Post on 23-Dec-2015
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Neurosurgery Case 2:CNS Neoplasms
3Med – CUST-FMS
58 year-old female
6 mont
hs PTA
•Complained of progressive, on and off headache
•Vague but persistent biparietal headache, relieved by analgesics
1 month PTA
•Difficulty of walking – “dragging left leg”
•Consult – dx: stroke; referred to physiatrist•Metoprolol 50mg
BID•Simvastatin 10mg
OD•Citicholine
500mg OD•Progressive
headache-> nausea, vomiting, blurring of vision
Admission
1 day PTA
• Focal seizures involving left foot progressing to leg, thigh, whole left half body – 5 minutes
• Past Medical History: dx to have migraine• Physical Exam:
– VS: PR 90/min, BP 170/86, RR 18/min, T 37C– Awake and oriented to 3 spheres– Pupils 6mm bilateral, sluggishly reactive to light– Fundoscopy: bilateral haziness of the temporal
aspects of the optic disc with areas of retinal hemorrhages
• Physical Exam:– 6 Nerve palsy L– Shallow L nasolabial fold– Tongue midline in protrusion– Able to do FTNT, APST– L hemiparesis; 3/5 LE weaker than UE– Right: 5/5 UE, 4/5 LE– DTR +++ on left, ++ on right– (+) Babinski L w/ ankle clonus
Primary and SecondaryBrain Tumors
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Primary Brain Tumor
• Arise from CNS tissue• In adults, 2/3 arise from structures above
tentorium• In children, 2/3 arise from structures below
tentorium• Gliomas, metastases, meningiomas, pituitary
adenomas, and acoustic neuromas account for 95% of all brain tumors
Primary Brain Tumor
Frequency• Annual incidence rate: 7-19.1 per 100k• An increase in HIV infection corresponds to an
increase in occurrence of primary CNS lymphoma
Primary Brain Tumors
Mortality/Morbidity• In the US, primary cancers of the CNS were
the cause of death in 13,100 people (1999)• Brain tumors are the 2nd most common cancer
in children – 15-25% of all pediatric malignancies
Primary Brain TumorSex• Meningiomas & pituitary adenomas: M<F• In general, M:F ratio is 1.5:1
Age• Tumors in posterior fossa predominate in preadolescent children, with
the incidence of supratentorial tumors increasing from adolescence to adulthood.
• Low-grade gliomas are more common in younger people than in older people. High-grade gliomas tend to originate in the fourth or fifth decade or beyond.
• In children, brain tumors are the most prevalent solid tumor, second only to leukemia as a cause of pediatric cancer.
Secondary Brain Tumor
• Metastatic tumors are among the most common mass lesions in the brain – can affect brain parenchyma, its covering and the skull
Secondary Brain Tumor
Frequency• Incidence of metastatic brain tumor accounts
for 50% of total brain tumors• Est. 100k new cases are diagnosed per year in
the US
Secondary Brain Tumor
• Mortality/MorbidityPrimary Tumor Site Percentage (%)
Lung 48
Breast 15
Melanoma 9
Lymphoma, mainly NHL 1
GI Tract 3
GU Tract 11
Osteosarcoma 10
Head and Neck 6
Secondary Brain TumorSex• Although melanoma spreads to the brain more commonly in males
than in females, gender does not affect the overall incidence of brain metastases
Age• About 60% of patients are aged 50-70 years.• CNS metastasis accounts for only 6% of CNS tumors in children.• Leukemia accounts for most metastatic CNS lesions in young patients,
followed by lymphoma, osteogenic sarcoma, and rhabdomyosarcoma.• Germ-cell tumors are common in adolescents and young adults aged
15-21 years
General clinical manifestations (focal deficits and irritation, mass effect; supratentoriai vs
infratentorial) of brain tumors
Signs and symptoms of increased ICP and its management
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• Intracranial tumors can cause brain injury from:– Mass effect– Dysfunction or destruction of adjacent neural
structures– Swelling– Abnormal electrical activity (seizures)
Schwartz's Principles of Surgery, 9th edition
SUPRATENTORIAL TUMORS
• Commonly present with focal neurologic deficit, such as:– Contralateral limb weakness– Visual field deficit– Headache– Siezure
Schwartz's Principles of Surgery, 9th edition
INFRATENTORIAL TUMORS
• Often cause increased ICP due to hydrocephalus– From compression of the fourth ventricle
• Leading to:– Headache– Nausea– Vomiting– Diplopia
Schwartz's Principles of Surgery, 9th edition
• Cerebellar hemisphere or brain stem dysfunction can result in:– Ataxia– Nystagmus– Cranial nerve palsies
• Infratentorial tumors rarely cause seizures
Schwartz's Principles of Surgery, 9th edition
RAISED INTRACRANIAL PRESSURE
• ICP normally varies between 4 and 14 mmHg• Sustained ICP levels above 20 mmHg can
injure the brain
Schwartz's Principles of Surgery, 9th edition
SIGNS & SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE (ICP)
* or Intracranial Hypertension (ICH)• Patients with increased ICP often will present
with:– Headache– Nausea– Vomiting– Progressive mental status decline
Schwartz's Principles of Surgery, 9th edition
• Cushing’s Triad is the classic presentation of ICH:– Hypertension– Bradycardia– Irregular respirations
• This triad is usually a late manifestation
Schwartz's Principles of Surgery, 9th edition
• Focal neurologic deficits such as hemiparesis may be present if there is a focal mass lesion causing the problem
• Patients with these symptoms should undergo head CT as soon as possible
Schwartz's Principles of Surgery, 9th edition
MANAGEMENT OF INCREASED INTRACRANIAL PRESSURE (ICP)
• Initial management of ICH includes:– Airway protection– Adequate ventilation
• A bolus of mannitol up to 1g/kg causes:– Free water diuresis– Increased serum osmolality– Extraction of water from the brain
Schwartz's Principles of Surgery, 9th edition
• Cases of ICH typically require rapid neurosurgical evaluation
• For definitive decompression, these may be needed:– Ventriculostomy– Craniotomy– Craniectomy
Schwartz's Principles of Surgery, 9th edition
Recognize specific syndromes; extra-axial and intra-axial inbrain tumor presentation.
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Extra-axial vs. Intra-axial
radiological descriptions: *"extra-axial“--- extrinsic to brain
e.g. meningioma and Schwannoma*"intra-axial“ ---in brain or spinal cord tissue
e.g. astrocytoma and oligodendroglioma
Extra-axial Symptoms*Seizures-common in tumors of the meniniges, the thin covering layers of the brain
and spinal cord. -caused by pressure and compression rather than by growth into brain tissue.
*Some of the possible meningioma symptoms are:- • Vision Blurring • Memory blocks • Seizures • Vomiting • Persistent or severe headaches that occur frequently • Extreme feeling of pressure felt on the inside of the skull • Blind spots at the back of the eye
Extra-axial Symptoms
• Mild to severe ringing in the ears, feeling as if the ears are obstructed
• Hearing loss
Intra-axial SymptomsBrain Stem - the Midbrain, Pons, Medulla Oblongata
Vomiting (usually just after awakening), Clumsy, uncoordinated walk,Muscle weakness on one side of the face causes a one-
sided smile or drooping eyelidDifficulty in swallowing and slurred or nasal speech are
also common.
*Symptoms may develop gradually.
Intra-axial Symptoms
Brain Stem - the Midbrain, Pons, Medulla Oblongata
Double vision with an inability to fully move one or both eyes might occur.
Headache, usually just after awakening, is common. Head tilt, drowsiness, hearing loss and/or
personality changes can also be present.
*Symptoms may develop gradually.
Intra-axial Symptoms
• Cerebellopontine Angle
Ringing or buzzing in the ear. Less often, dizziness might occur. As a tumor grows, deafness, loss of facial
sensation and/or facial weakness can occur.
*Other symptoms are similar to those of a brain stem tumor.
Intra-axial Symptoms
• Frontal Lobe
Tumors in the frontal lobe may initially be "silent." As they grow, they can cause a variety of symptoms including
one-sided paralysis, seizures, short-term memory loss, impaired judgment and personality or mental changes.
Urinary frequency and urgency can develop. Gait disturbances and communication problems are also
common. If the tumor is at the base of the frontal lobe, loss of smell,
impaired vision, and a swollen optic nerve can occur.
Intra-axial Symptoms
• Occipital Lobe
Blindness in one direction or other visual disturbances, and seizures are common symptoms.
Intra-axial Symptoms
Parietal Lobe
Seizures, language disturbances (if a tumor is in the dominant hemisphere) and loss of ability to read are common symptoms.
Spatial disorders, such as difficulty with body orientation in space or recognition of body parts, can also occur.
There may be difficulty knowing left from right and sentences containing comparisons or cross-references may not be understood.
Intra-Axial Symptoms
• Temporal Lobe
Seizures are the most common symptom of a tumor in this location.
The ability to recognize sounds or the source of sounds may be affected.
Vision can be impaired.
Intra-Axial Sypmtoms
• Corpus Callosum
Impaired judgment and defective memory are frequent symptoms of a tumor in the forward part of this area; behavioral changes are common with a tumor in the rear part.
A tumor in the middle of the corpus callosum might cause few, if any, symptoms until it grows quite large.
This tumor might invade other lobes of the cerebral hemispheres and produce symptoms common to tumors in those locations.
Seizures are uncommon.
Intra-Axial Symptoms
• Pineal Region
A tumor in this location causes hydrocephalus with the symptoms of increased intracranial pressure.
Problems with eye movement often occur. In children, hormonal disturbances such as
precocious puberty may occur.
Intra-Axial Symptoms
• Pituitary
A tumor in this gland may cause headache, vision changes, and/or diabetes insipidus (a type of hormone disturbance).
Because these tumors often secrete hormones inappropriately, other symptoms vary depending on the type of hormone secreted.
Breast enlargement and secretion are common.
Intra-Axial Symptoms
• Thalamus Common symptoms of a tumor in the thalamus include
sensory loss such as the sense of touch on the side of the body opposite the side of the tumor;
muscle weakness; decreased intellect; vision problems; speech difficulties; loss of urinary control; headache, nausea and vomitingdifficulties in walking due to the increased pressure caused
by obstructive hydrocephalus.
Intra-Axial Symptoms
• Third Ventricle
Hydrocephalus due to the blockage of cerebrospinal fluid is very common, causing symptoms of increased intracranial pressure.
Leg weakness, fainting spells, impaired memory and hypothalamic dysfunction are frequent symptoms.
Diagnostic tools that are currently used for evaluation
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Lumbar Puncture and CSF examination
• The patient is positioned side-lying, with back vertical on the edge of the bed and knees flexed up to the chest
• Area is prepared with an antiseptic solution and draped
• Insterspinous area is palpated and the skin is injected with lidocaine
• Lumbar puncture is done at the L3-L4 level in between two spinous process, pointed slightly cranially
Lumbar Puncture cont’d
• Needle passes through the interspinous ligament and the dura
• The fluid is drained and sent for examination
Lumbar Puncture cont’d
• Contraindications: increased ICP• Complications: - progression of brain herniation- progression of spinal cord compression- injury to the neural structures- headache- backache- infection—local and meningitis- implantation of epidermoid tumour (rare)
Skull X-ray
• Hyperostosis, eg. Meningioma
Skull X-ray cont’d
• bone erosion due to skull vault tumours• midline shift of the pineal gland—from space
occupying lesion
Skull X-ray cont’d
• abnormal calcification, e.g. tumours such as meningioma, oligodendroglioma, craniopharyngioma or calcified wall of an aneurysm
• signs of long-standing raised intracranial pressure—erosion of the dorsum sellae
Plain X-ray of the Spine
• Preliminary investigations for patients presenting with spinal pain
Things to be noted:• vertebral alignment• presence of degenerative disease with narrowing of the neural
foramina and spinal canal• evidence of metastatic tumour with erosion orsclerosis of the vertebral body, pedicles or lamina• enlargement of a neural foramen indicating aspinal schwannoma• congenital abnormalities such as spina bifida.
CT Scan
• Intro in the 1970s• Scan can be performed in both axial and
coronal planes• Sagittal reconstruction pictures can be obtained
by computer manipulation of the data• The CT scan is the initial investigation of choice
in the investigation of nearly all intracranial diseases
CT scan cont’d• Intracranial lesions that show calcificationon the plain CT scan include:• meningioma—will also show hyperostosis ofcranial vault• most oligodendrogliomasastrocytoma—30% of low-grade tumours but• infrequently in high-grade tumours• ependymoma and subependymoma• craniopharyngioma• wall of giant aneurysm, arteriovenousmalformations- The pineal gland is usually calcified and calcification of the choroid plexus, basal ganglia and falx may occur in normal scans.
CT scan cont’d
CT scan cont’d
• Enhancing lesions on Contrast - High grade cerebral gliomas- meningiomas- acoustic neuromas- large pituitary tumours- metastatic tumours
Contrast enhanced CT-scan
Cerebral angiography
• Angiography of the intra- and extra-vessels can be performed using digital subtraction technique
• Usually done under local anesthesia• The catheter is inserted through the femoral
artery and threaded up into the carotid artery or vertebral artery with the aid of an image intensifier
Cerebral Angiography
The major indications for angiography are:• investigation of cerebral ischaemia due tocarotid artery disease and intracranial atheroma• investigation of subarachnoid haemorrhage, e.g. cerebral aneurysm, arteriovenous malformation• investigation of venous sinus thrombosis• preoperative embolization of meningioma
Myelography
• Can be used in the investigation of spinal disease causing neural compression
• It is an x-ray examination of the skull whereby a contrast agent is injected around the spinal cord to display the spinal cord, spinal canal and nerve roots on X-ray
Myelography
Myelography
• The major indications for myelography were:- cervical disc prolapse- lumbar disc prolapse- spinal tumour- cervical canal stenosis causing cervicalmyelopathy- lumbar canal stenosis
MRI• Uses the magnetic properties of the body’s hydrogen
nuclei to produce a cross sectional image in any plane• How MRI works:1. A strong magnetic field aligns the protons in body within that
field2. Pulses of electromagnetic waves in the right frequency and
bandwidth induces the protons in the body to spin in unison3. External energy is removed and energy from the excited
protons is emitted as a radio signal which is picked up by sensitive antennae
MRI cont’d
MRI cont’d
• T1 – efficient of energy transfer from the protons to the adjacent molecular lattice
• T1 weighted image – shows anatomical structures in detail; CSF appears black
• T2 – rate of signal decay• T2 weighted image – shows intracranial pathologic
process; CSF appears white• FLAIR (fluid attenuation inversion recovery) – heavily
T2 weighted image which has pulse timing so that CSF signal is dulled
MRI cont’d
MRI, or nuclear magnetic resonance, has considerable potential advantages over CT scanning including:- no ionizing radiation- no bone artifact so that lesions around the- skull base are clearly identified- high resolution
PET
• PET utilizes positron-emitting isotopes which depend on a cyclotron for their production and, in general, their short half-life dictates that a cyclotron should be readily available
• Is used to study the biologic activity of brain tumors
PET
Evoked Potentials
• Visual, auditory and somatosensory evoked potential monitoring may be of value in the detection of neurological and neurosurgical diseases as well as providing useful intraoperative monitoring.
• Stimulation of the sensory receptor will evoke a signal in the appropriate region of the cerebral cortex
Biopsy
• Required to definitely diagnose a tumor• Involves removing a piece of the tumor to
view under the microscope• Biopsy is generally performed only for patients
with tumors in critical functional portions of the brain, where surgical removal (resection) would result in unacceptable neurologic injury
Understand the broad treatment strategies in the treatment of tumors
• Surgery• Radiosurgery• Radiation therapy• Chemotherapy
Surgery• The use of manipulative and operative methods• Invasive procedure• May be either open or minimally invasive• Uses:
– In abscesses, for aspiration– In tumors:
• To get a physical sample of the tumor for use in diagnosis • To remove as much of the tumor as possible (“Resection” or
“Debulking”)– May be curative– May relieve pressure from mass effect
Surgery• Pros:
– Able to treat large tumors– Immediate relief of mass effect– Direct removal of mass
• Cons:– Surgical and postsurgical complications
• Risk of damage to nearby structures which may result in neurologic deficit
• Risk of bleeding• Risk of infection• Risk of rupture and/or spread of tumor or abscess• Post surgical pain
Craniotomy• Surgical operation in which a bone flap is
temporarily removed from the skull to access the brain
• Form of open brain surgery• The amount of bone removed depends on the
type of surgery being performed• Usually performed under general anesthesia but
can be also done with the patient awake using a local anaesthetic
• Lesion is directly visualized and is resected
Endoscopic Surgery
• Surgical operation in which an endoscope is used in order to gain access to the brain
• Form of minimally invasive brain surgery• An example is endonasal endoscopy, in which
the nose is used as an access point– Used for pituitary tumors, craniopharyngiomas,
chordomas, and the repair of cerebrospinal fluid leaks
Radiosurgery
• The use of externally applied radiation, under precise mechanical orientation by a specialized apparatus, to directly target the lesion to be treated
• Noninvasive procedure• Uses:
– In tumors:• Treatment of benign and malignant tumors located
either intra or extracranially
Radiosurgery• Pros:
– Healthy tissues around the target lesion is relatively spared– Patients treated in 1 – 5 days as outpatient– Lower risks than surgery– Cheaper than surgery
• Cons:– Risk in treating masses more than 3 cm due to high required
dose of radiation– Does not physically remove tumors, just stops them from
growing• Contraindicated if the lesion presents with mass effects
– The duration of time required to achieve the desired effects is much longer than surgery
Stereotactic Surgery
• A minimally-invasive form of surgical intervention which makes use of a three-dimensional coordinates system to locate small targets inside the body and to perform on them some action such as ablation (removal), biopsy, lesion, injection, stimulation, implantation, radiosurgery (SRS) etc.
• Indicated with both benign and malignant tumors• Most frequently used for metastatic lesions to
the brain
Gamma Knife
• A device used to treat brain tumors with a high dose of radiation therapy in one day.
• Example of a Stereotactic Radiosurgical device• Aims gamma radiation through a target point
in the patient's brain• The patient wears a specialized helmet that is
surgically fixed to their skull so that the brain tumor remains stationary at the target point
Radiation therapy• The medical use of ionizing radiation as part of cancer treatment to
control malignant cells• May be either invasive or noninvasive• The type of radiation therapy most commonly administered to
patients consists of external radiation beams focused on the tumor plus a surrounding margin of normal tissue about 1 inch thick.
• Normally administered 5 days a week for 6 weeks, with each treatment lasting about 15 minutes.
• Source of radiation may be externally or internally applied• Uses:
– In Tumors:• Curative treatment• Adjuvant after another treatment such as surgery to prevent recurrence• Palliative treatment when cure is no longer possible
Radiation therapy• Pros:
– Provides a survival benefit usually on the order of months, and can provide even greater benefit when used as part of an aggressive treatment plan
– Painless procedure– Little to no side effects at low doses– Side effects at higher doses usually limited to area of treatment
• Cons:– Response related to tumor size
• Larger tumors respond less well than smaller tumors– Acute
• Damage to the epithelial surfaces• Swelling• May exacerbate cerebral edema and/or lead to increased ICP
– Chronic• Secondary malignancy• Damage to blood vessels and fibrosis of surrounding tissue• Cognitive decline• Hair loss
External Beam Radiotherapy
• The patient sits or lies on a couch and an external source of radiation is pointed at a particular part of the body.
• The most frequently used form of radiotherapy.
• X-rays are used to treat deep-seated tumors such as those found in the brain
Brachytherapy• Involves the precise placement of radiation
sources directly at the site of the cancerous tumor
• Irradiation only affects a very localized area around the radiation sources, thus exposure to radiation of healthy tissues further away from the sources is therefore reduced
• If the patient moves or if there is any movement of the tumor within the body during treatment, the radiation sources retain their correct position in relation to the tumor
Chemotherapy• The use of antineoplastic drugs used to treat cancer or the combination of these
drugs into a cytotoxic standardized treatment regimen• May also refer to the use of antibiotics, such as in the treatment of brain abscesses• May be either invasive or noninvasive• Multiple manners of delivery of chemotherapeutic agents (oral, IV, Intra-arterail,
Intratumoral, etc.)• Use:• In Abscesses:
– Antibiotic therapy is curative• In Tumors:
– Curative treatment– Neoadjuvant to shrink tumor size prior to surgery– Adjuvant after another treatment such as surgery to prevent recurrence– In combination with other therapeutic strategies– Palliative treatment when cure is no longer possible
Chemotherapy• Pros:
– Provides a survival benefit usually on the order of months, and can provide even greater benefit when used as part of an aggressive treatment plan
– Painless procedure– Cheapest form of therapy– Requires little to no external medical equipment
• Cons:– Emmergence of resistance to chemotherapeutic agent– Adverse effects specific to chemotherapeutic agent used– Systemic side effects:
• Immunosuppression• Myelosuppression• Nausea and vomiting
– Secondary Neoplasm
Clinical manifestations of abscess and focal infections due to local spread, hematogenous disease
associated with immune deficiency
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Etiology Etiologic agent Clinical manifestations
Osteomyelitis
(skull)
Contiguous spread from pyogenic sinus diseaseContamination by penetrating trauma
S. aureusS. epidermidis
redness, swelling,pain
Subdural empyema
(cerebral convexities)
Sinus diseasePenetrating traumaOtitis
StreptococcusStaphylococcus
Fever, headache, neck stiffness, FND (contralateral hemiparesis)
Cranial
CranialEtiology Etiologic agent Clinical
Manifestations
Brain abscess
(brain parenchyma)
Hematogenous spread (endocarditis or intracardiac or intrapulmonary R→L shunts)
S. viridans, S. aureus, Fusobacterium, Corynebacterium,Streptococcus spp.
Headache,(50-90%)
FND (hemiparesis) 50% nausea, lethargy, fever, seizure (40%), mental status changes (50%), vomitting, stiff neck
Migration from the sinuses or ear
Streptococcus spp.
Direct seeding by penetrating trauma
S. aureus
SpineEtiology Etiologic agent Clinical
Manifestations
Pyogenic Vertebral Osteomyelitis(vertebral body)
Hematogenous spread of distant disease, extension of adjacent disease such as psoas abscess or perinephric abscess
S. aureusEnterobacter spp.
Fever and back pain
Tuberculous Vertebral Osteomyelitis or Pott’s disease(upper lumbar or lower thoracic vertebrae)
Hematogenous spread of tuberculosis from other sites, often pulmonary
M. tuberculosis Back pain, fever, night sweating, anorexia, weight loss, spinal mass sometimes associated with numbness, paresthesia, or muscle weakness of legs
Etiology Etiologic agent Clinical Manifestations
Discitis(intervertebral disc space)
2º to post operative infections
S. epidermidisS. aureus
BACK PainRadicular pain, fevers, paraspinal muscle spasm, localized tenderness to palpation
Epidural abscess(arise from or spread to adjacent bone or disc)
Hematogenous spread, local extension, operative contamination
S. aureusStreptococcus spp.
Back pain, fever, tenderness to palpation of spine
Spine
What are the common primary foci of infection that leads to the development
of CNS infections?
C6
CNS infections
Brain Abscess
Subdural Empyema
CNS TB
Mechanism of Entry
Brain Abscess
Direct Extension sinuses, teeth, middle ear, or mastoid
Hematogenous Distant Infectious sites
Following penetrating injury head injury and
nuerosurgery
Direct extension
• Sinus, odontogenic, and otogenic sources are common– Streptococcus species (aerobic and anaerobic) are
most frequently isolated.– Other organisms include Bacteroides,
Enterobacteriaceae, Pseudomonas, Fusobacterium, Prevotella, Peptococcus, and Propionibacterium.
Hematogenous spread
• Pathogens depend on predisposing source. Some common examples are:– Endocarditis -Streptococcus viridans, Staphylococcus aureus – Pulmonary infections -Streptococcus, Fusobacterium,
Corynebacterium, and Peptococcus species– Cardiac defects with right-to-left shunt -Streptococcus species– Intra-abdominal infections -Klebsiella species, E coli, other
Enterobacteriaceae, Streptococcus species, anaerobes– Urinary tract infections - Enterobacteriaceae, Pseudomonas
species– Wound infection -S aureus
Penetrating head trauma, postoperative
• S aureus is most commonly isolated.• Enterobacteriaceae, other gram-negative
bacilli, S epidermidis, Clostridium species, anaerobes, and Pseudomonas species may also be found.
• Propionibacterium acnes, an indolent gram-positive anaerobic organism, may cause delayed postoperative brain abscess, even 10 years after an intracranial procedure.
Subdural Empyema
Paranasal sinusitis
Otitis Media
Post surgery
Trauma
Others
Etiologies %Paranasal sinusitis 67-75Otitis Media 14Post-surgery 4Trauma 3Others ( CHD, lung infection meningitis, etc..)
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Subdural Empyema• Paranasal sinusitis -Staphylococcus aureus, alpha-hemolytic streptococci,
anaerobic streptococci, Bacteroides species, Enterobacteriaceae• Otitis media, mastoiditis - Alpha-hemolytic streptococci, Pseudomonas
aeruginosa, Bacteroides species, S aureus • Trauma, postsurgical infection -S aureus, Staphylococcus epidermidis,
Enterobacteriaceae• Pulmonary spread -S pneumoniae, Klebsiella pneumoniae • Meningitis (infant or child) -S pneumoniae, H influenzae, Escherichia coli,
Neisseria meningitidis • Neonates - Enterobacteriaceae, group B streptococci, Listeria
monocytogenes • Others include hematogenous spread from skin postsurgery (eg,
abdominal surgery). Spread from a focus of tuberculosis infection could also occur. A case of subdural empyema developing after infection with Plasmodium falciparum malaria.
Organism % case
aerobic streptococcus 30-50%
staphylococci 15-20%
microaerophilic & anaerobic strep 15-25%
aerobic Gram negative rods 5-10%
other anaerobes 5-10%
CNS TBCranial
Spinal
Cranial
• Tuberculous Meningitis (TBM)• Serous (Sterile) TBM• CNS Tuberculoma• Tuberculous Brain Abscess• Focal Tuberculous Meningoencephalitis
Spinal
• Spinal Arachnoiditis with Radiculomyelitis• Space Occupying Lesions in the Spinal Canal:
– Intramedullary Tuberculoma– Epidural Tuberculous Granuloma +/- Tuberculous
Spinal Osteomyelitis (Pott’s Disease)
PATHOLOGICAL HALLMARK OF CENTRAL NERVOUS SYSTEM TUBERCULOSIS
• EXUDATE Fibrosis• VASCULITIS Infarction• GRANULOMA Mass Effect
Understand the general principles in the treatment of abscess and focal
intracranial infections.
C6
Management of Brain Abscess
Goal: eradicate pus collection• Non-surgical management• Surgical management
– craniotomy with primary extirpation and resection of the abscess membrane
– burr hole craniotomy and aspiration of pus with or without insertion of a drain
– stereotactic aspiration– ultrasound-guided aspiration– endoscopic aspiration– stereotactic endoscopic aspiration
General Principles
• Antibiotics- mainstay– Empiric treatment
• Covers both aerobes and anaerobes
– Surgery• Confirm diagnosis of abscess• Culture and sensitivity
– 2-3 weeks of antibiotic treatment size decrease in imaging studies
– 4-6 weeks of IV antibiotics, followed by oral antibiotics
General Principles
• Aspiration- treatment of choice– Often repeated before resolution occurs– Often treats significant mass effect– Prevents rupture of abscess to ventricular system
• Rupture is fatal because of herniation
– Other complications: epilepsy, increase edema, recurrence of abscess
– Eg. Stereotactic aspiration
General Principles
• Surgical resection (when accessible)– Patients with multiloculated abscess of nocardia
or actinomycotic etiology– Failed treatment after 3rd aspiration– Post-traumatic abscess with a foreign body or
fistula