Brain abscess at the site of recent primary intracerebral hemorrhage

Faisal Memon; Vikram Londhey; Rani D Meshram; Gautami M Kolhe

doi:10.4103/injms.injms_147_21

CASE REPORT

Year : 2022 | Volume : 13 | Issue : 3 | Page : 192-194

Brain abscess at the site of recent primary intracerebral hemorrhage

Faisal Memon, Vikram Londhey, Rani D Meshram, Gautami M Kolhe
Department of General Medicine, HBT Medical College and Dr RN Cooper Hospital, Mumbai, Maharashtra, India

Date of Submission	27-Dec-2021
Date of Decision	06-Feb-2022
Date of Acceptance	06-Feb-2022
Date of Web Publication	28-Jul-2022

Correspondence Address:
Dr. Gautami M Kolhe
Department of General Medicine, 4^th Floor, C Wing, Hospital Building, HBT Medical College and Dr RN Cooper Hospital, Juhu, Mumbai - 400 056, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_147_21

Abstract

Brain abscesses are rare and potentially lethal neurological lesions, requiring prompt attention. Although brain abscesses are known to complicate surgically intervened intracerebral hemorrhages (ICH), but the formation of a brain abscess at the site of an ICH treated without surgery is exceptional. We hereby report a case of a 14-year-old female presenting with a brain abscess 6 weeks after an episode of spontaneous ICH with no identifiable focus of infection. She was effectively treated with antibiotics in combination with craniotomy and excision of abscess and was discharged with good recovery.

Keywords: Brain abscess, computed tomography, intracerebral hemorrhage

How to cite this article:
Memon F, Londhey V, Meshram RD, Kolhe GM. Brain abscess at the site of recent primary intracerebral hemorrhage. Indian J Med Spec 2022;13:192-4

How to cite this URL:
Memon F, Londhey V, Meshram RD, Kolhe GM. Brain abscess at the site of recent primary intracerebral hemorrhage. Indian J Med Spec [serial online] 2022 [cited 2023 Jun 7];13:192-4. Available from: http://www.ijms.in/text.asp?2022/13/3/192/352632

Introduction

Brain abscesses are uncommon, serious, life-threatening infections requiring prompt surgical drainage and high-dose antibiotic therapy. A brain abscess may develop by spread from a contiguous cranial site of infection, such as paranasal sinusitis, otitis media, and mastoiditis following penetrating head trauma or neurosurgical procedure or by hematogenous spread from septic foci elsewhere in the body. In up to 40% of cases, no obvious source of infection is apparent.^[1] Risk factors for developing brain abscess are immunodeficiency, diabetes mellitus, age, and congenital heart diseases producing right-to-left shunt. Common organisms implicated in causing cerebral abscess include Streptococci, Bacteroides spp., Pseudomonas spp., Haemophilus spp., and Enterobacteriaceae.

Case Report

We hereby report case of a 14-year-old female with no previous comorbidities who presented with history of headache, nausea, vomiting, and behavioral changes in form of confusion and decrease interactions with siblings of 3 days duration. There was no history of fall or trauma to the head and no history of fever.

Neurological examination did not reveal any focal neurological deficit, neck stiffness, or visual disturbance.

A noncontrast computed tomography (CT) brain was done, which was suggestive of an acute intracerebral hemorrhage (ICH) of 3.5 cm × 2.5 cm × 5 cm in the left anterior temporal lobe extending into the left perisylvian temporoparietal lobe with perilesional edema and 3 mm midline shift to right [Figure 1]. A CT brain angiogram was done next day, where the findings of hemorrhage were consistent with the initial noncontrast CT brain findings and angiogram revealed a suspicious small aberrant vascular loop on superior aspect of the hemorrhage favoring to be a vascular malformation and hence four vessel digital subtraction angiography (DSA) was planned.

Figure 1: Brain computed tomography showing an intracerebral hemorrhage in the left temporal lobe on day 1

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Initial laboratory testing revealed normal complete blood count, prothrombin time, and partial thromboplastin time and the patient did not have any bleeding tendency in past or family history of bleeding problem, which ruled out any bleeding disorder in patient.

Patient was managed conservatively with antiepileptics, antiedema measures in the form of mannitol, and nonsteroidal anti-inflammatory drugs for headache to which the patient responded well and headache regressed significantly, hence the patient was discharged on the 4^th day of admission.

Four vessel DSA was done 1 week after episode of spontaneous ICH through the right transfemoral route to rule out vascular malformation or ruptured aneurysm, four vessel DSA revealed normal study, and hence bleed from vascular malformation or ruptured aneurysm was ruled out.

Six weeks later, patient was again hospitalized with history of gradually worsening headache, vomiting, and diplopia, which was present for the past 2 weeks. About 12 h before this admission patient became disoriented and was not responding to oral commands. In the emergency room, the patient was afebrile, drowsy but arousable and disoriented. On neurological examination, the patient was having neck rigidity with positive Babinski sign on the right side.

Patient underwent an emergency CT brain with contrast which revealed a 3.5 cm × 2.9 cm × 5.5 cm ring-enhancing hypodense lesion in the left temporoparietal region at the site of previous ICH with moderate perilesional edema and mass effect with midline shift of 11 mm to the right side favoring a cerebral abscess [Figure 2]. Patient underwent an emergency left temporal craniotomy with excision of abscess [Figure 3]. A well-encapsulated collection of pus admixed with blood was drained and capsule was excised. Histopathological examination of excised tissue revealed an organizing abscess and pus grew Pseudomonas species and based on culture pattern, the patient was treated with piperacillin/tazobactam, amikacin, and metronidazole for 6 weeks.

Figure 2: Development of a ring-enhancing lesion at the site of primary intracerebral hemorrhage with significant vasogenic edema and middle shift at 6 weeks

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Figure 3: Brain computed tomography on day 1 postsurgical evacuation

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Chest radiographs, echocardiogram, blood culture, urine culture, otolaryngological, and dental examination were negative for potential source of infection. CT brain done after completion of 6 weeks of antibiotic therapy showed abscess absorption with complete resolution of mass effect [Figure 4].

Figure 4: Brain computed tomography after completion of 6 weeks of antibiotic therapy, showing compete resolution of abscess

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Discussion

The classical clinical triad of a brain abscess has been described as headache, fever, and focal neurological deficit, but this classical triad is present in <20% of patients with brain abscess on admission.^[2] Headache is the most common symptom in patient with a brain abscess and is reported in 69% of patients, while fever is present only in 53% of patients at diagnosis and its absence does not exclude the diagnosis.^[2] Our patient did not have any focal neurological deficit at presentation, as the clinical presentation of brain abscess depends on its location, hemiparesis is usually seen in patients with frontal lobe abscess, whereas visual disturbances are common with temporal or parietal lobe abscess, which was present in our case in the form of diplopia.

Brain abscess formation at the site of an ICH is an extremely rare event with only a few cases reported in the literature. Brain abscesses have a high mortality rate and diagnosing brain abscess following ICH is very difficult unless a clinically high index of suspicion is maintained as differentiation between resolving ICH and brain abscess is difficult because similar ring enhancement is seen around ICH from 1 to 8 weeks after primary ICH.

ICH leads to disruption of the blood–brain barrier, systemic infections can reach such vascularized sites by hematogenous spread. Most of the previously reported cases of brain abscess at the site of untreated ICH were in patients of extreme ages with predisposing factors and these patients had some identifiable source of infection elsewhere in the body such as pneumonia, urinary tract infection, thrombophlebitis, arthritis, osteomyelitis, and infective endocarditis but our patient was of young age with no predisposing factors and cerebral abscess formation was not preceded by an obvious source of infection.^{[3],[4],[5],[6],[7]}

Our patient although underwent DSA procedure 5 weeks before presenting with cerebral abscess and this was the only preceding event in our patient. There are only a few reported cases in the literature of cerebral abscess formation after endovascular procedures such as intraarterial thrombolytic therapy or mechanical thrombectomy done for stroke but the risk of acquiring infection after such procedure is low and most infections are localized to the femoral artery, still the procedure of DSA could be a potential source of infection in our patient.^[8],[9]

Alternatively, the original presentation of ICH in our patient itself could have been a preexisting cerebral abscess with secondary hemorrhage in it. There are handful of case reports in which the initial diagnosis was ICH, but during surgical intervention, it turned out to be a cerebral abscess or case reports of hemorrhage into a preexisting abscess.^{[10],[11],[12]} The exact mechanism of hemorrhage in the cerebral abscess is not fully understood, but it could be due to breakdown of newly formed, fragile blood vessels in the abscess wall. It is possible that the hemorrhage in an underlying abscess could have masked the evidence of abscess in initial brain imaging studies in our patient. In our case, initial two CT scans had a clear evidence of hemorrhage and there was no suspicion of an alternate diagnosis, hence magnetic resonance imaging (MRI) brain was not done.

Our case highlights the importance of maintaining a high index of suspicion for a brain abscess following an ICH if the clinical and radiological picture differs from the expected course of a resolving ICH.

Despite diagnostic advancements with the introduction of CT and later MRI, as well as better antimicrobial agents and neurosurgical procedures, brain abscess continues to be a serious, potentially life-threatening condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

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