Endoscopic ultrasonic aspiration of brain abscess.

Brain abscess is a focal infection occurring within the brain parenchyma consisting of a pus collection surrounded by a vascularized capsule and a fibrinous-caseous layer between pus and capsule. Surgery is indicated for lesions with a diameter larger than 25mm. Different surgical approaches have been described, including puncturing of the abscess (under neuronavigation, stereotactic or ecographic guidance) with aspiration of the purulent fluid though a catheter, and craniotomy with microsurgical removal of the purulent material together with surrounding capsule. In the recent years endoscopic approach has become more frequently used to treat brain abscess. The theoretical advantages are the visual awareness of the completeness of pus removal, and the possibility to remove also the more solid fibrinoid component, that may be the source of recurrence. Craniotomy is likewise avoided. We present a case of an 11-year-old boy affected by parieto-occipital brain abscess and initial ventriculitis who underwent endoscopic surgery. An ultrasonic aspirator was used to wash and suck the purulent material and to fragment and remove the more solid fibrinoid component. The occipital horn of the lateral ventricle was also entered, and the pus removed. At the end of the procedure a ventricular drainage was left in the surgical cavity. It was removed 1 day later, because the cavity completely collapsed. Key surgical steps are presented. The procedure was uneventful, with very good clinical and radiological results. Endoscopic technique emerges as a safe and effective treatment option for intracranial abscess: in case of large superficial lesions the surgical risks appear not to be superior to simple drainage through catheters, with possibly reduction of the 20% recurrence rate, reported in literature. The use of an ultrasonic aspirator, may facilitate complete and faster pus removal, increasing efficacy of the procedure.