| Abstract|| |
The brainstem is an unusual location for a pyogenic abscess. Stereotactic aspiration or microsurgical drainage may be required in antibiotic refractory cases. Prolonged antibiotic therapy, along with symptomatic treatment may provide successful outcome. We report a case of cerebellar and brainstem abscess, managed successfully with prolonged antibiotic administration.
Keywords: Brainstem abscess, conservative treatment, pyogenic
|How to cite this article:|
Gupta R, Mohindra S, Chhabra R. Brainstem abscess: The nonsurgical management. Indian J Pathol Microbiol 2008;51:49-50
| Introduction|| |
Brainstem, an unusual location for a pyogenic abscess used to have fatal outcome three decades back, due to nonavailability of diagnostic tools.  Recently, the diagnosis and prognosis of brainstem abscesses have improved henceforth, with availability of computed tomography (CT scan), magnetic resonance imaging (MRI), and newer antimicrobial therapy.
Pons is the commonest site of these abscesses, followed by midbrain and medulla.  The present report describes a case of pontine abscess managed nonsurgically, with prolonged antibiotic administration.
| Case History|| |
A 50-year-old asthmatic female, on inhalational steroids for a decade, presented with 15 days' history of fever, left-sided sixth, seventh cranial nerve paresis and altered sensorium. On examination, she was unconscious but localizing to pain, with left-sided hemiparesis. Fundoscopy was suggestive of papilloedema.
Plain and contrast CT and MRI scans revealed left-sided pontine and cerebellar abscesses with hydrocephalous [Figure - 1]. The cerebellar abscess was tapped through a burr-hole and broad-spectrum antibiotics (vancomycin, 2 g per day; ceftriaxone, 4 g per day; and metronidazole, 2 g per day) were started.
The patients' deterioration continued relentlessly, requiring intubation and mechanical ventilation. External ventricular drainage was required to reduce the intracranial pressure (ICP). The pus from cerebellar abscess grew methicillin-sensitive staphylococcus aureus.
As the neurological and radiological status remained static, rifampicin (600 mg per day) was added. Gradually, patient improved from seventh week onward and became conscious and ambulant. Vancomycin and ceftriaxone were given for 6 weeks and rifampicin for 3 months. At 1-year of follow-up [Figure - 2], she has minimal residual cranial nerve paresis and lower limb spasticity.
| Discussion|| |
The cause of brain-stem abscess is hematogenous dissemination from a distant site. These patients may present with multiple cranial palsies, raised ICP, sepsis, and often rapidly deteriorating sensorium. The diagnosis requires a strong clinical suspicion and an urgent contrast-enhanced radiology.
The management strategy includes prolonged antibiotic administration with or without stereotactic or microsurgical aspiration of pus. ,, Aspiration provides the bacterial diagnosis and downloads the bacterial content. However, the facility of stereotactic aspiration may not be universally available. Microsurgical approach requires proper anatomical knowledge of the brainstem, and appropriate surgical approach for safe drainage of the abscess. Along with the direct attack on the pathology, the management warrants a close monitoring of raised ICP.
The present case describes rapid neurological deterioration due to increased pressure in both supra and infratentorial compartments. Cerebellar abscess was drained while hydrocephalous was relieved by ventricular drainage, as lifesaving measures. Aspirated pus provided the identity of the offending organism and relieved the pressure in the infratentorial compartment.
The present case describes a successful outcome of brainstem abscess, after prolonged antibiotic therapy. Careful wait-and-watch policy may prevent permanent brain-stem deficits. However, stereotactic aspiration may be a safe option, if the patient deterioration continues. 
| Conclusion|| |
Prolonged antibiotic therapy may be an option of management of pontine abscess. Supportive care and monitoring of ICP is however, mandatory.
| References|| |
|1.||Suzer T, Coskun E, Cirak B, Yagci B, Tahta K. Brain stem abscesses in childhood. Childs Nerv Syst 2005;21:27-31. [PUBMED] [FULLTEXT]|
|2.||Sarma S, Sekhar LN. Brain-stem abscess successfully treated by microsurgical drainage: A case report. Neurol Res 2001;23:855-61. [PUBMED] [FULLTEXT]|
|3.||Fuentes S, Bouillot P, Regis J, Lena G, Choux M. Management of brain stem abscess. Br J Neurosurg 2001;15:57-62. [PUBMED] |
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh
[Figure - 1], [Figure - 2]