Acta Neurochir (Wien) (2000) 142: 205±208 Acta Neurochirurgica > Springer-Verlag 2000 Printed in Austria Subarachnoid Haemorrhage as Initial Symptom of Multiple Brain Abscesses V. Rohde1, A. van Oosterhout1, M. Mull,2 and J. M. Gilsbach1 1 Department of Neurosurgery, University of Technology (RWTH) Aachen, Germany 2 Department of Neuroradiology, University of Technology (RWTH) Aachen, Germany Summary The case of evolving multiple brain abscesses which became symptomatic with a sudden hemianopsia and the clinical and radiological signs of a subarachnoid haemorrhage, is reported. A common pathomechanism which could explain both the sudden focal neurological de®cit and the subarachnoid bleeding is discussed. Keywords: Brain abscess; computerized tomography; cerebritis; subarachnoid haemorrhage. Introduction The typical clinical feature of spontaneous subarachnoid haemorrhage (SAH) is sudden onset of severe headache, usually in combination with nausea, vomiting, and syncope. The clinical investigation routinely reveals nuchal rigidity. Focal neurological de®cits and a decreased level of conciousness are usually found in more severe forms of SAH. In 75% to 92% of spontaneous SAHs, an intracranial aneurysm can be diagnosed [14]. In only 0.7% to 5% of the cases, SAH is caused by a cerebral arteriovenous malformation (AVM) [2, 14]. Sporadically, SAH is the initial symptom of benign and malignant intra- and extra-axial tumours [9, 13]. The authors report the ®rst case, in which SAH was the presenting sign of evolving multiple brain abscesses. Case Report This 56-year-old male patient came to admission one day after sudden onset of severe headache in combination with nausea and vertigo. Clinical examination revealed moderate nuchal rigidity and a left homonymous hemianopsia. Cerebral computerized tomography (CT) scans were performed immediatly and showed a SAH, which was con®ned to the right parietal sulci (Fig. 1). The subsequent angiography failed to show the suspected vascular malformation. CT scanning, which was repeated shortly after angiography, con®rmed the subarachnoid blood in the parietal sulci and showed slight contrast enhancement of the adjacent, swollen gyri. Magnetic resonance (MR) imaging was performed on day 6 after admission to rule out an angiographically occult vascular malformation. The T1 contrast enhanced MR-images showed a single frontal and multiple parietal lesions with marked ring enhancement and slight perifocal oedema (Fig. 2). The MR ®ndings now suggested the presence of multiple brain abscesses. The patient underwent frameless stereotactic puncture of the largest parietal lesion, and pus was drained. We failed to isolate the causative organism, but paranasal sinus infection could be identifed as a potential source of the infection. Following the drainage of the paranasal sinuses and intravenous administration of antibiotics, the patient made a complete recovery within four weeks. Discussion Fever, seizures and focal neurological de®cits are frequent symptoms of single and multiple brain abscesses [11, 17, 24]. In patients with brain abscess, headache with nausea is the ®rst symptom of increased intracranial pressure. A decreased level of conciousness emerges with increasing size of the abscess and the development of perifocal oedema. The symptoms of single and multiple brain abscesses are gradual in onset. The diagnosis is made by CT scanning or MR imaging [1, 4, 5, 10, 12, 15]. The radiological appearance is related to the stage of the abscess. In the early cerebritis stage, no contrast enhancement or partial ring contrast enhancement is observed. The infected tissue is hypodense in the CT scans, hypo-intense in the T1-weighted MR images and hyperintense in the T2weighted MR images. In the capsule formation stage, the typical radiological picture of a smooth, thin, regular contrast medium-enhancing wall and a nonenhancing central portion is seen on both CT scans and MR images. In the present case, the patient became suddenly symptomatic with severe headache, nuchal 206 V. Rohde et al. Fig. 1. The non-contrast computerized tomography (CT ) scan was obtained one day after sudden onset of severe headache, nausea and homonymous hemianopsia. The scan showed a subarachnoid haemorrhage, which was con®ned to the right parietal sulci Fig. 2. The gadolineum-enhanced axial and coronal T1-weighted magnetic resonance (MR) images, which were obtained six days after admission revealed a single left frontal lesion and multiple right parietal lesions with marked ring enhancement and perifocal oedema, which made the diagnosis of multiple brain abscesses probable 207 Subarachnoid Haemorrhage and Multiple Brain Abscesses rigidity and homonymous hemianopsia. The initial CT scans without contrast medium revealed subarachnoid blood in the parietal sulci. The subsequent CT scans after angiography con®rmed the subarachnoid blood and showed slight gyral contrast enhancement but failed to show areas of hypodensity or partial ring enhancement which usually indicate the early cerebritis stage [5]. In the absence of a space-occupying lesion, the severe headache and the nuchal rigidity could be best explained by the sulcal SAH, and not by beginning abscess formation. The authors are well aware, that, from the scienti®c point of view, con®rmation of the radiologically diagnosed subarachnoid bleeding by lumbar puncture would have been of value. However, lumbar puncture in cases of CT-proven SAH and typical symptoms is not an essential part of the diagnostic work-up and, therefore, was not performed. With the exception of cranial nerve palsy, a sudden neurological de®cit in conjunction with SAH is exceptional without a signi®cant amount of intracerebral blood. It is unlikely, that the circumscribed sulcal SAH caused the hemianopsia. The development of focal neurological de®cits in patients with brain abscess is related to the increasing size of abscess and perifocal oedema. However, we failed to identify any signi®cant space occupying lesion on the initial CT scans. Thus, the sudden visual ®eld cut could be best explained by cortical ischaemia [18]. Multiple brain abscesses are usually caused by haematogenous spread from congenital heart disease, endocarditis, and pulmonary abscesses, but are also found with middle ear infections and sinusitis [11, 17]. Possibly, septic emboli occluded cortical vessels in the vicinity of the visual cortex. Septic emboli also could explain the occurrence of sulcal SAH. Perivascular in¯ammation of the occluded cortical vessels results in weakening of the vessel wall with the risk of subsequent subarachnoid bleeding [4, 18]. If subcortical instead of cortical vessles are a¨ected, intracerebral haemorrhage could be the consequence [20, 21]. Brain abscesses are managed by framebased or frameless stereotactic puncture, drainage of the purulent material and subsequent antibiotic therapy, often accompanied by corticosteroids to decrease the size of the perifocal oedema [5, 6, 7, 11, 12, 19, 22, 23]. If antibiotic therapy is initated in the early cerebritis stage, that means, before formation of a ®rm capsule, which cannot be penetrated by antibiotics, surgery could sometimes be avoided [3, 8, 16]. 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J Neurosurg 55: 794±799 Correspondence: Veit Rohde, M.D., Department of Neurosurgery, University of Technology (RWTH) Aachen, Pauwelsstrasse 30, 52057 Aachen, Germany.