Tuberculous brain stem abscesses in children

Abstract

Tuberculous brain stem abscess is a highly uncommon entity. Three children with tuberculous brain stem abscesses of 1 month, 7 and 12 years of age were treated by microsurgical evacuation and biopsy of capsule, utilizing safe incisions over dorsal brain stem, through the floor of IV th ventricle. There was no added deficit postoperatively in these children. Microsurgical evacuation and biopsy helped in differentiating these lesions from pyogenic abscesses in two cases for appropriate treatment. The third operated case was a child, who while being on antituberculosis treatment for proven tuberculous meningitis for 1.5 year developed medullary and pontine abscess and tuberculoma exemplifying a paradoxical response to chemotherapy. Brain stem abscess especially tuberculous need surgical drainage, as it provides an accurate proof of offending organism and also takes care of a paradoxical response to antituberculosis chemotherapy in diagnosed cases. The safe incisions on brain stem are helpful to avoid the morbidity. (J Pediatr Neurol 2004; 2(2): 101-106).Key words: brain stem abscess, tuberculosis. IntroductionThe brain stem is an uncommon site for abscess to occur. It accounts for only 0.5-6% of brain abscesses (1) while, tuberculous abscess is further rare in brain stem. It is an infrequently recognized entity. This together with an old neurosurgical dogma, that brain stem lesions were inoperable, contributed to the uniformly fatal outcome of this disease. The better understanding of microsurgical anatomy and different microsurgical approaches to each segment of brain stem has resulted in few case reports of successful outcome. The best and safe method of treatment for brain stem abscess is yet to be defined. It can be managed by medical treatment alone, stereotactic aspiration of pus and medical treatment, or surgical excision/drainage of the abscess. Here we are presenting three children of brain stem tuberculous abscesses, who were treated surgically along with antituberculosis chemotherapy. The clinical profile, microsurgical incisions over brain stem for drainage, and outcome of these children is discussed here. Case Reports Case 11-month-old female child presented to us with intermittent fever for 15 days, deviation of angle of mouth to left for 15 days and weakness of left side of body for 4 days. On examination she was conscious, alert, following light and sound, had right VI th and VII th nerve paresis. She had left sided hemiparesis (muscle power 3/5) with extensor plantar response. On investigation, her hemoglobin was (9.2 g/dL), total leukocyte count 7600/mm 3 . Contrasted computed tomography (CT) of head showed a ring enhancing lesion with thick ring, placed eccentrically to right in pons with its extension into upper medulla (2.5x2 cm in size) with perilesional edema. It had a daughter nodular ring projecting posteriorly in 4th ventricle (Figure 1). A clinico-radiological diagnosis of pyogenic pontine abscess was considered. Midline suboccipital craniectomy and drainage of abscess was done th...

Perforating Arteries of the Lemniscal Trigone: A Microsurgical Neuroanatomic Description

“…The intracollicular safe entry zone was firstly described by Bricolo and Turazzi (Bricolo et al, 1991;Bricolo and Turazzi, 1995) and later supported by other studies (Cantore et al, 1999;Kumar and Singhi, 2004;Ramina et al, 2011;Yagmurlu et al, 2014;Cavalcanti et al, 2016;Kalani et al, 2016;Matsushima FIGURE 8 | The right hemisphere, oblique view. Particular: magnification of the arachnoidal layers illustrated in Figure 7.…”