Our findings suggest that IVROBA strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology.

Sixty-two cases of brain abscess with congenital cyanotic heart disease are reviewed. A sharp peak in the age distribution was seen at 4 to 7 years of age. Of 62 cases, 38 (61.2%) had a tetralogy of Fallot, and six had a transposition of the great vessels. The majority of these abscesses were supratentorial and 76% of abscesses were found in the frontal, temporal, and parietal lobes. Multiple abscesses were present in 19.4% of cases. Sterile cultures were obtained in 61% of the abscesses, and the increasing percentage of sterile cultures seems to be the result of broad-spectrum antibiotic therapy. The overall mortality rate was 37% but there were no deaths after surgical excision secondary to aspiration. Since the introduction of computerized tomography, aspiration without total excision has produced good results, and therefore it is believed that the number of cases which are cured with aspiration therapy alone will gradually increase in the future.

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Brain abscess is a serious complication of congenital cyanotic heart disease. We retrospectively evaluated the risk factors for brain abscess in 21 such patients treated between 1975 and 1990 in comparison with a control group. The mean arterial oxygen saturation, arterial partial pressure of O2, arterial blood oxygen content, and base excess in patients with brain abscess were significantly lower than in the control patients. The mean arterial partial pressure of CO2, pH, hematocrit, hemoglobin, and red blood cell content in patients with brain abscess were not significantly different. Patients with congenital cyanotic heart disease may develop minute encephalomalacia due to severe hypoxemia and increased blood viscosity resulting from compensatory polycythemia. The increased blood viscosity and reduced blood flow in the microcirculation may induce cerebral thrombosis or exaggerate minute encephalomalacia during dehydration or cardiac dysfunction, and shunted blood containing infectious organisms at such sites may be followed by focal cerebritis.

A 56-year-old female experienced sudden excruciating pain extending from the upper neck to the lower back. She had mild disturbance of consciousness, and a lumbar puncture revealed bloody cerebrospinal fluid. The positive neurological findings were meningitis, spastic paraparesis, hyperesthesia of the left L3 dermatome, bilateral Babinski, disappearance of anal reflex, and urinary retention. Computed tomography scans, myelography, and magnetic resonance images revealed diffuse subarachnoid hematoma and hematomyelia from Th12 to L3. Spinal angiography was tried twice before surgery but no origin of this diffuse hematoma could be found. Laminectomy was performed from Th12 to L1 and organized hematoma was found in the subarachnoid space. After the hematoma removal, non-pulsating tortuous vessels were observed on the surface of the spinal cord at the L1 level which ran into the intramedullary region. However, there was no further abnormality to define spinal arteriovenous malformation or fistula within the limits of exposure. The postoperative course was uneventful and about 2 months later she was able to walk by herself.

The authors report the clinicopathological findings in six cases of bacterial intracranial aneurysms. All patients received appropriate high-dose antibiotics, and four were treated surgically. One patient with multiple aneurysms of the main trunks died of disseminated intravascular coagulation. Autopsy disclosed no apparent aneurysm or inflammatory cell infiltration, but a partially interrupted internal elastic lamina and thickened intima were disclosed at the angiographical aneurysm sites. These findings suggest that 1) appropriate high-dose antibiotics are effective against inoperable bacterial aneurysms in the main trunks, 2) new aneurysms may be formed in patients with cyanotic congenital heart disease, because bacterial emboli can directly reach the cerebral circulation and reimplant on the fragile arterial walls after vasculitis. Histological examination of aneurysmal walls revealed inflam matory cell infiltration after resolution of clinical endocarditis. This suggests that both appropriate high-dose antibiotic therapy and surgery should be considered in patients with distal bacterial aneurysms.

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A patient who presented with a tumor of the left ambient cistern, a left cerebellopontine angle tumor, and a left orbital tumor causing left hearing loss and left exophthalmos without café au lait spots or cutaneous neurofibromas is described. There was no family history of von Recklinghausen's disease. A cerebellopontine angle tumor removed by a suboccipital craniectomy was an acoustic neurinoma. An ambient cistern tumor was approached through a subtemporal route. A tumor arising from the trigeminal nerve was also a neurinoma. An orbital neurofibroma was excised by a frontal craniotomy with removal of the orbital roof. This rare unilateral association of neurinomas and a neurofibroma on the left side was thought to be a forme fruste of von Recklinghausen's disease, and it could be considered a presentation of a mosaic of von Recklinghausen's disease.