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NEUROCIRUGÍA

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www.elsev ier .es /neuroc i rugia

ase Report

ntracerebral abscess: A rare complication of deep braintimulation

va Brandãoa,∗, Maria José Rosasb, Pedro Abreub, Paulo Linharesc,d, Rui Vazc,d

Department of Neurology, Hospital de S. Sebastião, Santa Maria da Feira, PortugalDepartment of Neurology, Hospital de S.João, Porto, PortugalDepartment of Neurosurgery, Hospital de S.João, Porto, PortugalFaculty of Medicine, University of Porto, Porto, Portugal

r t i c l e i n f o

rticle history:

eceived 1 August 2011

ccepted 1 November 2011

vailable online 24 October 2012

eywords:

arkinson’s disease

eep brain stimulation

urgery

nfection

bscess

a b s t r a c t

Introduction: Deep Brain Stimulation (DBS) is a therapeutic option for some forms of

Parkinson’s disease (PD). The main adverse effects of this surgery are: infection (2–9%),

haemorrhage (1–4%) and seizures (1–3%). We report a rare complication of DBS: an intracra-

nial abscess.

Case report: A 59-year-old male who had suffered PD for 19 years was submitted to bilateral

subthalamic nucleus DBS in September 2003, when he was 52. One month later, he developed

an inflammatory reaction of the skin and subcutaneous tissue surrounding the area of the

subcutaneous DBS system. No infectious agent was isolated. In the following 12 months he

required 5 major surgeries due to a process of systematic inflammation/infection through-

out different locations of the DBS system. A few days after removal of the DBS device, he

developed a right oculomotor nerve paresis and mild left hemiparesis. A CT scan revealed

an abscess in the right thalamo-mesencephalic area. Both the new neurological deficits and

the previous tremor and rigidity improved after surgical drainage and medical treatment.

Conclusion: This case report illustrates a rare complication of DBS surgery. Nevertheless,

Parkinsonism improved, probably because the abscess acted like a subthalomotomy.

© 2011 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L. All rights

reserved.

Absceso intracerebral: una rara complicación de la estimulación cerebralprofunda

alabras clave:

r e s u m e n

Introducción: La estimulación cerebral profunda (DBS) es una opción terapéutica en algu-

nfermedad de Parkinson nas formas de la enfermedad de Parkinson (PD). Sus complicaciones principales son las

s hemorragias (1–4%) y las convulsiones (1–3%). Se presenta una com-

stimulación cerebral profunda infecciónes (2–9%), la irugía

nfección

bsceso

plicación rara de la DBS: un absceso intracraneal.

Caso clínico: Un paciente de 59 anos fue enviado para estimulación bilateral del núcleo sub-

talámico en setiembre del 2003 tras 19 anos de enfermedad. Un mes más tarde desarrolló

∗ Corresponding author at: Servico de Neurologia, Hospital S. Sebastião, Rua Dr. Candido de Pinho, 4520-211, Santa Maria da Feira, Portugal.E-mail address: brandaoeva@gmail.com (E. Brandão).

130-1473/$ – see front matter © 2011 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L. All rights reserved.ttp://dx.doi.org/10.1016/j.neucir.2011.11.008

34 n e u r o c i r u g i a . 2 0 1 3;2 4(1):33–36

una reacción inflamatoria de la piel y tejido subcutáneo en las zonas adyacentes al sistema

de DBS, no se consiguiendo aislar ningún microorganismo. Durante los 12 meses siguientes

fueron necesarios cinco drenajes quirúrgicas por infecciones o inflamaciones en diferentes

localizaciones del sistema. Finalmente se decidió retirar todo el sistema, pero unos días más

tarde desarrolló una paresia del III par derecho y una discreta hemiparesia izquierda. Un

TAC cerebral reveló la presencia de un absceso en la región talamo-mesencefalica. Tanto

estos últimos déficits, como el temblor y la rigidez previos, mejoraron después del drenaje

quirúrgico y del tratamiento médico.

Conclusión: Este caso, ilustra una complicación rara de la cirugía de DBS. Sin embargo el

paciente mejoró de su Parkinson ya que el absceso se “comportó” como una subtalamo-

tomía.© 2011 Sociedad Espanola de Neurocirugía. Publicado por Elsevier España, S.L. Todos los

inantly in right side. In March 2011 (59 years old), 7 yearsafter the last surgery, with 200 mg of L-dopa, he had cervi-cal dyskinesias as well as in the right upper limb but without

Introduction

Patients with Parkinson’s disease are candidates for surgeryif they still achieve some benefit from medication, buthave significant side effects such as motor fluctuations anddyskinesias.1,2

Subthalamic deep brain stimulation has proved its efficacyto control major symptoms in Parkinson disease.2,3 Nonethe-less, numerous surgical, hardware-related, or infective com-plications may develop after surgery.4,5 In literature the majoradverse effects of this surgery are brain haemorrhage – about1–4%; hardware-related complications (including migration ormisplacement of the leads – 5.1%, lead fractures – 5.0%, skinerosion – 1.3%); infections 1–9%; and seizures 1–3%. The vastmajorities of infections are superficial and normally involvethe implanted pulse generator pocket and the connectingwires. The most typical complication is the scar above the con-nection between the electrode and the extension cable andtheir ulterior infection.6–10 Literature reports of cerebritis orbrain abscess are extremely rare.5,8,10–12

Case report

A 59-year-old male, suffering from Parkinson Disease for 19years was submitted to a bilateral subthalamic nucleus DBSwhen he was 52 (in September 2003). The patient had sig-nificant side effects related to medication (650 mg L-dopa,45 mg bromocriptine), like unpredictable on/off fluctuationsand dyskinesias. He was not depressed or demented. The Uni-fied Parkinson’s Disease Rating Scale (UPDRS)13 (part 3) scorewas 35 Off and 10 On. A bilateral subthalamic nucleus DBSwas done in September 2003, without any complications. Fif-teen days later, when discharged home, he was independentwith an UPDRS (Med Off/STM ON) -13, still with 500 mg L-dopa without agonists. No dyskinesias were observed nor offperiods.

A month after surgery, he developed an inflammatoryreaction of the skin and subcutaneous tissue around the sub-cutaneous DBS system. In a period of 12 months, he was

submitted to five surgical interventions due to a process ofsystematic inflammation/infections in different locations ofthe DBS device, before total removal of the system. Empiricalantibiotic was provided but no infectious agent was isolated

derechos reservados.

(even from the electrode tips). The skin allergies tests totalc gloves and to the device material (sent by Medtronic)were negative. Skin biopsy revealed: presence of giant cells,macrophages, lymphocytes and eosinophil.

Few days after removing the DBS electrodes (August 2004),he developed a right oculomotor paresis and a mild lefthemiparesis. He had fever, headache, somnolence and nuchalrigidity. He had no seizures. A CT Scan revealed an abscessin right thalamo-mesencephalic region (Fig. 1). The patientunderwent stereotactic drainage of the abscess. A Staphylo-coccus aureus was isolated from CSF, and he started antibiotictreatment during 21 days (vancomycin1500 mg/day ev), withimprovement of his state. He was a slight diplopia, mild lefthemiparesis and no parkinsonic tremor, bradykinesia andrigidity on the opposite side of abscess as well as no dyskine-sias. UPDRS (part III) 12; Hoehn and Yahr state – 2. The controlCT scan revealed only sequelae (Fig. 2).

PD has been progressing slowly over the years predom-

Fig. 1 – (CT scan) Cerebral abscess before drainage.

n e u r o c i r u g i a . 2 0 1 3

Fig. 2 – (CT scan) Abscess sequelae after treatment.

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disease control therapy 1999: N1-3169.

yskinesias in the left side. He kept a good walking with-ut instability. Without dopa he had rest tremor, bradikinesia,igidity on the right limbs and walking with freezing, butemained without rigidity and tremor on the left side.

iscussion

eep brain stimulation (DBS) is established as a therapy forovement disorders. DBS is non-ablative, offering the advan-

ages of reversibility and adjustability. This might permitherapeutic effectiveness to be enhanced or side effects to be

inimized.14 The complications of DBS can be separated intohose related to surgical procedure, device/equipment, and thetimulation itself. Thus, seizure and hemorrhage are possibleonsequences of lead implantation, although rare. Exceptionalre literature reports of serious adverse effects, such as deathtwo patients with implanted DBS systems died when exposedo therapeutic ultrasound or diathermy).14

Infections requiring removal of the leads have been listeds a rare adverse effect of STN-DBS but without substantialnformation regarding location and extend of infection.3,12

ergani et al.5 described two patients (1,4%) that experiencednfection of the intracranial lead. In both cases the control MRIhowed a signal change in both T1 and T2 sequences along theead. Cultures were positive for Staphylococcus aureus in oneatient and negative in the other.

We found another two cases reported in the literature ofntracerebral electrode infection. In both there were no signsf localized external infection.11,12

Merello et al.11 described an abscess in corona radiate and

anderHorst12 reported a frontal abscess. In our patient thebscess is in talamo-mesencephalic region (near subthalamicrea), the first case with this localization.

1

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Although no microorganism was isolated, we think that inour case the process of systematic inflammation of skin andsubcutaneous tissue around several parts of the subcutaneousDBS system was a local infection.

Extracranial infection usually involve skin flora, includingStaphylococcus aureus, Propionibacterium acnes, and Staphylococ-cus epidermidis.4,5,12 In our patient the intracranial infectionwas probably an extent of the extracranial, nevertheless whenwas detected the skin scar had resolved.

Like the majority of DBS hardware related infection, inour case the extracranial infection occurs after a month.4

However, the intracranial infection became clinically apparentafter a year. Merello et al.11 reported a case of a delayed intra-cerebral electrode infection (detected 6 months after DBS).

After treatment and removal of DBS device, the patientpresented an improvement in his left parkinsonism, prob-ably because the abscess acted like a subthalomotomy. Hestill needs medical treatment with L-dopa and equivalentsbecause of his right parkinsonism. Even with L-dopa he hadno dyskinesias in the left side.

Conclusion

This case reports a rare complication of DBS surgery. Neverthe-less patient’s left parkinsonism improved, probably becausethe abscess acted like a subthalomotomy.

e f e r e n c e s

1. Lozano AM. Surgery for Parkinson’s disease, the five w’s: why,who, what, where, and when. Adv Neurol. 2003;91:303–7.

2. Pollak P, Fraix V, Krack P, Moro E, Mendes A, Chabardes S, et al.Treatment results: Parkinson’s disease. Mov Disord. 2002;17Suppl 3:S75–83.

3. Kleiner-Fisman G, Herzog J, Fisman DN, Tamma F, Lyons KE,Pahwa R, et al. Subthalamic nucleus deep brain stimulation:summary and meta-analysis of outcomes. Mov Disord.2006;21 Suppl 14:S290–304.

4. Chan DT, Zhu XL, Yeung JH, Mok VC, Wong E, Lau C, et al.Complications of deep brain stimulation: a collective review.Asian J Surg. 2009;32:258–63.

5. Vergani F, Landi A, Pirillo D, Cilia R, Antonini A, Sganzerla EP.Surgical, medical, and hardware adverse events in a series of141 patients undergoing subthalamic deep brain stimulationfor Parkinson disease. World Neurosurg. 2010;73:338–44.

6. Bhatia S, Zhang K, Oh M, Angle C, Whiting D. Infectionsand hardware salvage after deep brain stimulation surgery:a single-center study and review of the literature. StereotactFunct Neurosurg. 2010;88:147–55 [Epub 1 April 2010].

7. Hamani C, Lozano AM. Hardware-related complications ofdeep brain stimulation: a review of the published literature.Stereotact Funct Neurosurg. 2006;84:248–51.

8. Lyons KE, Wilkinson SB, Overman J, Pahwa R. Surgical andhardware complications of subthalamic stimulation: a seriesof 160 procedures. Neurology. 2004;63 Suppl 4:612–6.

9. Medtronic: global clinical study report: activa Parkinson’s

0. Oh MY, Abosh A, Kim SH, Lang AE, Lozano AM. Long-termhardware related complications of deep brain stimulation.Neurosurgery. 2002;50 Suppl 6:1268–74.

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36 n e u r o c i r u g i

1. Merello M, Cammarota A, Leiguarda R, Pikielny R. Delayedintracerebral electrode infection after bilateral STNimplantation for Parkinson’s disease. Case report. Mov

Disord. 2001;16:168–70.

2. Vanderhorst VG, Papavassiliou E, Tarsy D, Shih L. Early brainabscess: a rare complication of deep brain stimulation. MovDisord. 2009;24:1395–7.

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3. Richards M, Marder K, Cote L, Mayeux R. Interrater reliabilityof the Unified Parkonson’s Disease Rating Scale motor

4. Geenberg B, Rezai AR. Mechanisms and the current state ofdeep brain stimulation in neuropsychiatry. CNS Spectr. 2003;8Suppl 7:522–6.