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Brain Abscess Following Ischemic Stroke with Secondary Hemorrhage

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Brain Abscess Following Ischemic Stroke with Secondary Hemorrhage Arq Neuropsiquiatr 2008;66(1):104-106 BRAIN ABSCESS FOLLOWING ISCHEMIC STROKE WITH SECONDARY HEMORRHAGE Jorge Luiz Kraemer1, Paulo Valdeci Worm2, Mário de Barros Faria2, Alexandre Maulaz3 Cerebral vascular events constitute the most common driasis, and tomographic evidence of hemispheric edema com- group of neurological diseases, and are usually followed by promising the left MCA distribution with intracerebral hemor- systemic infections, being pneumonia, urinary tract infec- rhage and significant mass effect. A decompressive craniotomy tion and sepsis the most frequent1. Brain abscess compro- was performed, and a ventricular catheter for intracranial pres- mising the infarcted cerebral tissue is a rare condition 2,3. sure (ICP) measurement was placed (Fig 1). It most frequently happens a few weeks after an infec- Elevated ICP was managed with mannitol and hypertonic tious systemic insult, which had usually followed the isch- saline. Four days after the ictus, patient developed fever (38oC) emic stroke. There are only a few case reports on this sub- with negative blood cultures. Pseudomonas aeruginosa and ject in the literature. In spite of that, those patients with Staphylococcus aureus were then isolated in the tracheal as- ischemic stroke should be considered at high risk of de- pirate, being both ciprofloxacin sensitive. Patient persisted fe- veloping brain abscess, and should have this condition in- brile after seven days of antimicrobial therapy, and the previous cluded in their differential diagnosis once neurologic or germs were both once again isolated in the tracheal aspirate. An- even systemic deterioration takes place following pre- aerobic gram positive cocci disposed in chains were identified vious recovery. Cerebral ischemia is considered to be a in the blood culture; piperacilin and tazobactan for ciprofloxa- predisposing factor for the genesis of brain abscess after cin resistant pseudomonas were introduced, with favorable out- stroke4. Due to impaired cerebral oxigenation and blood come. Seven weeks after the stroke, patient started with low brain barrier disruption in the infarcted area, the forma- grade fever and local swelling over the decompressive craniot- tion of an abscess becomes feasible following bacteremia, omy. Brain CT revealed a multiloculated hypodense lesion over a fact that has recently caught the attention of neurolo- the previously infarcted area, with mass effect and peripheral gists and neurosurgeons2,3,5. enhancement after contrast injection (Figs 2A and B), suggest- ing cerebral abscess. Eritrocyte sedimentation rate was elevat- CASE ed and blood count showed microcytosis and hypocromia, with mild leukocytosis and left shift. Transesophagic echocardiogra- A previously healthy 33-year-old white woman is admited to the emergency room complaining of severe right hemipa- phy revealed no abnormalities, similar to the one performed on resis of acute onset and motor disphasia, which progressed to admission. By means of a small skin incision, abscess punture was complete aphasia in a few minutes. Brain computed tomogra- performed, with drainage of 40 ml of purulent secretion whose phy (CT) revealed no abnormalities. Due to the hypothesis of culture in anaerobic media revealed gram negative cocci orga- acute obstruction of the left middle cerebral artery (MCA), a ce- nized in chains, identified as group C Streptococcus sp. Patient rebral angiography was performed five hours after the onset of was treated with vancomycin and imipenem for 10 weeks, show- the symptoms, indicating oclusion of the distal portion of the ing good response. She remains hemiparetic, but follows com- left intracranial carotid artery, compromising both anterior and mands and articulates words. middle cerebral arteries. Intra-arterial thrombolytics were ad- The area of cranial decompression became flacid, and con- ministered, with total reperfusion of the anterior cerebral artery trol CT showed the infarcted territory still containing the en- territory. A MCA suboclusion (M2 segment) remained, despite hanced abscess capsule. The bone flap, which had been kept multiple attempts to perform angioplasty with stent deploy- transitorially in the subcutaneous fat of the abdomen, was re- ment. Patient was transferred to the intensive care unit (ICU) placed 12 months after the stroke, and the tomographic control and was started on intravenous anticoagulants. About 24 hours demonstrated the left encephalomalatic area with complete res- after the procedure, patient developed anisocoria with left my- olution of the abscess (Fig 3). ABSCESSO CEREBRAL APÓS INFARTO ISQUÊMICO COM TRANSFORMAÇÃO HEMORRÁGICA Hospital São José, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre RS, Brazil: 1MD, PhD, Professor of Neurological Surgery, Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre; 2MD, Resident in Neurological Surgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre; 3MD, Neurologist, Department of Neurology, Policlínica Santa Clara - Santa Casa de Misericórdia de Porto Alegre. Received 31 August 2007, received in final form 21 November 2007. Accepted 3 December 2007. Dr. Mário de Barros Faria – Rua Engenheiro Olavo Nunes 153 / 301 - 90440-170 Porto Alegre RS - Brasil. E-mail: [email protected] 104 Brain abscess: stroke Arq Neuropsiquiatr 2008;66(1) Kraemer et al. Fig 1. Non-enhanced CT obtained Fig 2. (A) Contrast enhanced CT, revealing an irregular hipodense and Fig 3. Tomographic control 12 following decompressive craniot- multiloculated lesion with sharp peripheral enhancement compro- months after the stroke showing omy, demonstrating massive left mising the infarcted territory. The image is compatible with brain left hemispheric area of enceph- hemispheric ischemia with cen- abscess, and protrudes from the cranial defect (B). alomalacia, with complete resolu- tral area of hemorrhage and sur- tion of the abscess. rounding edema; ventricular cath- eter for ICP measurement placed in the third ventricle. DISCUSSION cerebral stroke may be obtunded, aphasic, incapable of The acute onset of right hemiparesis, aphasia and im- complaining of headache. Commonly, he or she has al- paired consciousness on admission suggested a massive ready presented evident motor deficit, and may be febrile ischemic stroke compromising the cerebral territory sup- due to infectious complications secondary to prolonged plied by the left MCA. Despite the abscence of tomo- hospital admission. The recognition of a brain abscess in a graphic confirmation, performed early in the course of patient like this becomes an exclusion diagnosis, and due the disease, the characteristic presentation prompted the to its low frequency, it relies on a high index of suspicion medical team to attempt reperfusion of the obtructed for this specific entity in this group of patients. vessel by means of endovascular techniques. The second The pathogenesis of brain abscess over an infarcted CT already demonstrated the infarcted area with signifi- area involves previous local brain damage and a distant cant mass effect and midline shift, which in association focus of infection. The vascular event, ischemic or hem- with aditional impairement of consciousness, revealed the orrhagic, produces local blood brain barrier disruption, necessity for a decompressive craniotomy and ICP mea- which makes this region vulnerable to microbial seeding in surement (Fig 1). The clinical course progressed in a slow the event of bacteremia secondary to systemic infection, pace, complicated by infectious events and long term ICU leading to the formation of cerebral abscess3. Staphylo- admission. coccus aureus is reported in the literature as the most fre- There is no pathognomonic syndrome for the presen- quent etiologic agent. In this report, patient had a respi- tation of brain abscess, and because of that it is frequently ratory tract infection caused by Pseudomonas aeruginosa misdiagnosed as neoplasia or other intracranial mass le- and Staphylococcus aureus, blood culture positive for an- sion6. Headache, fever and impaired consciousness are aerobic gram-positive cocci in chains, and Streptococcus the most prevalent presenting symptoms, although this sp isolated in the abscess secretion. Brain abscess devel- triad is found in less than one third of the patients with oped five weeks after the stroke, although it took longer brain abscess7,8. The intensity, or even abscence, of fever to be diagnosed in more than 70% of the cases reported is variable among patients, depending on their age, im- in the literature9-15. The reduced delivery of antibiotics to munologic state and type of etiologic agent involved in ischemic areas decreases the effectiveness of treatment the genesis of the abscess. The diagnosis of this entity in and prolongs its course16,17. Kaplan9, however, reported patients with massive ischemic or hemorrhagic stroke be- three cases with favorable response to eight weeks of an- comes a challenge to the attending physician due to the timicrobial therapy. The treatment of brain abscess usually similarities between those clinical pictures. The present- involves surgical drainage, performed whether by stereo- ing symptoms of both pathologies overlap along the clini- tactic puncture and aspiration or open surgical resection cal course of those diseases, leading to a clinical scenario of the abscess and its capsule, followed by antimicrobial in which the development of a brain abscess over a pre- therapy for six to eight weeks. Mampalam
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