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Frameless, pinless stereotactic aspiration of cerebral abscess in grown-up congenital heart disease: mitigating surgical and anaesthetic risk
EANS Academy. doke t. Sep 27, 2019; 276165; EP12063
Mr. thomas doke
Mr. thomas doke

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Abstract
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Background: Cerebral abscess is a potentially life threatening condition that occurs with increased incidence in patients with grown-up congenital heart disease (GUCH) due to several putative mechanisms; Eisenmenger syndrome and resultant cyanotic heart disease lead to hypoxaemia and hyperviscosity syndrome along with a right-to-left intra-cardiac shunt; systemic infections thereby spreading haematogenously to the brain. GUCH patients pose a considerable anaesthetic challenge complicating their surgical management.
Methods: Case series of two consecutive cases managed surgically in our regional Neurosurgery unit in the same week.
Results: Case One: 54 year old female with background of transposition of the great arteries, multiple previous cardiac surgeries, residual VSD and pulmonary hypertension. Presented with headache, no lateralising neurology. CT and MRI demonstrated right temporo-parietal abscess for which she underwent frameless, pinless stereotactic burr hole aspiration under local anaesthetic using electromagnetic navigation. Surgical management was expedited as the patient was compliant with local anaesthetic aspiration.
Case Two: 41 year old male with background of Down syndrome, dementia, ventriculo-septal defect and obstructive sleep apnoea. Presented with left hemiparesis and sepsis. CT and MRI demonstrated right fronto-parietal abscess for which he underwent stereotactic burr-hole aspiration under general anaesthetic using optical navigation and Mayfield pins. High general anaesthetic risk delayed surgical management.
Conclusions: Patients with GUCH are at increased risk of cerebral abscess and managing clinicians should maintain a high index of suspicion for their development. The mainstay of management is surgical drainage followed by antimicrobial therapy. Frameless, pinless, stereotactic burr hole aspiration under local anaesthetic is the preferable surgical strategy as it avoids significant risks of general anaesthesia however it relies on patient compliance. Optimal management of cerebral abscess in patients with GUCH should be tailored to individual patient needs and requires a multi-disciplinary approach with expertise concentrated in supra-regional centres.
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