First-line Stereotactic Treatment of Thalamic Abscesses: Report of Three Cases and Review of the Literature

Abstract

Solitary pyogenic thalamic and basal ganglia abscesses are relatively uncommon. Even if widespread antibiotic therapy and modern imaging technologies combined with minimally invasive techniques have improved the outcome in patients with brain abscesses, this is counterbalanced by an increasing population of immunocompromised patients. Basal ganglia, thalamic, brainstem or multiple abscesses are usually of hematogenous origin with an underlying source of infection which can include congenital heart disease, thoracic sepsis or, less frequently, an odontogenic or otogenic source. However, no evident foci of sepsis or predisposing factors may be found. Only a few studies are reported in the literature, because midline abscesses are usually included in studies dealing on the treatment of abscesses in general. Different treatment options and the timing of treatment are described. We report our experience in 3 consecutive cases of thalamic abscess, treated by stereotactic puncture as the first step, followed by histological analysis, external drainage and targeted intrathecal and systemic antibiotic therapy. Deep-seated abscesses seem to behave differently as they are associated with an increased risk of intraventricular rupture and antibiotic resistance, a fact which justifies a more aggressive and immediate surgical treatment. We review the literature on this topic in the last 20 years.

Zusammenfassung

Pyogene Abszesse im Bereich des Thalamus und der Basalganglien sind relativ selten. Die Prognose hat sich in den letzten Jahren durch minimal-invasive operative Verfahren, exaktere Bildgebung und den Einsatz von neueren Antibiotika verbessert. Gewöhnlich entstehen diese Abszesse durch eine hämatogene Aussaat bei Infektionen, die im Rahmen von angeborenen Herzkrankheiten und von Lungenerkrankungen auftreten. Seltener haben die Abszesse einen odontogen oder otogenen Ursprung. Manchmal lässt sich kein Herd identifizieren. Bislang ist kaum fokussiert über Abszesse des Thalamus und der Basalganglien berichtet worden. Wir beschreiben unsere Erfahrungen, die wir bei der Behandlung von drei konsekutiven thalamischen Abszessen gemacht haben. Diese wurden stereotaktisch punktiert und mit einer externen Drainage versorgt. Gemäß der mikrobiologischen Aufbereitung erfolgte eine gezielte lokale sowie eine systemische Antibiose. Wir analysierten zudem die Literatur der letzten 20 Jahre zu diesem Thema und kommen zu dem Schluss, dass eine rasche und auch aggressive Therapie der thalamischen Abszesse zur Vermeidung einer prognostisch ungünstigen Ruptur in das Ventrikelsystem erfolgen sollte.

Key words

brain abscess - thalamus - stereotactic surgery

Schlüsselwörter

Hirnabszess - Thalamus - Stereotaktische Chirurgie

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