Neurosurgery Case 2: CNS Neoplasms

Neurosurgery Case 2: CNS Neoplasms
3Med – C UST-FMS

58 year-old female Complained of progressive, on and off headache
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 Secondary Brain Tumors

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 Tumor Sex 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/Morbidity Primary 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 Tumor Sex
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 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 years

Signs and symptoms of increased ICP and its management
General clinical manifestations (focal deficits and irritation, mass effect; supratentoriai vs infratentorial) of brain tumors Signs and symptoms of increased ICP and its management C2

Schwartz's Principles of Surgery, 9th edition
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 The Monro-Kellie doctrine states that the cranial vault is a rigid structure, and therefore the total volume of the contents determines ICP. The three normal contents of the cranial vault are brain, blood, and CSF. The brain's contents can expand due to swelling from traumatic brain injury (TBI), stroke, or reactive edema. Blood volume can increase by extravasation to form a hematoma, or by reactive vasodilation in a hypoventilating, hypercarbic patient. CSF volume increases in the setting of hydrocephalus. Figure 41-2 demonstrates classic CT findings of hydrocephalus. Addition of a fourth element, such as a tumor or abscess, will also increase ICP. The pressure-volume curve depicted in Fig demonstrates a compensated region with a small P/V, and an uncompensated region with large P/V. In the compensated region, increased volume is offset by decreased volume of CSF and blood. 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 Initial management of ICH includes airway protection and adequate ventilation. A bolus of mannitol up to 1 g/kg causes free water diuresis, increased serum osmolality, and extraction of water from the brain. The effect is delayed by about 20 minutes and has a transient benefit. Driving serum osmolality above 300 mOsm/L is of indeterminate benefit and can have deleterious cardiovascular side effects, such as hypovolemia that leads to hypotension and decreased brain perfusion. 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 It is critical to note that lethargic or obtunded patients often have decreased respiratory drive. This causes the partial pressure of arterial carbon dioxide (PaCO2) to increase, resulting in cerebral vasodilation and worsening of ICH. This cycle causes a characteristic "crashing patient," who rapidly loses airway protection, becomes apneic, and herniates. Emergent intubation and ventilation to reduce PaCO2 to roughly 35 mm Hg can reverse the process and save the patient's life. Schwartz's Principles of Surgery, 9th edition

Recognize specific syndromes; extra-axial and intra-axial in brain tumor presentation.

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 Symptoms Brain 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 eyelid Difficulty in swallowing and slurred or nasal speech are also common. *Symptoms may develop gradually. The brain stem controls basic life functions including blood pressure, heart beat, and breathing. The reticular formation (the central core of the brain stem) controls consciousness, eating and sleeping patterns, drowsiness and attention.

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. The brain stem controls basic life functions including blood pressure, heart beat, and breathing. The reticular formation (the central core of the brain stem) controls consciousness, eating and sleeping patterns, drowsiness and attention.

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. The frontal lobe of each hemisphere controls voluntary movement, usually on the opposite side of the body. The frontal lobe of the dominant hemisphere controls language and writing. (The dominant hemisphere is the left hemisphere in all right-handed and some left-handed individuals, and the right hemisphere in most left-handed people.) Other frontal lobe activities include intellectual functioning, thought processes, behavior, and memory.

Intra-axial Symptoms Occipital Lobe
Blindness in one direction or other visual disturbances, and seizures are common symptoms. The occipital lobe is involved in the understanding of visual images and the meaning of written word.

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. The parietal lobe receives and interprets sensations including pain, temperature, touch, pressure, size, shape, and body-part awareness. Other activities of the parietal lobe are hearing, reasoning and memory. The parietal lobe also controls language and the ability to do arithmetic. Numbers may be read, but there may be difficulty with calculations.

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. The temporal lobe is involved in the understanding of sounds and spoken words, as well as emotion and memory. Depth perception and the sense of time are also controlled by the temporal lobe

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. The pituitary is called the "master gland." It secretes several important hormones.

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 vomiting difficulties in walking due to the increased pressure caused by obstructive hydrocephalus. The thalamus monitors input from the senses and acts as a relay station for the sensory center of the cerebrum.

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

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 or sclerosis of the vertebral body, pedicles or lamina enlargement of a neural foramen indicating a spinal 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 calcification
on the plain CT scan include: meningioma—will also show hyperostosis of cranial vault most oligodendrogliomas astrocytoma—30% of low-grade tumours but infrequently in high-grade tumours ependymoma and subependymoma craniopharyngioma wall of giant aneurysm, arteriovenous malformations - 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 to carotid 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 cervical myelopathy - 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: A strong magnetic field aligns the protons in body within that field Pulses of electromagnetic waves in the right frequency and bandwidth induces the protons in the body to spin in unison 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

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: Cons: 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: Cons:
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: Cons:
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: Cons:
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 C5

Cranial (skull) (cerebral convexities) Osteomyelitis Subdural empyema
Etiology Etiologic agent Clinical manifestations Osteomyelitis (skull) Contiguous spread from pyogenic sinus disease Contamination by penetrating trauma S. aureus S. epidermidis redness, swelling, pain Subdural empyema (cerebral convexities) Sinus disease Penetrating trauma Otitis Streptococcus Staphylococcus Fever, headache, neck stiffness, FND (contralateral hemiparesis) For Subdural Empyema, FND = Focal neurologic deficit. Neurologic deficit results from inflammation of cortical blood vessels leading to thrombosis and stroke. Most common: contralateral hemiparesis

Cranial Headache,(50-90%) (brain parenchyma) FND (hemiparesis) 50%
Etiology 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 Direct seeding by penetrating trauma S. aureus For Brain abscess, alternatively may present as extremis if the abscess ruptures into the ventricular system

Spine Pyogenic Vertebral Osteomyelitis
Etiology 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. aureus Enterobacter 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

Spine Discitis Epidural abscess Etiology Etiologic agent
Clinical Manifestations Discitis (intervertebral disc space) 2º to post operative infections S. epidermidis S. aureus BACK Pain Radicular 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 Streptococcus spp. Back pain, fever, tenderness to palpation of spine For epidural abscess, the most significant risk is weakness leading to paralysis due to spinal cord or nerve root damage.

What are the common primary foci of infection that leads to the development of CNS infections?

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 67-75 Otitis Media 14 Post-surgery 4 Trauma 3 Others ( CHD, lung infection meningitis, etc..) 11

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

CNS TB Cranial 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.

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 Surgery
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

Neurosurgery Case 2: CNS Neoplasms

Similar presentations

Presentation on theme: "Neurosurgery Case 2: CNS Neoplasms"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Neurosurgery Case 2: CNS Neoplasms

Similar presentations

Presentation on theme: "Neurosurgery Case 2: CNS Neoplasms"— Presentation transcript:

Similar presentations

About project

Feedback