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.

Ventriculo-peritoneal shunt: A rare cause of basal ganglia and thalamic abscess

“…[123] Immuno-compromised state is one of the predisposing factors; however, in many cases source of sepsis or predisposing factor could not be determined. [24] In our case, there was a retrograde spread of shunt infection from the colonic bacteria as the shunt that was protruding through the anus was only repositioned and not completely replaced. This is the most likely cause of thalamic abscess in our patient.…”

“…Treatment options include stereotactic aspiration with or without continuous drainage,[467] free hand aspirations through a burr hole,[3] stereo-endoscopic aspiration,[89] ultrasound guided aspiration, surgical trans-ventricular approach, and medical management. Stereotactic aspiration remains the preferred treatment as it drains the contents of the abscess, reduces mass effect, and confirms diagnosis.…”

Silent diabetes mellitus, periodontitis and a new case of thalamic abscess

“…The mortality rate from a thalamic abscess is 9–14%,2 4 rising to 80% with the occurrence of intraventricular rupture 3. Survivors are at risk of permanent neurological damage: in published series, totalling 24 cases, 5 cases of minimal or moderate neurological damage and 1 case of severe disability were reported 3 4…”

“…Survivors are at risk of permanent neurological damage: in published series, totalling 24 cases, 5 cases of minimal or moderate neurological damage and 1 case of severe disability were reported 3 4…”

“…Diagnostic errors have been reported leading to inappropriate and delayed treatment. Often a tissue diagnosis is necessary,3 4 although the use of diffusion-weighted MRI (DWI) may add to the diagnostic potential of imaging 6. Given radiological uncertainty, the diagnosis of thalamic abscess is often made by the presence of predisposing conditions, which include: metastatic infection—secondary to congenital heart disease or chest sepsis: local infection arising from skull bone, ear, tooth or sinuses: diabetes mellitus or other causes for immunosuppression 2–4 7…”