Suppurative intracranial complications of sinusitis in adolescence. Single institute experience and review of literature

The objective of this study was to investigate the outcome of neurosurgical treated children with suppurative intracranial complications (SIC) of sinusitis over the past 28 years in our hospital. We reviewed the cases notes of a series of 11 consecutive paediatric patients, who were subjected to surgery for sinusitis-induced SIC, retrospectively. Eleven children (10 males and only one female) were underwent neurosurgical procedure in our hospital between 1978 and 2006. Their age at the time of diagnosis ranging from 13 to 17 years (mean 15.27 years, SD 1.737). The commonest presenting symptoms were headaches (81.8%) followed by vomiting (45.5%) and swelling of the forehead (45.5%). The most often involved sinus was the frontal sinus (63.6%) and sinus surgery was performed in eight (72.72%) of 11 cases. The neurosurgical procedures carried out included burr hole drainage or aspiration of abscess in five cases, craniotomy and evacuation of empyema in seven cases and craniectomy in two cases. Four (36.4%) of 11 patients had more than one neurosurgical operation due to re-accumulation of pus and worsening of their clinical status. Most common pathogen was Streptococcus species (81.9%), and anaerobes were isolated in three (27.3%) cases. Postoperative antibiotic treatment lasted from 26 to 70 days (mean 45.45 days, SD 15.280). Epilepsy was diagnosed in two patients, postoperatively. During the follow-up period, persistent focal neurological deficits were present in five (45.5%) of 11 patients. Interestingly, five (45.45%) cases occurred over the last 2 years (2005-2006) and the other six over the previous 16 years (1978-2006). Prompt and aggressive medical and neurosurgical intervention is required, aiming to minimize the morbidity and mortality and also to maximize the favourable outcome of those children.     

Spinal epidural abscess successfully treated with percutaneous,computed tomography-guided,needle aspiration and parenteral antibiotic therapy: case report and review of the literature

OBJECTIVE AND IMPORTANCE: We describe a case of a posterior spinal epidural abscess that was successfully treated with percutaneous, computed tomography-guided, needle aspiration and parenteral antibiotic therapy. CLINICAL PRESENTATION: A 48-year-old man experienced acute pain in the paralumbar region for 1 week, followed by gait disturbance and micturition difficulty. Laboratory studies demonstrated leukocytosis and hyperglycemia. Blood cultures yielded Staphylococcus aureus. Magnetic resonance imaging scans of the thoracolumbar spine revealed a posterior spinal epidural abscess located between L2 and the lower cervical spine. INTERVENTION: The patient's low back pain persisted despite 10 days of antibiotic therapy. Therefore, percutaneous, computed tomography-guided, needle aspiration was performed. The low back pain was relieved dramatically and immediately after the procedure. The spinal epidural abscess completely resolved after 6 weeks of antibiotic treatment. CONCLUSION: Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscesses. Selected patients may be treated nonsurgically. Rarely, percutaneous drainage of the abscess has been reported to be helpful. Our case suggests that percutaneous, computed tomography-guided, needle aspiration might be a rational alternative to surgical decompression for treatment of spinal epidural abscesses.     

Use of the computerized tomographic scan in the diagnosis and treatment of abscesses

Over a 5 year period, 89 patients underwent one or more computerized tomographic scans to locate an abscess during 92 hospitalizations. The scans were a most sensitive (93 percent), specific (98 percent), and accurate (96 percent) means of abscess detection. Thirty-nine patients had positive scans. Sixteen patients were treated directly by open surgical methods, 1 of whom required percutaneous drainage in the postoperative period for incomplete drainage. An additional 23 patients underwent attempted percutaneous abscess drainage. In 17 patients, drainage was successful. Five patients underwent percutaneous drainage and later required laparotomy, two of whom underwent unavoidable surgical procedures and three surgery for incomplete drainage. Overall, percutaneous abscess drainage was successful in 83 percent. Of 11 deaths, 8 occurred in the group with computerized tomographic scans negative for abscess. Three of these were false-negative scans. Three deaths occurred in the group with scans positive for abscess. All were of patients with hepatic abscesses treated by open surgical drainage, one after failed percutaneous drainage. Twelve patients had multiple organ failure, and 8 of these patients died, for a mortality of 67 percent. The computerized tomographic scan is the diagnostic procedure of choice in the diagnosis of abscesses. In selected patients, percutaneous abscess drainage is also a successful means of abscess treatment and avoids the complications of a laparotomy. The onset of multiple organ failure in the surgical patient should alert the diagnostician to the possibility of a septic focus. The role of early laparotomy in these patients is uncertain. We recommend early use of the computerized tomographic scan in the septic surgical patient. Prompt diagnosis and treatment of abscesses, whether by open or percutaneous routes, may avert the development of multiple organ failure and reduce morbidity and mortality.     

Dermal sinus and dermoid cyst revealed by abscess formation in posterior fossa. Report of 2 pediatric cases and review of the litterature

Cranial dermal sinus, usually associated with dermoid cyst, is the persistance of an abnormal embryonal communication between the skin and the central nervous system. It may be the source of intracranial infection, most often a meningitis and rarely an abscess formation. Two cases of little girls (18 months and 2 years) having dermal sinus with dermoid cyst revealed by cerebellar abscess formations are reported. In the first case there were multiple cerebellar abscesses with hydrocephalus leading to a raised intracranial pressure. In the second case there was an abscess formation adjacent to the dermoid cyst. CT scan showed cysts and abscesses but MRI, achieved in the second case, was useful in demonstrating the sinus tract as well as the associated cyst and abscess. The two patients underwent a posterior fossa surgery with antibiotic therapy. In the first case abscess drainage and ventricular external drainage were necessary before sinus and cyst excision. Two months after surgery the two patients were neurologically intact and developping well. Surgery with total excision of dermal sinus and dermoid cyst, even sometimes difficult, must be preferred to the simple abscess drainage and antibiotic therapy.     

Spinal epidural abscess in the lumbar spine after dental extraction in a 53-year-old man

Spinal epidural abscess is rare in patients following dental extraction. Only seven cases have been described in the literature. We report the first case of an epidural abscess in the lumbar spine following dental extraction, and present a review of the relevant literature. A 53-year-old man presented with low back pain 1 week following dental extraction, and imaging revealed the presence of a lumbar epidural abscess. He underwent surgical drainage by decompressive laminectomy with evacuation of pus and debridement of the infected bone, and he was treated with a prolonged course of intravenous antibiotics. The patient demonstrated no neurologic sequelae at the 6-month follow-up examination. A search of the relevant literature showed that, of the seven epidural abscesses that occurred following dental extractions, five were cervical and two were intracranial. An epidural abscess in the lumbar spine following dental extraction had not been reported. Thus, this is the first report of an epidural abscess in the lumbar spine following dental extraction. It is also the first case of epidural abscess following dental extraction that was determined to be caused by Streptococcus suis. Our findings indicate that epidural abscess must be considered as a diagnosis for all patients presenting with intractable low back pain, with or without fever and neurologic impairment, after a recent dental extraction. We conclude that appropriate imaging must be conducted for early diagnosis.     

Unusual complications and presentations of intracranial abscess: experience of a single institution

BACKGROUND: Complicating events and unusual presentations associated with intracranial abscess are rare but potentially fatal conditions. This study was undertaken to shed light on the unusual complications and presentations of intracranial abscess treated at a single institution. METHODS: We retrospectively reviewed 116 cases of intracranial abscesses that were treated at our institution over the last 10 years and identified 11 (9.4%) cases with unusual complications. RESULTS: These complications consisted of (1) rupture within the abscess, (2) hemorrhage into the abscess, (3) hemispheric infarction due to ICA thrombosis, (4) acute visual loss due to pituitary abscess, (5) acute neurologic deterioration due to rapid gas formation within the abscess, (6) acute hydrocephalus, (7) trigeminal neuralgia, (8) fungal abscess developing secondary to intracranial extension of a temporal bone tumor, (9) Cryptococcus abscess with different morphology, (10) pontine infarction, and (11) sigmoid sinus thrombosis. Sinusitis accompanied 8 (72.7%) of the cases, and there were 5 (45.4%) mortalities. Culture results were unyielding in 4 patients, whereas Streptococcus species were identified in 4 and fungi in the rest. CONCLUSION: Intracranial abscesses and their complications still continue to be challenging entities in the neurosurgical practice. Our experience may provide an informational source for those who are taking care of patients with intracranial abscess.     

Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy

We report on the transabdominal resection of infected lumbosacral bone, synthetic mesh, and sinus tract following sacral colpopexy. A 45-year-old nulliparous patient who had undergone transvaginal mesh followed by robot-assisted sacral colpopexy presented with increasing back pain and foul-smelling vaginal drainage. An epidural abscess required surgical intervention, including diskectomy, sacral debridement, and mesh removal to drain the abscess and vaginal sinus tract. Recognized complications of open prolapse procedures also manifest following minimally invasive approaches. Osteomyelitis of the sacral promontory following sacral colpopexy may require gynecologic and neurosurgical management.     

Focal intracranial infections due to Propionibacterium acnes: report of three cases

OBJECTIVE AND IMPORTANCE: Except for its role in shunt infections, Propionibacterium acnes has been of little interest to neurosurgeons. The rarity and indolent nature of focal intracranial infections by P. acnes limit their recognition. Three cases of serious intracranial infection due to this organism are described. CLINCAL PRESENTATION: Three patients with histories of immunosuppression and neurosurgical procedures developed nonspecific, delayed presentations (5 wk to 5 yr after surgery) of intracranial infections. In two patients, radiological investigations showed enhancing lesions that were later found to be brain abscesses. A subdural empyema was found in the third patient. INTERVENTION: All three patients underwent surgical drainage of the purulent collections. P. acnes was isolated in each case, and each patient was treated with a 6-week course of intravenous penicillin. All three patients made good recoveries, and subsequent imaging showed no recurrence of the infectious collections. CONCLUSION: P. acnes is an indolent organism that may rarely cause severe intracranial infections. This organism should be suspected when an intracranial purulent collection is discovered in a patient with a history of neurosurgical procedures. Immunosuppressed patients may be susceptible to this otherwise benign organism. Surgical drainage and treatment with intravenous penicillin should be considered standard therapy.     

Subdural empyema and epidural abscess in children

From January 1, 1954, through December 31, 1981, 31 children were treated at The Hospital for Sick Children in Toronto, Ontario, for subdural empyema (22 cases), epidural abscess (6 cases), and infected nidi at both subdural and epidural sites (3 cases). All but four of the children with subdural empyema were from 6 months to 2 years of age or from 12 years to 16 years of age; all children with epidural abscess fitted into the older age group. The subdural empyemas developed from varied sources, but the paranasal sinuses, the ears, and the mastoids processes were predominantly affected. Five subdural empyemas developed following craniotomy or shunt procedures. The epidural abscesses developed mostly from infections in the paranasal sinuses and the middle ears. Two of the combined infections developed from the paranasal sinuses; the third followed craniotomy. The infecting bacteria varied, but were usually Streptococci and were common to both the subdural and epidural sites. The subdural empyemas presented as focal seizures in the older group, and that group of patients was more seriously ill and had greater focal deficit; the mortality rate was 13%. Epidural abscesses only rarely presented with focal deficit, and diagnosis was delayed in most instances; no deaths occurred in this group. Two cases are reported in detail to illustrate the principles and pitfalls of surgical management of these intracranial infections in the pediatric age group.     

Combined approach for otogenic brain abscess

Otogenic intracranial infections usually require both neurosurgical and otolaryngological surgery. This prospective, non-randomized study investigated the value of combining both surgical procedures. Thirteen patients with otogenic intracranial abscess were treated by mastoidectomy and abscess removal through the same incision between 1993 and 2002. Another 12 patients underwent abscess removal or mastoidectomy followed by the other procedure within 7 days. The clinical features of the patients were compared. Four patients died in our series. All four patients had Glasgow Coma Scale (GCS) scores of 7 or less. The preoperative GCS score was the main factor in mortality. One patient had recurrence after the combined approach compared to nine patients with recurrence after separate procedures. The surgical procedure was the main factor affecting the recurrence rate. The combined approach and total capsule excision of the abscess may reduce the risk of recurrence of otogenic intracranial abscess.     

Intracranial abscess and empyema: neurosurgical management]

Brain abscesses and empyemas are severe infections with lethal outcomes in the case of inappropriate treatment. The files of 34 patients with brain abscesses, and nine with intracranial empyemas treated over eight years (1990-1997) were analyzed retrospectively. Cases were evaluated for treatment and compared with data from the literature. Patients with brain abscess underwent either aspiration of the lesion through a burr hole (79.5% of the cases), or craniotomy and excision (8.8% of the cases); 11.7% were treated only with antibiotics. The operative mortality was 2.9% and the outcome was satisfactory in 85% of patients. These results are in agreement with data from the literature. Prognosis is strongly related to the initial clinical status. Current methods of treatment include surgical aspiration of large abscesses with a mass effect, and are usually associated with a poor clinical status. Excision is suggested whenever aspiration procedures have failed, or in the presence of foreign material or fungal abscess. Medical treatment is indicated for small and deeply located abscesses in patients with satisfactory clinical states. Empyemas in our series were treated with burr hole and pus aspiration. The mortality rate was 11%, and 62.5% of the patients made a good recovery. In agreement with other reported studies, the method of treating subdural empyema is much less significant than an aggressive early drainage of the infection. Although brain abscesses and empyema remain a significant neurosurgical concern, aggressive treatment can result in an excellent outcome in the majority of patients.     

Brain abscesses in the young

Brain abscesses in the young are rare. Only 14 such abscesses have been seen at Texas Children's Hospital since 1968. Most abscesses developed in association with congenital heart disease (5), although sinusitis and mastoiditis were precipitating causes in two patients and one patient, respectively. The latter three patients' cases are reviewed in detail. Clinical and bacteriologic findings in all patients are discussed. There were signs of increased intracranial pressure in nine patients (64%). All abscesses were drained; in several, repeated drainage was necessary. Anaerobic organisms were recovered in six patients (43%), aerobic organisms were recovered in five (36%), and both were recovered in two (14%). In one patient no growth was reported. Antimicrobial therapy was administered to all patients but one, whose abscess was completely excised. Morbidity and mortality remained significant: three patients (21%) died and one has a residual hemiparesis.     

Intracranial extension of sphenoid sinusitis

Background. The incidence of sphenoid sinusitis has decreased significantly since the pre-antibiotic era. Intracranial complications from isolated sphenoid sinusitis are rare but have a high morbidity and mortality. Methods. A case of intracranial extension of sphenoid sinusitis in a 64-year-old woman is reported. Results. A 64-year-old woman was initially seen unconscious with bacterial meningitis and cerebrospinal fluid (CSF) fistula. Imaging suggested sphenoid sinusitis with intracranial extension. She underwent a sinus drainage procedure, was placed on antibiotic therapy, and underwent a definitive sphenoid sinus obliteration. The patient made a satisfactory recovery. Conclusions. Despite the low incidence of intracranial complications of sphenoid sinusitis, the potential morbidity and mortality from such complications is high. We advocate aggressive management consisting of antibiotic therapy, sinus drainage, and definitive CSF fistula repair. © 1995 Jons Wiley & Sons, Inc.     

Strategies in the management of pyogenic psoas abscesses.

The presentation and management of eight patients with pyogenic psoas abscesses treated at the National Naval Medical Center, Bethesda, Maryland, between January 1986 and July 1989 are presented. The psoas abscesses were secondary to underlying gastrointestinal disease in six patients and sacral osteomyelitis in one patient. In one patient, the etiology of the abscess could not be determined. The average duration of symptoms in these patients was 16 days. Computed tomography was useful in identifying the abscess, defining its complexity, and planning therapy in all eight patients. Seven patients had complex, multiloculated abscesses, and one patient had a simple abscess. Extraperitoneal drainage was used in all patients. The patients with multiloculated abscesses had open surgical drainage, while the patient with the simple abscess had percutaneous catheter drainage. Most patients with a gastrointestinal etiology for their abscess underwent staged resection 3 to 6 weeks after the drainage procedure. There were no deaths, recurrent abscesses, or fistulae in these patients. Two patients developed thromboembolic complications postoperatively. Extraperitoneal drainage with staged resection of underlying gastrointestinal pathology is a safe and effective way of treating patients with psoas abscesses.     

Aggressive thoracic actinomycosis complicated by vertebral osteomyelitis and epidural abscess leading to spinal cord compression

STUDY DESIGN: Report of a successfully diagnosed and treated case of spinal cord compression due to epidural actinomycosis. OBJECTIVE: To illustrate that proper use of imaging strategy can greatly facilitate diagnosis and management of this rare condition. SUMMARY OF BACKGROUND DATA: Spinal actinomycosis causing epidural abscess and significant spinal cord compression is an uncommon condition. Although diagnosis is difficult, favorable results are widely reported when specific therapy is instituted. METHODS: A 32-year-old Chinese man had extensive dorsal thoracic soft tissue swelling and lower limb weakness. Collapse of the T5 vertebral body was found on plain radiographs with mediastinal infiltrates on chest radiograph. It took magnetic resonance imaging (MRI) to fully delineate the epidural abscess and dorsal muscular abscesses, which were not depicted by computed tomographic (CT) scan. Diagnosis was made by examination of CT-guided aspirate and tissue recovered during surgery by a microbiologist. The patient received high-dose intravenous penicillin and prompt spinal decompression once diagnosis of actinomycosis was confirmed. RESULTS: The dorsal muscular abscesses and upper thoracic epidural abscess resolved rapidly after intravenous antibiotics and surgical drainage. This was well documented by follow-up MRI and the full recovery of motor power and lower limb sensation in the patient. CONCLUSIONS: High clinical suspicion and proper use of imaging data led to timely diagnosis of this rare case of mediastinal, epidural, and intramuscular thoracic actinomycosis. Specific antibiotic therapy and timely, well-targeted surgical intervention greatly improve the outcome of this condition.     

Percutaneous abdominal abscess drainage: Portland area experience

After reviewing 21 patients who have had percutaneous abdominal abscess drainage, we believe that the procedure should be considered for those abscesses that are unilocular without septations, with safe access being a key variable dictating the use of percutaneous abdominal abscess drainage rather than surgery. A computerized tomographic scan of the abdomen should be employed at some stage of the percutaneous abdominal abscess drainage procedure to facilitate safe access to the abscess and to distinguish a synchronous abscess where present. In addition, we believe that percutaneous abdominal abscess drainage should be considered for postsurgical abscesses only and not those that are spontaneous in nature or where the original abnormality cannot be accurately surmised. With regard to catheter management, frequent irrigation of the catheter must be carried out at least every 4 to 6 hours, with high levels of antibiotics present in the blood before irrigation. This must be done to obviate the most frequent and potentially lethal complication of the procedure, namely sepsis. Percutaneous abdominal abscess drainage, although safe for the most part, is capable of inducing considerable morbidity. Our data suggest that percutaneous abdominal abscess drainage is not as efficacious as previous reports have suggested. Traditional surgical drainage techniques are best utilized for those abscesses that are multiple, highly viscous, inaccessible, spontaneous, or unresponsive to percutaneous abdominal abscess drainage.     

Percutaneous drainage of perisigmoid abscesses of diverticular origin

STUDY AIM: The aim of this multicentric retrospective study was to report the results on the percutaneous drainage of perisigmoid abscesses during acute sigmoid diverticulitis in 12 patients. PATIENTS AND METHOD: Between January 1993 and March 2000. 12 patients with a perisigmoid diverticular abscess were treated by antibiotic therapy and percutaneous drainage of the abscess. The patient population consisted of eight males and four females (mean age: 50.2 years). The diagnosis was established in two out of seven cases by enema, in four cases out of seven by abdominal ultrasonography, and in eight cases out of 11 by CT scan. Percutaneous drainage was carried out in all cases, and was guided by ultrasonography (n = 3) and CT scan (n = 9). The mean duration of drainage was 6.5 days. RESULTS: No drainage-associated complications were observed. Drainage combined with antibiotic treatment provided satisfactory results in ten out of 12 cases. Two cases of failure of the method occurred, and the patients involved were operated on day 4 and week 5 by colectomy with protective lateral ileostomy. There was an early recurrence of the abscess in three patients, who were treated by the Hartmann procedure in one case, and by one-stage colectomy in two cases. Five patients underwent a secondary one-stage colectomy. Two patients in whom no residual abscess was detected were not operated on at the time of the study. CONCLUSION: Percutaneous drainage of perisigmoid diverticular abscesses combined with antibiotic therapy provided efficient treatment in ten out of 12 cases. Secondary one-stage colectomy was performed in seven out of the eight patients requiring further surgery.     

Basilar artery vasculitis secondary to sphenoid sinusitis--case report

A 35-year-old male presented with basilar artery vasculitis secondary to sphenoid sinusitis manifesting as rapidly deteriorating symptoms including consciousness disturbance and right hemiparesis. Computed tomography (CT) on admission showed sphenoid sinusitis without intracranial lesion. Emergency angiography demonstrated basilar artery stenosis. The neurological deterioration was considered to be caused by ischemia of the perforating arteries branching from the stenotic portion of the basilar artery. The patient was treated with urokinase infusion through a microcatheter just proximal to the stenosis 3 hours after the onset of the symptoms. His consciousness level and right hemiparesis markedly improved immediately after the procedure. Magnetic resonance (MR) imaging on day 5 revealed that extension of the sphenoid sinusitis into the prepontine cistern had formed an abscess which was attached to the clivus. The basilar artery was embedded in the abscess at the angiographic stenosis. Cerebrospinal fluid (CSF) analysis showed white blood cell count of 601/mm3 with 82% neutrophils, 89.2 mg/dl protein, and 31 mg/dl glucose. No causative organism in the CSF could be identified by smear or culture. Early MR imaging and CSF examination are recommended when patients present with both ischemic symptoms involving the basilar artery and opacification of the sphenoid sinus on CT to identify basilar artery vasculitis secondary to sphenoid sinusitis.