The clinical characteristics of mold infections of the CNS warrant assessment for possible biopsy and neurosurgical intervention. A definitive diagnosis almost invariably requires a biopsy, with prompt inspection of the specimen by means of wet-mount preparation with calcofluor white stain, culture, and histologic analysis (with Gomori methenamine silver stain and periodic acid–Schiff stain). In situ hybridization and immunohistochemical analysis may be helpful if cultures of biopsy specimens are negative.
Criteria for Neurosurgical or Neuroradiologic Intervention
| Indication | Intervention | Comments |
| CNS space-occupying lesion with mass effects | Surgical decompression with debulking of lesion or stereotactic drainage | Choice of approach depends on lesion size, location, and severity; large masses with evidence of brain or spinal cord compression or herniation syndromes (with or without increases in intracranial pressure) should immediately be decompressed, especially in patients with a rapid onset of clinical deterioration |
| Hydrocephalus | Insertion of extraventricular drainage catheter | Clinical deterioration with rostrocaudal brain herniation can occur rapidly as a result of unrecognized hydrocephalus; an external ventricular drain allows monitoring of intracranial pressure and collection of CSF samples |
| Lesion thought to be fungal in origin but not responding to antifungal therapy | Surgical open biopsy or stereotactic biopsy | Choice of approach depends on lesion location and size |
| Acute hemispheric stroke with mass effects (ischemic or hemorrhagic) | Hemicraniectomy for large middle-cerebral-artery stroke; hematoma aspiration | Skull bone removal (craniectomy) reduces intracranial pressure and brain herniation |
| Mycotic aneurysm with subarachnoid hemorrhage | Coiling or surgical aneurysm, parent-artery occlusion, or both | Severe subarachnoid hemorrhage induced arterial vasospasm may require catheter angioplasty |
References:
- McCarthy M, Rosengart A, Schuetz AN, Kontoyiannis DP, Walsh TJ. Mold infections of the central nervous system. N Engl J Med. 2014 Jul 10;371(2):150-60.[Medline]
- Davis LE. Fungal infections of the central nervous system. Neurol Clin. 1999 Nov;17(4):761-81. [Medline]
Created Sep 04, 2014.
