Update on the treatment of cerebral aspergillosis

In aspergillus infections of the central nervous system (CNS) the mortality risk usually exceeds 90%. Data from case-reports and a recent retrospective study suggest that neurosurgical interventions, such as abscess resections, stereotactic drainages, or the use of intraventricular catheters, might improve the outcome in CNS aspergillosis. However, there is a lack of clear evidence supporting an extensive neurosurgical management in these patients. A major reason for the devastating prognosis in CNS aspergillosis is a poor penetration of antifungal drugs into the CNS, with the exception of voriconazole. Treatment with voriconazole results in measurable drug levels in the cerebrospinal fluid, which may exceed the minimal inhibitory concentration for aspergillus. Moreover, voriconazole brain tissue levels exceed those measured for other antifungal drugs. In a recent retrospective study, a complete or partial response occurred in 35% of patients who were treated with voriconazole for CNS aspergillosis with a survival rate of 31%. These data support the use of voriconazole in this clinical setting. An intense neurosurgical management and higher doses of voriconazole might further improve the outcome in CNS aspergillosis, but this needs to be evaluated in future studies.