NEUROSURGERY ASPECT

in TROPICAL MEDICINE
Dr. dr. Rr. Suzy Indharty, M.Kes, Sp.BS
 Epidemiology
Children (1 mo-15 yo)
• H. influenzae 40-60%
• N. meningitidis 25-40%
• S. pneumo10-20%
Adults (> 15 yo)
• S. pneumo30-50%
• N. Meningitidis 10-35%
– Major cause in epidemics
• Gm (-) Bacilli 1-10%
– Elderly
• S. aureus 5-15%
• H. influenzae 1-3%

Brouwer MC, Tunkel AR, Van de Beek D.

Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. Clin Microbiol Rev 2010; 23(3):467-492.
 INTRACRANIAL INFECTION

MYELITIS

hidrocephalus
Centers for Disease Control and Prevention. Meningitis.
USA. May 12, 2010.
B#

PET SCAN
Necrosis:merah=anoxia
Apoptosis;kuning=hipoxi

MR-SPECTROSCOPY
Cholin :↓(mitosis)
Ch:Creatine=↑(neovascular)
Creatine;↑(sisa zat met sel,vasc.tdk baik).
NAA : SSP= ↓(extraaxial)
Lactat : ↑↑met.anaerob(anabolik)=infeksi,iskemi
Lipid :↑ metastase,>TB.,infeksi.
Alanin :↑ extraaxial=meningioma
 Lumbal Puncture / Kernig’s
Tapping ventricel

CSF Analisis+kultur Nuchal

rigidity
Brudzinki I

MenSer: MenPur:
- Kronik - Akut
- Demam>7hr - Demam<7hr
- Somnolen- - Apatis
sopor - Pulih GCS
- Pulih GCS Cepat
lama -
- TIK ↑ TIK>180mmH
- MN sel ↑ g
- Th/ Obat TB - PMN sel↑
- Th/ AB
- Fungi Brouwer MC, Tunkel AR, Van de Beek D. Epidemiology, diagnosis, and antimicrobial
treatment of acute bacterial meningitis. Clin Microbiol Rev 2010; 23(3):467-492.
- parasite
Pathophysiology ( Kim KS. Pathogenesis of bacterial meningitis: form bacteraemia to
neuronal injury. Nature reviews neuroscience 2003;4:376-385)

Trojan mek.(macrophage)
Para/transselular Vasculitis
→edema
→ ischemia

CSF→ventriculitis
Hidrocephalus
Focal; CN palsies
Abcess

encephalitis

Diffuse:edema
 Brouwer MC, Tunkel AR, Van de Beek D. Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. Clin Microbiol Rev
2010; 23(3):467-492.
MENINGITIS virus,bacteri,fungi,parasit
• Hidrocephalus drainage CSF: ETV
VP-shunt
VA shunt
Vpleura
shunt etc

EVD
drain pus+intraventricular AB

VPleura
VENTRICULITIS (virus,bacteria,fungi,parasite)
EVD:Pus drainage + Intraventicular AB
Antimicrobal Antimicrobal
IntraVena Intraventricular
Depent on the culture
EVD:count cell ≥10
1/10 - 1/8 IV dose

BLOOD BRAIN Parasit/fungi:AMB + corticosteroid

BARIER Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice
guidelines for the management of bacterialmeningitis. Clin
Antibiotika !!! Dis, 2004;39:1267-1284.
ENCEPALITIS Diffuse: Edema
Craniectomy?
Focal: Abcess

a focal,intracerebral infection that begins as a localized area of cerebritis and develops

into a collection of pus surrounded by a well-vascularized capsule (Mathisen & Johnson, 1997)
Was uniformly fatal before the late 1800’s
• Mortality 30-60% f1945-1970’s
– Introduction of antibiotic (penicillin, chloramphenicol)
– newer surgical techniques
• Mortality 0-24% over the past 3 decades:-CT scanning (1974), MRI
• - Stereotactic biopsy/aspiration techniques
Newer AB (cephalosporins metronidazole + better treatment of predisposing conditions
• Corticosteroid:
Indication: significant mass effect on CT/MRI, with mental status change
Disadvantage: slow capsule formation, ↑↑risk ventricular rupture, ↓↓ penetration ab iv
Clinical use: Dexamethasone loading 10mg iv followed by 4 mg q6h
Taper rapidly: 3~7 days after stabilization
Brain abscess CT scan Britt’s Staging

Burrhole/Craniotomy
 NCCT
17/9/2013
Capsulated
Stage

Marsupialisasi
+ Intra abses AB
DOC:Vancomycin
 Association between surgical method and outcome

GA→risk>> local→ku↓

Siregar AJ ,Tan WM,Saffari M,Haspani M,Treatment Outcome of Superficial Cerebral Abscess : An Analysis of 2 Surgical Method,Malaysian J
Med Sci,2010;17:23-29
 TUBERCULOMA perkejuan

Th/ : extrapulmonal TBC :

9-12 months OAT

Ct scan +/-
kontras
 ABCES SPINE
1. Epidural →spinal cord/cauda equina compression→parese
½ cases misdiagnosed/delayed diagnosis=nonspecific backpain
no classical inflamation signs,mimicking MCI/acute abdomen
2. Cold abses =TBC (corpus)
3. Psoas abces (iliopsoas) 1
drainage pus 2
squestrectomy
+/- stabilisasi

3
 VIRAL INFECTION
I. HIV
Imunosuppression
Progressive
Multifocal
Encephalitis

II.Neuro
syphilis
Tabes dorsalis GUMA
 III. TORCH
HCP
vasculitis

syphilis

HCP
vasculitis

H.simplex
IV.VARICELLA + H.ZOSTER

Abcess
Hidrocephalus

Subacute Scleroting
Panencephalitis
(SSEP)
Hidrocephalus
Abcess
meningitis

V.RABIES
 VI .DHF

VasculitisMeningoencephalitis,hidrocephalus,abcess
NEUROBORRELIOSIS
LYME DISEASE
VI. EBOLA
 NEURO
LEPTOSPIROSIS

Abcess,vasculitis
Encephalitis,myelitis
Hydrocephalus
 Neuro
brucellosis

Meningoencephalitis,
Vasculitis,myelitis
Abcess BBB Breakdown
Hydrocephalus
MERS Middle East Respiratory Syndrome CoA

Abcess cerebri
myelitis,vasculitis
Hidrocephalus
Meningoencephalitis
INFLUENZA

INFLUENZA
VIRUS
Brain

Meningoencephalitis
Myelitis
Hidrocephalus
Abcess,vasculitis
 CNS PARASIT
1. Protozoa :
- Toxoplasmosis
- Malaria Cerebral
2. Cestoda :
- Cysticercosis (Taenia)
- Echinococcus
- Coenurus cerebralis
3. Amoeba :
- Naegleria fowleri
- Acanthamoeba spp
- Entamoeba Histolitica
4. Trematoda :
- Paragonimus Spp
- Schistosomiasis spp
- Fasciola spp 1,5-3dosis,
- African Trypanosomiasi
multidrugs
5. Nematoda :
- Trichinosis
- Ascaris lumbricoides
- Strongyloides stercoralis
- Toxocara spp
- Baylisascaris sp
- Angiostrongylus spp
- Gnathostoma sp
- Dirofilaria immitis
- Loa loa
 HE
PROTOZOA
NEUROTOXOPLASMOSIS
T.Gondii >>> Giemsa

Abcess,myelitis
Hidrocephalus
Meningoencephalitis
MALARIA SPONGIFORM
ENCEPHALOPATHY
Edema cerebri>>
ICH>> Anopheles

falcifarum
 CESTODA Neurocysticercosis
(Taenia Solium- Taenia Saginata-Toxocara Canis Sparganosis)
Abcess,Myelitis
Hidrocephalus
Meningoencephalitis
 CESTODA
ECHINOCOCCUS (Hydatid disease)
 Meningoencephalitis
Abcess,Myelitis

CEREBRAL
AMEBIASIS
>>
CEREBRAL NAEGLERIA FOWLERI
AMEBIASIS
ACANTHAMOEBA spp

PCR Fluroscent Hybrid MpC15

 TREMATODA
NEUROSCHISTOSOMIASIS >>

Brain &
Spinal
cord
 Unembryonated

TREMATODA eggs

NEUROPARAGONIMUS
embryonated
eggs
 Vasculitis,
Myelitis,
NEMATODA
Meningoencephalitis
Abcess Neurotrichonosis>>
 NEUROTRYPANOSOMIASIS
SLEEPING SICKNESS (African T.Brucei Gambiense)
CHAGAS Disease(American T.Cruzi)
T.Rhodiense
 CNS FUNGI
1.Yeast: Candida 3-64%(†11-67%)
Cryptococcus 67-84%
2.Dimorphic:Blastomyces 40%
Histoplasma 5-20%
Coccidoides 25%
Paracoccidoides
3.Filamentous:Cladophialophora 100%
Aspergillus 4-6%
†80-90%
Rhizopus
aspergillus
Rhizomucor
Mucor
Zygomycetes 65%
† 79-98%
 Treatment
CNS FUNGI
ASPERGILLUS/CANDIDA,CRIPTOCOCCUS N
(6-10weeks)
1.Variconazole(6mg/kg iv /12h=1 days
→ 4mg/kg/ 12h (max 200mg/days)
2. Alternative L-AMB(Liposomal-Amphotericin B)
: 3-5mg/kg/day/iv
3. ABLC(AMB Lipid Complex): 5mg/kg/day/iv
4.Micafungin : 100-150mg/kg/day/iv
5.Posaconazole : 200mg/6hour/day/oral
6.Itraconazole
7.Fluconazole
 Sintesis hifa
Olfactory Nerve
→BRAIN

Immune defence breakdown

Neutropil bone marrow supp

Vasculitis
Mycotic aneurysm

Hidrocephalus
Ventriculitis,Myelitis

PF
FUNGI