Middle cerebellar peduncle approach for Nocardia brainstem abscess: illustrative case

BACKGROUND: Nocardia cyriacigeorgica represents a rare cause of cerebral abscesses. Rarer still are brainstem abscesses caused by this bacterial species in immunocompetent hosts. In fact, only one such brainstem abscess case has been described in the neurosurgical literature to our knowledge to date. Herein, a case of Nocardia cyriacigeorgica abscess in the pons is reported, as well as a description of its surgical evacuation via the transpetrosal fissure, middle cerebellar peduncle approach. The authors review the utility of this well-described approach in treating such lesions safely and effectively. Finally, the authors briefly review, compare, and contrast related cases to this one. OBSERVATIONS: Augmented reality is additive to and useful for well-described safe entry corridors to the brainstem. Despite surgical success, patients may not regain previously lost neurological function. LESSONS: The transpetrosal fissure, middle cerebellar peduncle approach is safe and effective in evacuating pontine abscesses. Augmented reality guidance supplements but does not replace thorough knowledge of operative anatomy for this complex procedure. A reasonable degree of suspicion for brainstem abscess is prudent even in immunocompetent hosts. A multidisciplinary team is critical to the successful treatment of central nervous system Nocardiosis.