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| Year : 2001 | Volume
: 49
| Issue : 1 | Page : 91-3 |
Cerebral abscess with astrocytoma.
Bansal S, Vasishta RK, Pathak A, Jindal VN, Khosla VK, Banerjee AK
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh - 160012, India.
Correspondence Address:
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh - 160012, India.
A child with a right parieto-occipital astrocytoma, caped by a large acute pyogenic abscess with flimsy capsule, detected at emergency craniotomy, is presented. Patient succumbed to the disease three hours following surgery.
How to cite this article:
Bansal S, Vasishta R K, Pathak A, Jindal V N, Khosla V K, Banerjee A K. Cerebral abscess with astrocytoma. Neurol India 2001;49:91 |
Abscess in an intracranial tumour is an extremely uncommon occurrence. Most of the abscesses associated with such tumours have been located in sellar/suprasellar region i.e. pituitary tumours and craniopharyngiomas.[1],[2] Intact brain is quite resistant to infection.[3] Therefore, abscesses due to bacteraemia evolve in infarcts, intracerebral haematomas (ICH), malignant necrotic tumours (gliomas, metastases).[4],[5] Recently, abscesses have been reported with ependymoma and meningioma.[6]
A 11 years female child was admitted with history of left focal seizures becomming generalised of one year duration. The seizure commenced in left lower limb. There was no preceding aura. The seizures recurred almost every fortnight. History of headache, vomiting, fever, head trauma or family history of anyother neurological ailment was denied. Examination at admission revealed no systemic abnormality. She had early bilateral papilloedema. Skull and chest X-rays were normal. Noncontrast computed tomography scan (NCCT) of brain demonstrated a wedge shaped hypodense lesion in right posterior parieto-occipital region [Figure 1a]. Contrast enhanced computed tomography scan (CECT) delineated two concentric semilunar hyperdensities along with an intense irregular cord/garland like enhancement in the centre of the lesion [Figure 1b]. There was no mass effect or shift. Transfemoral arteriography revealed no intracranial vascular lesion. She had high grade fever along with signs of meningeal irritation following arteriography. Sudden onset left hemiparesis was noted on fifth day of angiography. Surgery was delayed due to meningitis and intense pyrexia. Haematological investigations showed leucocytosis (12400/mm3, when febrile and 8000/mm3 at admission with 70% polymorphs in both samples), high ESR (44 mm first hour) and normal coagulation profile. Renal, liver functions, serum analysis, urine, blood culture, chest X-ray and ECG were normal.
Fever did not abate despite antibiotic therapy in antimeningitic dosage. Her consciousness continued to deteriorate even on cerebral decongestive therapy. An emergency right parieto-occipital craniotomy was performed and a large tumour of variegated consistency and moderate vascularity was excised. This tumour was caped around by poorly capsulated foul smelling pus. Tumour was subtotally excised and around 100 ml foul smelling pus was drained. In postoperative period, her pupils remained dilated and spontaneous breathing effort was still inadequate, hence she was maintained on assisted ventilation. Three hours later, she developed cardiac arrest from which she could not be revived. Autopsy was not permitted. Histopathological examination showed a tumour composed of astrocytic cells, which were fibrillary in many areas. There was reactive mesenchymal proliferation and vascular proliferation around an area of abscess of recent origin [Figure - 2]. This abscess was seen in tumour areas. The pus was teaming with gram negative bacilli and showed heavy growth of pseudomonas aeruginosa.
Only 22 patients of intracranial tumours with adjoining abscesses have been reported.[1],[2],[5],[6],[7],[8],[9],[10] Out of these, 7 were pituitary tumours, 4 craniopharyngiomas and 3 meningiomas.[2],[6] Cerebral parenchymal tumours with abscesses have been first described by Hasearts and Retif in 1963.[7] Subsequently, a few reports in this context appeared in the literature. The intracerebral tumours included: 3 astrocytomas, 2 glioblastomas, 1 metastases, 1 ependymoma and 1 not specified.[5],[10] Staphylococcus aureus, salmonella enteritidis, E.coli and bacteroides were grown from the pus.[5] The patient under report had astrocytoma and pseudomonas was grown from the pus. Most of these lesions have been reported in young and middle aged individuals. One 62 years old man harboured a metastatic lesion from bronchogenic carcinoma along with an abscess.[7] Recently, two patients of abscess, one surrounding falx and another a parasaggital meningioma with central necrosis, have been reported.[6],[11]The initial presenting features in these patients were related to tumour in 4, both tumour and abscess in 3 and abscess alone in one patient.[5],[6],[7],[8] Usually, the abscess was responsible for sudden deterioration which proved fatal in six of them. The case under discussion had astrocytoma with surrounding poorly capsulated large abscess. The focal seizures were due to parieto-occipital tumour and uncontrolled high grade fever, hemiplegia, unconsciousness, laboured respiration resulted from meningitis and abscess. Acute deterioration due to fulminant meningitis, 5 days following angiography and an associated large purulent collection of an expected age of less than 13 days found at surgery, suggests septic embolisation during angiography in our patient. Nasser et al reported a 32 month old child, with ependymoma of the fourth ventricle and abscess underneath, along with meningitic illness.[6] Ours is the second patient with meningitis and intracerebral collection of pus around a tumour.
The postulations on pathogenesis of abscess around tumour are based on clinical experiences of various authors and histopathological and autopsy findings. Most of the tumours reported with this association were necrotic. The necrotic centre or haematoma forms a suitable medium for growth of micro-organisms.[7] An alteration in metabolism of neural tissue due to local anoxia resulting from ischaemia and venous stasis are prerequisite for abscess formation. Immune mechanism is already at stake in gliomas. This is further suppressed by frequently used steroid therapy; thereby, flora with low virulence can also flourish.[12] Breach in blood brain barrier (BBB) adds to permeation of organisms to the tumour tissue. All these factors form an ideal mileau for bacterial emboli to settle and grow, hence helping an abscess formation.
Dual embolisation from lungs can be responsible for cerebral metastases with abscess.[7] Intracerebral tumours are more vulnerable to infective embolisation due to presence of necrosis, arteriovenous shunts, haematoma, poor oxygenation and disrupted BBB.[7]
Histopathological findings recorded in these lesions include well defined tumour with necrotic centre and a demarcation interface of tumour from abscess. There is perivascular and intratumoural infiltration by polymorphs and microbial colonies; the later are sufficient enough to be cultured. These criteria are mandatory to establish a diagnosis of purulent tumour.[7] This combination had been dreadful in most of the cases whereas both conditions, in an individual setting, fare satisfactorily well. The dominant culprit for an acute neurological deterioration is abscess with poor or no encapsulation, with or without meningitis. Seepage of infection to surrounding white matter initiate cascade of changes leading on to abscess formation.
In unusual presentations e.g. acute deterioration, febrile and meningitic illness with equivocal diagnosis, a fresh imaging, preferably magnetic resonance imaging, may be of help to arrive at this diagnosis.[5]
Markedly elevated C-reactive protein, though nonspecific, may arouse a suspicion of infection.[13] Appropriate antibiotics in adequate dosages, cerebral decongestive therapy, anticonvulsant therapy and close drainage of abscess are indicated to achieve control of infection. A definitive surgery follows only after attaining a stable neurological and general physical status to attain a satisfactory post-operative outcome.
| 1. | Obrador S, Blazquez MG : Pituitary abscess in a craniopharyngioma : case report. J Neurosurg 1972; 36 : 385-389.  |
| 2. | Nelson PB, Harvey Kos H, Martinez AJ et al : Abscess formation within pituitary tumours. Neurosurgery 1983; 12 : 331-333. |
| 3. | Groff A : Experimental production of abscess of the brain in cats. Arch Neurol Neurosurg Psychiatry 1934; 31 : 199-204. |
| 4. | Malinari GF, Smith L, Goldstein MN et al : Brain abscess from septic cerebral embolization - an experimental model. Neurology 1973; 23 : 1205-1210. |
| 5. | Ichikawa M, Shimizu Y, Sato M et al : Abscess with a glioblastoma multiforme -case report. Neurologia Medicochirurgica 1992; 32 : 829-832. |
| 6. | Nasser SI, Haddad FS, Hanball FS et al : Abscess superimposed on brain tumour. Two case reports and review of the literature. Surg Neurol 1997; 47 : 484-488 |
| 7. | Hasearts R, Retif J : Le problemie les tumers cerebrates abcedees. Acta Neurological et Psychiatrica Belgica 1963; 63 : 1013-1022. |
| 8. | Prusty GK : Abscess within a metastatic tumour. Neurol India 1997; 45 : 113. |
| 9. | Noguerado A, Cabanyes J, Vivancos J et al : Abscesses caused by salmonella enteritidis within a glioblastoma multiforme : case Report. J Infect 1987; 15 : 61-63. |
| 10. | Sharma S, Raja A, Shivananda PG : Isolation of salmonella typhi from brain tumour : case report. Indian J Sci 1986; 40 : 233-235. |
| 11. | Eisenberg MB, Lopez R, Stanek A : Abscess formation with a parasagittal meningioma : case report. J Neurosurg 1988; 88 : 895-897. |
| 12. | Rehman Zurin AA, Ushikoshi S, Houkin K et al : Cerebral abscess as an unusual complication of coil embolization in dural arteriovenous fistula : case report. J Neurosurg 1997; 87 : 109-112. |
| 13. | Hirchberg H, Bosnes V : C-reactive protein levels in the differential diagnosis of brain abscess. J Neurosurg 1987;67:358-360. |
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