Neurosurgery Case 2: CNS Neoplasms

Neurosurgery Case 2:CNS Neoplasms

3Med – CUST-FMS

58 year-old female

6 months 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


Frequency• Incidence of metastatic brain tumor accounts

for 50% of total brain tumors• Est. 100k new cases are diagnosed per year in

the US


• 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


INFRATENTORIAL TUMORS

• Often cause increased ICP due to hydrocephalus– From compression of the fourth ventricle

• Leading to:– Headache– Nausea– Vomiting– Diplopia


• Cerebellar hemisphere or brain stem dysfunction can result in:– Ataxia– Nystagmus– Cranial nerve palsies

• Infratentorial tumors rarely cause seizures


RAISED INTRACRANIAL PRESSURE

• ICP normally varies between 4 and 14 mmHg• Sustained ICP levels above 20 mmHg can

injure the brain


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


• Cushing’s Triad is the classic presentation of ICH:– Hypertension– Bradycardia– Irregular respirations

• This triad is usually a late manifestation


• 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


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


• Cases of ICH typically require rapid neurosurgical evaluation

• For definitive decompression, these may be needed:– Ventriculostomy– Craniotomy– Craniectomy


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.


• 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.


• Occipital Lobe

Blindness in one direction or other visual disturbances, and seizures are common 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.


• 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.


• 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.


• 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

ManifestationsBrain 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

ManifestationsPyogenic 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?

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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.

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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

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Neurosurgery Case 2: CNS Neoplasms