A case of brain abscess after deep electrostimulation in patients with plant state was reported and reviewed in literature.

Deep brain stimulation (DBS) surgery is increasingly used in the treatment of functional neurosurgery diseases such as motor disorders, chronic pain, and obsessive compulsive disorder.
DBS may promote the recovery of consciousness in patients with post-severe brain injury, including plant or micro-conscious states.
DBS surgical site includes the top of the head, behind the ear, or the pulse generator site, and infection at the surgical site (surgical site, SSI) is one of the major postoperative complications of DBS.
the cause may be contamination of the device itself, or it can be secondary to a leak in the cerebrospinal fluid or a skin infection at the surgical site.
brain abscess is one of the rare and severe SSI.
this study summarizes and analyzes the diagnosis and treatment of brain abscesses that occur after DBS surgery in 1 patient with plant state, and discusses the factors, prevention and treatment measures of DBS postoperative SSI in the light of literature review.
1. Clinical data patient male, aged 59, was treated at a local hospital on May 12, 2017 for a sudden brain haemorrhage.
to our hospital on August 21, 2017 after the patient's persistent consciousness was unclear.
was diagnosed as plant state, cerebral hemorrhage recovery period, improved coma recovery scale (CRS-R) score: 4 points (0-1-2-0-0-1).
29, 2017, more than half a year after the onset of the disease in the double-sided DBS electrode implantation of the whole hemp;
review of the skull CT the day after surgery showed that the electrode position in the brain was good, no bleeding and other abnormal changes.
7d (December 6, 2017) after surgery, the next day there was blood seepage from the front of the left forehead wound, disinfection, local helium laser treatment 3d after the wound healed.
December 22, 2017, the patient was found to have seepage from the left forehead, a break in the back of the inlet, and a small amount of pus was visible from the squeeze;
the wound is cut (about 3 cm long), the wound is stitched, with the scalp needle catheter to do the wound negative pressure diversion.
the next day the patient's body temperature returned to normal, blood routine examination did not see white blood cells rise.
the daily flow rate of about 5 to 10mL.
a brain abscess, about 2.0 cm x 2.0 cm (Figure 1A), was revealed on December 25, 2017.
3 times on December 26, 29, and 31, 2017, the patients sent wound fluid to bacterial culture, while empiric treatment was given to vancomycin and cephalosporine and lyphenicol.
on December 28, 2017, the cerebrospinal fluid pressure 270mmH2O, normal.
was treated with glycol dehydration.
3 times sent to test the results of the introduction fluid culture are pneumonia Kreb bacteria, aamine pernan, loxyfluorosamine and other 20 kinds of drug resistance, only sensitive to compound new nomin.
other antibiotics will be suspended from 3 January 2018 and 4 tablets (0.48g/tablet) of compound nomin will be given, 1/8h, with gastric tube injection.
at this time the patient's scalp infles have healed well, the diversion flow is very small, to remove the lead tube.
review of lumbar wear, cerebrospinal fluid pressure 350mmH2O on January 8, 2018;
the use of glycol will gradually decrease from 11 January 2018, in conjunction with oral psilocycosm.
was suspended on January 19, 2018;
patient was discharged from the hospital 2 months after surgery and was discharged without fever.
its DBS started 2 weeks after surgery, the patient's consciousness level increased to micro-conscious state, there is eye visual tracking performance, CRS-R score 10 points (1-3-2-1-0-3).
on March 10, 2018 after 3 months of continuous use by the Company.
more than a month after the suspension of the drug (April 27, 2018) to review the skull MRI show that the abnormal signal near the electrode in the left forehead basically disappeared (Figure 1B).
2. Discuss that postoperative surgical site infection can occur during or after surgery, and the most important risk factor is cerebrospinal fluid leakage, which can provide a pathway for pathogenic bacteria to enter the skull.
SSI is an in-hospital infection that causes severe microbial resistance, including drug-resistant Staphylococcus aotetropsia and drug-resistant bacillus, which are often planted on the patient's body surface before SSI occurs, such as Staphylococcus apt.
This patient in the ICU contaminated with drug-resistant pneumonia Kreb bacteria, planted in the skin, incision does not heal, bacterial contamination incision, along the incision, electrode into the skull, the formation of brain abscess;
after surgical treatment and drug treatment, the infection was cured, and after long-term follow-up, it was judged that the patient's intracranial infection had been eliminated.
considering that the patient's brain abscess range is small, has not yet formed an abscess wall, the response to antibiotics is relatively good, and considering the importance of the patient to open DBS early, decided to suspend the removal of intracranial electrodes.
Risks of this practice include an increased risk of recurrence of infection, severe cerebral edema and even cerebral palsy during treatment, the spread of inflammation to cerebrospinal fluid, and resistance to pathogenic bacteria due to a long course of treatment.
after the occurrence of intracranial infection, do not remove the implants at the infected site, which poses a challenge to the root cause of infection, so when judging whether to remove the implants after infection, the adaptation certificate should be strictly grasped.
the following literature to explore the incidence of DBS surgical site infection, influence factors, prevention and treatment measures.
Review published in 2012 summarized SSI reported by 16 centers, with infection rates ranging from 0.63 percent to 14.3 percent.
with the improvement of surgical equipment and the optimization of surgical procedures, the rate of SSI decreased overall.
this study focuses on summarizing the incidence and characteristics of SSI reported in the literature since 2012, with the total incidence rate distributed between 1.24% and 9.02% (excluding the extreme values on both sides).
age of the patient, skull thickness, other combined diseases and surgical operations may be factors in the occurrence of infection.
however, Bjerknes and others investigated the incidence of infection among 368 patients of different ages, genders, diagnoses, surgical targets, combined diabetes and smoking, and did not draw any statistically significant conclusions.
Zhang Yuqing and other reports, DBS surgery patients, non-Parkinson's disease group (special tremors, dystial dystance disorders, etc.) patients significantly higher incidence of infection than Parkinson's disease patients.
DBS pulse generator is driven by an unchargeable battery and needs to be replaced when it runs out of power.
that the infection rate of replacement pulse generator surgery is significantly higher than that of the initial installation pulse generator surgery.
addition, there was no significant difference in infection rate between mrI's operating room and routine operating room line DBS implantation.
brain abscesses are rare in all SSIs and are only reported sporadicly.
brain abscess may be secondary to scalp collapse or may occur in the absence of visible skin damage, which is more prone to early omission.
MRI detection rate of brain abscess is higher than CT, and is more suitable for early diagnosis.
Staphylococcus aureus accounts for 36% to 57% of all SSI pathogenic bacteria, the remaining pathogenic bacteria include E. coli, false monocytobacteria, fake silk yeast, pneumonia Krebs, acne acrylic bacteria, sare bacteria and so on.
nasal implants are the main risk factors for Staphylococcus apt staphylococcus infection in hospitals, including SSI.
2017, a single-center, pre-control clinical study of staphylococcus aureus infection prevention measures for DBS found that the use of preoperative Staphylococcus aureus screening and the use of Mopiro nasal ointments on carriers, and the use of pinot nostril ointments for several consecutive days before surgery, significantly reduced the rate of SSI in all patients using shampoly to clean the skin in the area.
other centers have also confirmed the role of conventional preoperative scalp cleaning.
previous controlled study showed that the SSI rate was reduced from 9.02% to 0 by using only the process of washing the patient's hair with ethanol-based standard cleaning fluid the night before and early in the morning of the operation.
intraoperative/intraoperative and postoperative venous application of cephalosporine antibiotics has been used as a standard procedure in many centers.
some centers in the country partially applied vancomycin powder to prevent infection before closing the insement, and the results showed that it was safe and effective (the infection rate was controlled at 1.3%).
some centres have adopted methods such as postoperative one-time intramuscular injections to reduce the forced removal of implants caused by immune rejection-related infections, and have confirmed that the method itself does not increase the risk of complications such as infection or mental disorders.
For SSI that occurs after surgery, cerebrospinal fluid leakage is one of the important risk factors, and controlling the range of epidural inlet during surgery, using bioprotein glue to block the epidural leakage, etc. may reduce the leakage of cerebrospinal fluid to the inlet skin.
Another important factor in postoperative infection is skin collapse in the implanted area, so ensure that the wires are buried under the skin rather than inside the skin, and that prominent structures such as wires and extension wire connectors are not placed in the vulnerable areas of the scalp;
SSI has three treatment strategies: (1) removing all implants and applying antibiotics intravenously; (2) retaining intracranial electrodes, removing electrode extension cords and pulse generators, while applying antibiotics orally or intravenously; and (3) combining or not combining local cleansing with antibiotic treatment, without removing implants.
for infections suspected to have occurred, the pathogenic evidence of infection should be obtained as soon as possible, the secretions at the site of infection should be repeatedly sent for examination, and the results of pathogenic bacteria and drug sensitivity should be clearly defined as the basis for drug treatment.
No matter what pathogenic microbial infection, once clear, should be used throughout the body antibiotics, and do the infection site of the clean-up treatment;
the centers have different practices regarding whether to partially or completely remove the implants.
nearly half of all infections are caused by Staphylococcus amethyst, which is characterized by rapid progression within 1 month of surgery, early onset of abscesses, and the need to remove implants decisively.
In fact, Staphylococcus amethyst or coagulation enzyme-negative staphylococcus is an important cause of infection because it can form a membrane on the surface of the implant, thus becoming resistant to the host immune mechanism or antibiotics.
after preventive anti-Staphylococcus against Staphylococcus alas, the rate of implant removal in infected cases appears to have decreased at the same time as the infection rate decreased significantly.
for whether to remove the implant, some of the central proposition is that according to the SSI grading decision, II., III. class SSI, that is, deep infection, should be removed in the first phase of the implant.
some advocate retaining implants as much as possible, although the practice of retaining electrodes is a challenge for anti-infective treatment itself.
because the difficulty and risk of re-stereotactic electrode implantation exceeds that of initial implantation, some central advocates that some implants should be removed first and that intracranial electrodes should be retained as much as possible.
in patients with severe dystial dystypathy, DBS is also allowed to externally place the wire and pulse generator, which ensures that DBS works continuously while the wound heals.
patients with Parkinson's disease DBS implants are forced to remove all intracranial electrodes, one-sided pale ball damage may be considered as a remedy to improve motor symptoms.
can also be used to remove the implant, wound first-stage clean stitching, re-implantation after 3 months.
If the infection collapse occurs at the back of the ear electrode conductor and extension wire interface, special attention should be paid, usually the intracranial electrode and extension line should be removed, only do in-place clean-up buried may cause the infection to spread around the IPG caused greater harm.
for DBS postoperative brain abscesses, the usual diagnosis and treatment strategies are early pathogenic examination, high-dose application of sensitive antibiotics and removal of implants.
, the incidence of SSI is affected by factors such as the patient's underlying disease and DBS surgery.
preoperative cleaning area of the skin, preoperative, postoperative preventive application of antibiotics and other measures can reduce the occurrence of infection.
For infections that have occurred, pathogenic evidence should be obtained as early as possible and drug sensitivity tests should be used as a basis for antibiotic treatment;
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