior to surgical excision of a midline dermoid cyst, given the risk for dermal sinus tract with intracranial communication. We also discuss potential mechanisms for bacterial inoculation of this cyst with Prevotella melaninogenica. This pathogen has not previously been reported as a complication of dermoid cysts.

Preoperative external tissue expansion for complex cranial reconstructions.

OBJECTIVE Reconstruction of large solitary cranial defects after multiple craniotomies is challenging because scalp contraction generally requires more than simple subcutaneous undermining to ensure effective and cosmetically appealing closure. In plastic and reconstructive surgery, soft tissue expansion is considered the gold standard for reconstructing scalp defects; however, these techniques are not well known nor are they routinely practiced among neurosurgeons. The authors here describe a simple external tissue expansion technique that is associated with low morbidity and results in high cosmetic satisfaction among patients. METHODS The authors reviewed the medical records of patients with large cranial defects (> 5 cm) following multiple complicated craniotomies who had undergone reconstructive cranioplasty with preoperative tissue expansion using the DermaClose RC device. In addition to gathering data on patient age, sex, primary pathology, number of craniotomies and/or craniectomies, history of radiation therapy, and duration of external scalp tissue expansion, the authors screened patient charts for cerebrospinal fluid (CSF) leak, meningitis, intracranial abscess formation, dermatitis, and patient satisfaction rates. RESULTS The 6 identified patients (5 female, 1 male) had an age range from 36 to 70 years. All patients had complicating factors such as recalcitrant scalp infections after multiple craniotomies or cranial radiation, which led to secondary scalp tissue scarring and retraction. All patients were deemed to be potential candidates for rotational flaps with or without skin grafts. All patients underwent the same preoperative tissue expansion followed by standard cranial bone reconstruction. None of the patients developed CSF leak, meningitis, intracranial abscess, dermatitis, or permanent cosmetic defects. None of the patients required a reoperation. Mean follow-up was 117 days. CONCLUSIONS Preoperative scalp tissue expansion with the DermaClose RC device allows for simple and reliable completion of complicated cranial reconstruction with low morbidity rates and high cosmetic satisfaction among patients.

Intracranial abscess in Ectopia Cordis

We present a case of intracranial abscess in a young female with Ectopia Cordis, an exceptionally rare cardiac condition. The neurosurgical implication is the predisposition to intracranial abscess formation. A heightened awareness of this association will aid diagnosis in similar clinical scenarios.

Secondary brain abscess following simple renal cyst infection: a case report

BackgroundEscherichia coli (E. coli) is the most common causative bacteria of neonatal meningitis, but hematogenous intracranial E. coli infection is rare in adults. Moreover, intracranial abscess formation owing to E. coli, including brain abscesses and subdural empyema formation, is extremely rare. We herein present a case involving a patient with a brain abscess owing to E. coli following a simple renal cyst infection. A review of the literature is also presented.Case presentationA 77-year-old Japanese woman with a history of polymyalgia rheumatica was admitted to our hospital because of persistent fever, right flank pain, and pyuria. Intravenous antibiotics were administered; however, her level of consciousness deteriorated 6 days after admission. Contrast-enhanced magnetic resonance imaging showed a brain abscess in the left occipital lobe and pyogenic ventriculitis. Enhanced abdominal computed tomography revealed a right renal cyst with heterogeneous content. Culture of urine, blood, and aspirated pus from the infected cyst revealed E. coli with identical antibiotic sensitivity in all sites, suggesting that the cyst infection and subsequent bacteremia might have caused the brain abscess. The patient recovered after a 6-week course of meropenem.ConclusionThe prognosis of patients with E. coli-associated intracranial abscess is usually poor. Advanced age and immunosuppression may be potent risk factors for intracranial abscess formation owing to the hematogenous spread of E. coli.

Intracranial Abscess from Acute Sinusitis without Craniotomy

Objective: To evaluate the success of treatment of intracranial abscess occurring from acute sinus disease without utilizing craniotomy. Method: Retrospective chart review based at a tertiarty care children’s medical center. Children were evaluated from 1995 to 2010 with intracranial abscess formation from acute sinusitis. The main outcome measures were treatment modalities for acute intracranial and sinus disease. Results: Twenty-five children were evaluated from 1995 to 2010 with acute sinusitis resulting in brain abscesses. Over the first 10 years, 15 were treated successfully with an intracranial procedure and sinus surgery. Over the past 5 years, 10 cases of intracranial abscess were encountered, with 5 out of 10 treated successfully without the need for craniotomy. 4 out of 5 had small epidural abscesses treated with endoscopic sinus surgery and intravenous antibiotic, and 1 out of 5 had a small epidural and subdural abscess treated with medical therapy alone. Conclusion: Medical management of intracranial abscess along with medical or surgical treatment of acute sinusitis may be a viable option for certain children with small epidural abscesses caused by acute sinusitis.

Orbital and intracranial complications after acute rhinosinusitis

BACKGROUND/OBJECTIVES: Nowadays, intracranial abscess is a rare complication of acute rhinosinusitis. The consequent orbital and intracranial complications of acute rhinosinusitis are rare but must be mutually excluded in complicated rhinosinusitis even when proper surgical and medical treatment tend to efficiently heal the orbital complication. METHODS: We report a case of a patient who primarily revealed symptoms of orbitocellulitis as a complication of odontogenous rhinosinusitis. Proper diagnostic and therapeutical measures were undertaken to manage the disease immediately after stationary admission. RESULTS: Two weeks after an inconspicuous healing period, hemiparesis due to formation of an intracranial abscess developed. An emergent situation reveals which was unusual to the clinical situation. CONCLUSION: The possible role of underlying mechanisms of intracranial abscess formation is discussed and review of literature concerning orbital and intracranial rhinosinusitis complications is performed. The correct indication of imaging methods and accurate evaluation of diminutive symptoms are essential. We assume that performance of a complementary CT of the brain or MRI even when previous CT scan of the orbit/paranasal sinuses reveals no cerebral pathology should be done to avoid or minimize future patients with consecutive orbital and intracranial complications of acute rhinosinusitis.

Orbital and intracranial complications after acute rhinosinusitis

Background/objectives: Nowadays, intracranial abscess is a rare complication of acute rhinosinusitis. The consequent orbital and intracranial complications of acute rhinosinusitis are rare but must be mutually excluded in complicated rhinosinusitis even when proper surgical and medical treatment tend to efficiently heal the orbital complication. Methods: We report a case of a patient who primarily revealed symptoms of orbitocellulitis as a complication of odontogenous rhinosinusitis. Proper diagnostic and therapeutical measures were undertaken to manage the disease immediately after stationary admission. Results: Two weeks after an inconspicuous healing period, hemiparesis due to formation of an intracranial abscess developed. An emergent situation reveals which was unusual to the clinical situation. Conclusion: The possible role of underlying mechanisms of intracranial abscess formation is discussed and review of literature concerning orbital and intracranial rhinosinusitis complications is performed. The correct indication of imaging methods and accurate evaluation of diminutive symptoms are essential. We assume that performance of a complementary CT of the brain or MRI even when previous CT scan of the orbit/paranasal sinuses reveals no cerebral pathology should be done to avoid or minimize future patients with consecutive orbital and intracranial complications of acute rhinosinusitis.

Temporal Lobe Abscess in a Patient With Isolated Fungal Sphenoiditis

Pathology References Isolated sphenoid sinusitis accounts for 2-3% of all sinus infections evaluated by radiologic imaging. Fungal sphenoiditis is present in approximately 5% of isolated sphenoiditis. The most common presenting symptom is frontal/retro-orbital headache; this occurs in roughly 70% of cases. Nasal obstruction is the next most common symptom presenting in 30% of cases. Noninvasive fungal sphenoid sinusitis rarely presents with serious complications. However, diplopia and/or transient vision loss have been the most severe reported complications and have been seen in up to 3% of cases. Intracranial extension and cerebral abscess is another serious complication of fungal sphenoiditis, and to our knowledge has not been reported until now. Intracranial extension from sinusitis is a rare but potentially fatal disease characterized by bony erosion of the skull base and fungal extension into the adjacent cavities, such as the orbit or cranial vault. It is usually associated with acute fulminant invasive fungal sinusitis (AFIFS) in the immunocompromised population, such as patients who have undergone hematopoietic stem cell transplantation or solid organ transplant, those with HIV/AIDS or diabetes mellitus, or those who are undergoing treatment with chemotherapy or immunosuppressants.3, 4 However, this complication has now been shown to very rarely occur in immunocompetent individuals as well, and seems to be increasing in frequency in this population.4-7 Of the approximately twenty pathogenic fungi, the three most common fungal infections in the nasal sinuses are the opportunistic genera of Aspergillus, Mucor, and Candida, of which Aspergillus is the most prevalent organism.1, 8 While rare, each of these can invade the adjacent structures, with Mucor being the most invasive and requiring the most aggressive surgical treatments. Intracranial extension and abscess formation most commonly occurs from the frontal sinus to the frontal and frontoparietal areas of the brain. 4 The rarest occurrence of invasive fungal sinusitis is seen in the sphenoid sinus, due to only 2.7% of all sinus infections occurring there.9 The rarity of this infection in comparison to other sinuses is because of both the anatomical orientation of the sphenoid sinus receiving little directed airflow, and because the sinus mucosa is lined by relatively few glands, producing less mucus to serve as a reservoir for infection.10 When invasion does occur from the sphenoid sinus, it can occur through one of two mechanisms: retrograde thrombophlebitis through diploic veins of the skull, or by direct extension through normal anatomic pathways or wall erosion.11 The fungus can either enter the frontoparietal areas of the brain similar to extension from the frontal and ethmoid sinuses, or it can extend into the cavernous sinus, causing visual defects secondary to destruction of cranial nerves III, IV, V, and VI. Another potential site of invasion is the temporal lobe, which has rarely been documented.10, 11 Case Report

Intracranial abscess after anterior skull base defect: does pneumocephalus play a role?

Intracranial complications of skull base defects are uncommon; however, they can be devastating when they do occur. Often these complications arise suddenly and without warning. Identifying patients at risk for intracranial abscesses may help with early diagnosis and allow for early interventions. We report on 2 patients with traumatic pneumocephalus who developed intracranial abscesses. Our objective was to evaluate these cases and investigate the relationship between the presence of pneumocephalus and the formation of intracranial infection. Data was reviewed on the cases of 2 patients who developed intracranial abscesses after pneumocephalus in the context of skull base defects. Two patients presented to our institution separately with the presence of intracranial abscesses. Both patients had violation of their anterior skull base--one from endoscopic sinus surgery, one from blunt trauma. Both patients had massive pneumocephalus prior to their abscess formation. Intracranial abscess formation, traumatic skull base defects, and massive pneumocephalus are uncommon entities, which may be associated. It may be prudent to have heightened suspicion for the presence of intracranial abscess formation in patients with massive pneumocephalus secondary to anterior skull base trauma.

Skull Base Osteomyelitis

Skull base osteomyelitis may develop as a complication of paranasal sinusitis or other regional infectious process or as an unfortunate sequelae of iatrogenic injury or trauma. Afflicted patients generally have some form of systemic immunocompromise, most often diabetes, or a history of external beam radiotherapy for a head and neck malignancy with the radiation portal encompassing the area of the skull base. Before the era of systemic antimicrobial therapy, skull base osteomyelitis was almost universally fatal. Acute osteomyelitis often results in rapid lytic destruction of the skull base bone commonly associated with cranial nerve palsy/paralysis, and rarely, with craniovertebral instability and intracranial abscess formation. It may or may not be associated with a deep fascial, orbital or intracranial soft tissue component. Chronic osteomyelitis, as seen in granulomatous conditions, is often much more indolent and slowly progressive. Patients may still exhibit cranial nerve palsies, albeit usually more slowly. As such, they are often able to compensate for these losses over time and hence often delay their clinical presentation. In contradistinction to malignant otitis externa (otologic skull base osteomyelitis), nonotologic skull base osteomyelitis may pose a significant diagnostic clinical challenge. There are no pathognomic findings on clinical or radiographic examination which confirm skull base osteomyelitis. Tissue diagnosis is the key to both diagnosis and management of this rare entity. Preoperative CT or MRI-guided fine needle aspiration of accessible lesions is warranted for all skull base lesions. Unfortunately, this is not feasible in many cases due to inaccessibility. Thus, advanced open and/or endoscopic craniofacial approaches are required to allow for safe exposure of the affected areas. Preoperatively, it may not be possible to differentiate infectious from neoplastic entities that can present in a similar fashion. Once access has been achieved, confirmatory biopsy should be sent for pathologic analysis. If osteomyelitis is confirmed, then aggressive surgical debridement of grossly affected bone, preserving neurovascular anatomy whenever possible, followed by culturedriven systemic antibiotic therapy (generally for 6 weeks) is the mainstay of treatment. Initial or suspected nonotologic osteomyelitis should be treated empirically to provide coverage for Staphylococcus aureus. This is in contradistinction again to otologic osteomyelitis where empiric coverage for Pseudomonas aeruginosa should be provided. Cultures should always be sent to evaluate for possible fungal and tuberculosis pathologies as well. Serial gallium scans may be useful to follow these patients postoperatively as a marker of response to treatment. Serial CT and MRI scanning seems to be less useful in this regard. With aggressive surgical debridement facilitated by the broad exposure provided by modern craniofacial approaches, followed by tissue-guided systemic antimicrobial therapy, one can anticipate resolution of the progressive radiographic findings, and often times, note reversal or improvement of neural deficits (especially those of recent onset). Refractory cases and those arising in a radiated field may benefit from the adjunctive use of hyperbaric oxygen therapy (minimum of 30 dives). The major difficulty encountered by the clinician treating this patient population remains that of establishing a sound diagnosis and differentiating this lesion from a neoplastic process.

Computer-assisted image-guided surgery in pediatric skull-base procedures

Skull-base surgery is characterized by the variety of important neural and vascular structures within a narrow operating field. Although preoperative imaging by computed tomography (CT) and magnetic resonance imaging (MRI) and the use of microsurgical techniques have improved intraoperative orientation, a large number of complications still are caused by localization problems. Especially in pediatric skull-base surgery, maximum localization accuracy during surgery is required. The authors developed a localizing system based on tomographic imaging (such as CT or MRI) to achieve safer surgery by providing highly accurate location information. The preliminary successful experience in the use of the Aachen computer-assisted surgery device for pediatric skull-base surgery (14 cases) is presented. Indications include juvenile angiofibroma of the nasopharynx, infectious and tumorous diseases of the paranasal sinuses, orbital tumors, foreign bodies, and intracranial abscess formation.

Intracranial Complications of Sinusitis in Childhood

Complications of sinusitis in children, such as intracranial abscess formation, are uncommon and are often clinically unremarkable in comparison to similar disease processes in adults. Between 1983 and 1991, 443 children were admitted to Children's National Medical Center in Washington, DC, for treatment of sinusitis. Fourteen of these children presented with intracranial extension of the infection and abscess formation. A retrospective review of these patients revealed that the risk of developing an intracranial abscess secondary to sinusitis was 3%. The management of these patients included surgical drainage of the infected sinuses and intracranial surgical exploration. Cranialization and exenteration of the frontal sinus proved to be effective single-stage procedures. While not indicated in all patients, these procedures eliminated the sinus as a source of continued or potential infection and obviated the need for a second obliterative procedure. Combined antimicrobial therapy and surgical drainage should be the management protocol.

Benign nasal polyposis presenting as an intracranial mass: Case report

An interesting case of benign nasal polyposis with intracranial extension and subsequent abscess formation is described. Its diagnosis and treatment are presented and the pathology is demonstrated. The literature related to this rare disease process is discussed in detail.

Oral presentation of toxic epidermal necrolysis

According to Kruger, infection spreading from the mandible can find a pathway to the temporal region. Malan and the authors of this article agree with Kruger. The infection may penetrate the periosteum lingually, superior to the mylohyoid muscle, and may be located next to the lingual nerve in the infratemporal fossa. The infection may easily escape from the infratemporal fossa, pass through the mandibular notch, and drain into the temporal fossa to perforate the temporal fascia and skin. A sinus tract thus could be formed. This may have been the pathogenesis of the sinus tracts in patients 2 and 3. Patient I had undergone various surgical procedures, and their probable distortion of the normal anatomy could have made it easier for sinus tracts to form. Extended infections can lead to serious complications such as intracranial infection and abscess formation! Infection of dental origin can also be 59

The Clinical Presentation of Intracranial Abscesses

A retrospective case note survey of 67 surgically proven cases of intracranial abscess formation has been carried out. Males predominated, especially in the third decade. Only 15 per cent had a predisposing condition such as cyanotic heart disease though the majority had some evidence of a systemic infection or fever. A peripheral leucocytosis and elevated erythrocyte sedimentation rate (ESR) were also more frequently encountered than in a comparable group of cases of cerebral tumour. Despite these pointers to an infective process the correct diagnosis was commonly not considered on admission. Headache, vomiting, drowsiness and focal symptoms sometimes accompanied by focal or generalized seizures remain the classical features in the history, with papilloedema and focal signs commonly found in a drowsy ill-looking patient. Many individuals failed to show all these features however. The progressive nature of the clinical picture should itself be enough to prompt urgent referral for investigation, electro-encephalography, nuclear scanning and CT scanning all being reliable.

Post neurosurgery Gram-negative bacillary meningitis

The findings of a retrospective analysis of 20 patients who developed Gram-negative bacillary meningitis (GNBM) following neurosurgery are reported. The predisposing causes included surgery for skull fracture or cerebral contusion (9 patients), neoplasm (6) and vascular disease (2). Nine of the patients (45 per cent) had a cerebrospinal fluid (CSF) leak from a fistula. The organisms isolated, which included Pseudomonas aeruginosa (6), Klebsiella spp. (5) and Escherichia coli (4), had, in 75 per cent of cases, been isolated from other sites prior to the onset of GNBM. Initial diagnosis was achieved by Gram-stain of CSF in 15 of 19 cases (78 per cent). Culture of lumbar CSF was positive in 19 of the patients (95 per cent) and concommittant ventriculitis was confirmed by positive culture of ventricular CSF in 10 of 11 cases (91 per cent) from whom it was obtained. The overall mortality was 80 per cent, 11 patients dying of causes directly related to GNBM. Eradication of the infecting organism from CSF was achieved in 79 per cent of patients receiving intraventricular aminoglycoside therapy, but in only 40 per cent of those receiving intralumbar therapy. Deaths in the latter group were associated with ventriculitis whereas those in patients receiving intraventricular therapy resulted from intracranial abscess formation. These findings, plus the observation of chloramphenicol resistance in 80 per cent of the isolates, suggest that systemic and intraventricular aminoglycoside administration is indicated in patients with post-neurosurgical GNBM.