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| Year : 1999 | Volume
: 47
| Issue : 3 | Page : 202-5 |
Pyogenic brain abscess managed by repeated elective aspiration.
Srinivasan US, Gajendran R, Joseph MJ
Department of Neurosurgery, PSG Institute of Medical Sciences and Research, Coimbatore, 641041, India.
Correspondence Address:
Department of Neurosurgery, PSG Institute of Medical Sciences and Research, Coimbatore, 641041, India.
37 cases of capsular stage of brain abscess based upon CT scan staging were treated by repeated elective aspiration through a burr hole and intracavitary application of antibiotics on alternate days, till two consecutive negative aspirations were obtained. A combination of furosemide and antibiotics in multiple doses were also given. The mortality rate was 2.7% and the morbidity rate 8.3%. Corticosteroids were not used in the management of brain abscess. Thus, repeated elective aspiration was found to be an effective mode of surgical management of brain abscess.
How to cite this article:
Srinivasan U S, Gajendran R, Joseph M J. Pyogenic brain abscess managed by repeated elective aspiration. Neurol India 1999;47:202 |
The diagnosis, treatment and prognosis of patients with brain abscess have improved during the last two decades because of technological advances in medicine like computerised tomographic scanning and refinements in microbiological techniques. Nevertheless the management of brain abscess is still a controversial subject.[1] In this paper, we present the effectiveness of repeated elective aspiration as the mode of management of capsular stage of brain abscess.
During October 1989 to January 1997, based on CT staging of brain abscess by Britt et al,[2] thirty seven cases of capsular stage of brain abscess were treated. In all these cases a detailed clinical evaluation was made. Relevant investigations were done to find out the primary source of brain abscess and the pus was sent for culture and sensitivity.
All the patients were managed as outlined below. Initially furosemide in the dose of 0.75mg/kg/body weight and antibiotics were given intravenously. On the same day the abscess cavity was gently aspirated through a burr hole. It was washed with 1 in 10 diluted solution of gentamicin till clear fluid was aspirated. Then 3 ml of the gentamicin solution was instilled into the cavity. Aspiration was done on alternate days irrespective of the clinical condition of the patient till two consecutive negative aspirations were obtained. Antibiotics in standard doses were given intravenously for the first two weeks and orally during the next four weeks. Patients were given crystalline penicillin, gentamicin and metronidazole intravenously till the pus culture report was available. In case of sterile culture, the same antibiotics were continued for 2 weeks, followed by co-trimoxazole orally. In case of a positive culture, the appropriate antibiotic was given.
Furosemide was given parenterally in divided doses for the first 10 days in a dose mentioned above. Anticonvulsants were also given. Corticosteroids were not used during therapy, except in a single case of psoriasis who was already on steroids for more than two years. In this case steroid were used in the immediate post-operative period and were gradually tapered. In all patients follow up CT scan of brain was performed after 10 days and at the end of 3 months [Figure 1] [Figure 2]. The patients were discharged after 2 weeks and reviewed at monthly intervals.
A total of 37 cases have been analysed. The highest incidence of abscess (81.1%) was in the age group of 1-20 years. Two cases occurred in infants (5.4%) and none over the age of forty. Thirty cases (81.1%) were in the GCS score of 12-15 and six were between GCS 8-11. Only one case had a GCS score of 4.
The primary source of infection was chronic suppurative otitis media (70.3%), congenital heart disease (13.5%) and superior venacaval obstruction (2.7%). In one case the infection was secondary to prolonged steroid use. Exact source could not be detected in 10.8% of cases. Brain abscess was located in temporal lobe in 15 cases, cerebellum in 7, parietal lobe in 5, frontal lobe in 4 and in occipital lobe in 3 cases. 3 patients had abscess at multiple sites. Sterile cultures were reported in 20 out of 37 pus cultures (54.05%). Streptococcus was isolated in 18.9%, Staphylococcus aureus in 16.2% and various other gram negative organisms in 10.3% cases.
The mortality rate was 2.7%. Secondary excision was not carried out in any case. Uncontrolled status epilepticus after first aspiration was the cause of death in the single patient who had tetralogy of Fallot and had presented with generalised seizures. There was no deterioration in the clinical status in the rest of the patients. In 90% of cases, no pus was aspirated after fifth postoperative day (i.e. after 3rd aspiration). Follow up CT scan on 10th day showed shrinkage of abscess cavity with fragmentation of capsule and decrease in the surrounding oedema in all the 36 cases [Figure 1] [Figure 2].
The follow up period ranged from 3 months to 4 years. At 3 months follow up there were no clinical features or CT evidence of recurrence of abscess in 32 cases (88.88%). In the rest 4 cases follow up CT scan at the end of 3 months could not be obtained, but there were no clinical features of recurrence. Seizures occurred in four patients (11.11%). Post operative morbidity was divided into four types as suggested by Kagawa et al.[3] On follow up in our series, 33 cases (91.67%) had no neurological deficit. Mild to moderate focal dysfunction in routine activities was observed in 2 cases (5.55%). Incapacitating deficit was present only in one case whose GCS score was 4 at admission. Overall morbidity rate was only 8.33% (3/36).
The mode of management of brain abscess continues to be under discussion.[1] Successful non-surgical management of brain abscess is currently being reported.[4],[5] Rosenblum et al1 and Black et al[6] advocated surgery especially in larger brain abscess because of the drawbacks of non-surgical management. Various surgical procedures have been advocated for the management of brain abscess with variable results.[1],[2],[7],[8],[9] The mortality rate in our series was only 2.7% as compared to other series where the mortality ranged between 5% to 50%.[2],[8],[10] Duma et al[7] reported zero percent mortality in their series of 29 cases treated by image guided stereotactic aspiration. In our series morbidity rate was 8.33% in contrast to near 30% recorded in other series.[1] No new neurologic deficit occurred after surgery as compared to 7% reported by Duma et al,[7] where a zero percent mortality was recorded.
Rupture of abscess cavity into the ventricles due to delay in repeat aspiration and increase in the surrounding oedema leading to abrupt herniation were the main causes of death in most of the series.[2] The proliferation of bacteria within the central core of necrotic material is said to be one of the causes of increase in the surrounding oedema.[11] In our series, both the risks were eliminated by repeated elective aspiration of abscess. Follow up CT scan showed reduction in the size of abscess cavity, fragmentation of the capsule and decrease in the surrounding oedema [Figure 1] [Figure 2] lending support to the above statement. Our study also supports the report by Kala et al[12] that local application of antibiotics within the abscess cavity has beneficial effect in treating the cerebral abscess.
Yamamoto et al,[13] state that multiple dose administration of antibiotics and prior drainage of pus significantly increased the antibiotic concentration within the abscess cavity. This supports our proposal of repeated elective aspiration of pus and multiple dose administration of antibiotics. Hence, this procedure is recommended in patients with capsular stage of pyogenic brain abscess, as the primary operative treatment, because of its low mortality, morbidity and non-requirement of serial CT scans or ultrasound evaluation of abscess cavity.
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| 11. | Wallenfang T, Boli J, Kretzschmar K : Evolution of brain abscess in cats. Formation of capsule and resolution of oedema. Neurosurg Rev 1980; 3 : 101-111. |
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