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(BQ) Part 2 book Oxford challenging concepts in neurosurgery - Cases with expert commentary has contents: Trigeminal neuralgia, cerebral metastasis, the surgical management of the rheumatoid spine, cervical spondylotic myelopathy, peripheral nerve injury,... and other contents.
CA SE 11 Intracranial abscess Ciaran Scott Hill Expert commentary George Samandouras Case history A 20-year-old right-handed man presented to the Emergency department with a 4-week history of right-sided earache associated with a foul smelling purulent discharge He had suffered from intermittent ear discharge since childhood, but he had been well for the previous year The current episode had been treated with a 1-week course of antibiotics by the general practitioner without any effect The patient then developed general malaise, positional headaches, and was now describing intermittent horizontal vertigo, the sensation of movement as if the environment were spinning There were no meningitis symptoms He had no headache, neck stiffness, or photophobia His past medical history was otherwise unremarkable On examination, there was an erythematous, boggy swelling over the right mastoid process The right external auditory meatus was completely occluded by pus and the pinna was pushed anteriorly The patient was admitted under the ear, nose, and throat surgeons who requested routine laboratory investigations and a microbiology swab that was sent for microscopy, culture, and sensitivity A CT scan was performed and the CT images are shown in Figure 11.1 A diagnosis of mastoiditis was made and the patient was placed on the emergency theatre list for an exploratory mastoidectomy However, the next day the patient was noted to have developed a mild right-sided hemiparesis and was referred to neurosurgery Review of the CT scans (Figure 11.2) with brain windows demonstrated a hypodensity of the right cerebellum in association with subtle triventricular hydrocephalus and displacement of the IVth ventricle It was felt these images were consistent with cerebritis and a T1, T2 and T2 FLAIR MR scan was requested (Figure 11.3) Additionally, a T1 scan with contrast (Figure 11.4), diffusion-weighted imaging (Figure 11.5) and magnetic resonance venography (MRV) was performed (Figure 11.6) Expert comment The role of steroids remains controversial in the literature, with some studies supporting their use, while others advocate against them Cerebral oedema is a major cause of morbidity and mortality in patients with brain abscess When the patient is on a targeted antibiotic treatment, administration of dexamethasone, in the presence of oedema on imaging, is often an essential part of the patient’s management Long-term use should be discouraged Rapidly deteriorating patients referred from district general hospitals requiring urgent treatment can have, prior to transfer, administration of broad spectrum antibiotics and dexamethasone after obtaining blood cultures Expert comment The classic clinical triad of headache, high temperature, and focal neurological deficit occurs in