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Management of Brain Abscess
Perspectives Commentary on: Brain Abscess: Management and Outcome Analysis of a Computed Tomography Era Experience with 973 Patients by Nathoo et al. pp. 716-726.
Basant Kumar Misra, M.Ch. Diplomate of National Board Department of Neurosurgery and Gamma Knife Centre P.D.Hinduja National Hospital and Medical Research Centre
Management of Brain Abscess Basant Kumar Misra
T
he French surgeon Morand has been credited with the first successful operation for brain abscess (BA) in 1752 (6). In 1774, Jean Louis Petit made a trephine opening for a traumatic BA and the abscess later bursted externally (6). Similar principles of management were occasionally reported until the authoritative work of Sir William Macewen of Glasgow, Pyogenic Infective Diseases of the Brain and Spinal Cord in 1893 (3). He recommended drainage of BA and treatment of the underlying sinusitis and reported the results of 19 patients of whom 18 recovered. Dandy, in 1926, recommended burr hole aspiration of the abscess as the primary treatment—today, this surgical principle is followed in the majority of patients (4). Vincent, in 1936, demonstrated the efficacy of complete excision of BA and Heineman and colleagues were the first to treat BA medically (1, 5). The introduction of antibiotics led to a dramatic decline in the morbidity and mortality, as well as a reduction in the incidence of recurrent abscess. Improved health care facilities and availability of neurosurgical manpower has resulted in the decrease in BA secondary to open head injury, paranasal sinus, otogenic infection, and congenital heart disease. Widespread availability of computerized tomography scan and stereotactic procedures has led to earlier diagnosis and minimally invasive management of BA. Although the earlier reported high incidence of BA in developing countries (8% of all intracranial space occupying lesions) is diminishing, it is still a major problem (2). In addition, resistant strains, because of inappropriate use and overuse of antibiotics and opportunistic infections in immunocompromised patients, have raised unique problems in the management of BA. In their article, Nathoo et al. presented a retrospective analysis of a large series of 973 cases of BA treated during a 20-year period
Key words 䡲 Brain abscess 䡲 Cranial infections 䡲 Health care 䡲 Otogenic 䡲 Paranasal 䡲 Sinusitis 䡲 Trauma
612
Abbreviations and Acronyms BA: Brain abscess
www.SCIENCEDIRECT.com
(1983-2002) at the 106-bed Wentworth Hospital, Durban, South Africa, the sole public sector neurosurgical referral center for the province of KwaZulu-Natal, until its closure in December 2002. The vast majority of the patients were male and young. Otorhinogenic and post-traumatic injury were common etiologic factors and nearly 90% of the BA were located in the supratentorial compartment. Surgical drainage was the main stay of treatment and nearly 75% of patients had a good outcome. The fact that 130 patients died shows the gravity of the problem. It was reassuring to learn that the incidence of BA reduced over time. The supratentorial BA was approached by either burr hole or limited craniotomy and drained. The infratentorial abscess was drained after a suboccipital craniectomy. Patients were initially started on a triple antibiotic therapy (empirically)—penicillin, chloramphenicol, and metronidazole— until the sensitivity report and then changed appropriately. The investigators have to be congratulated for their efforts and presenting in detail their experience, which will be useful to any neurosurgeon interested in the subject. Of particular importance is their recommendation for eradication of the primary source or ear, nose, and throat procedures under the same anesthesia. Although desirable, it is neither always possible nor mandatory to do the ear, nose, and throat procedure under the same anesthesia. What is, however, important is early eradication of the primary source, lest BA recurs. It is important to mention that the data presented pertains to the 20th century. Many advances have taken place. An empiric triple antibiotic regimen, as practiced then, is rarely used today (especially chloramphenicol); open drainage of abscess into “strategically placed sodium hypochlorite soaked gauze” is of historic interest and has no place in modern neurosurgery
Department of Neurosurgery and Gamma Knife Centre, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India To whom correspondence should be addressed: Basant Kumar Misra, M.Ch. [E-mail: [email protected]] Citation: World Neurosurg. (2011) 75, 5/6:612-613. DOI: 10.1016/j.wneu.2011.01.037
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.01.037
PERSPECTIVES
today. Although frame-based stereotactic drainages were performed in the investigators’ series in only 3.2% of patients, some form of image guidance is almost routine today while draining BAs. Many advances in neuroimaging, especially the newer magnetic resonance imaging sequences and magnetic resonance spectroscopy provides a clue to the pathologic type of BA, fungal, mycobacterial, or other, to initiate early chemotherapy.
REFERENCES 1. Antunes ACM, Franciscatto AC, Modkovski R, De Avila TT: BA. In: Kalangu KKN ed. Essential Practice of Neurosurgery. Nagoya: Access Publishing Co. Ltd.; 2009:1350-1362. 2. Bhatia R, Tandon PN, Banerji AK: Brain abscess—an analysis of 55 cases. Int Surg 58:565-568, 1973. 3. Canale DJ: William Macewen and the treatment of brain abscess revisited after one hundred years. J Neurosurg 84:133-142, 1996.
In spite of the newer antibiotics and advances in neuroimaging, the most critical factor in the decrease of incidence of BA and improvement in the outcome of treatment is improvement in the socioeconomic status and healthcare facility in the community and early diagnosis with a contrast enhanced computerized tomography scan. The investigators have to be congratulated for highlighting these issues. It would have been better, however, if the article had not been so long!
4. Dandy WE: Treatment of chronic abscesses of the brain by tapping. Preliminary note. JAMA 87:14771478, 1926. 5. Heineman HS, Braude AI, Osterholm JL: Intracranial suppurative disease. Early presumptive diagnosis and successful treatment without surgery. JAMA 218: 1542-1547, 1971. 6. Sambasivan M, Ramamurthi B: Pyogenic infections. In: Ramamurthi B, Tandon PN, eds. Textbook of Neurosurgery, 2nd ed. New Delhi: Churchill Livingstone; 1996:447-467.
WORLD NEUROSURGERY 75 [5/6]: 612-613, MAY/JUNE 2011
Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Citation: World Neurosurg. (2011) 75, 5/6:612-613. DOI: 10.1016/j.wneu.2011.01.037 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Published by Elsevier Inc.
www.WORLDNEUROSURGERY.org
613
Basant Kumar Misra, M.Ch. Diplomate of National Board Department of Neurosurgery and Gamma Knife Centre P.D.Hinduja National Hospital and Medical Research Centre
Management of Brain Abscess Basant Kumar Misra
T
he French surgeon Morand has been credited with the first successful operation for brain abscess (BA) in 1752 (6). In 1774, Jean Louis Petit made a trephine opening for a traumatic BA and the abscess later bursted externally (6). Similar principles of management were occasionally reported until the authoritative work of Sir William Macewen of Glasgow, Pyogenic Infective Diseases of the Brain and Spinal Cord in 1893 (3). He recommended drainage of BA and treatment of the underlying sinusitis and reported the results of 19 patients of whom 18 recovered. Dandy, in 1926, recommended burr hole aspiration of the abscess as the primary treatment—today, this surgical principle is followed in the majority of patients (4). Vincent, in 1936, demonstrated the efficacy of complete excision of BA and Heineman and colleagues were the first to treat BA medically (1, 5). The introduction of antibiotics led to a dramatic decline in the morbidity and mortality, as well as a reduction in the incidence of recurrent abscess. Improved health care facilities and availability of neurosurgical manpower has resulted in the decrease in BA secondary to open head injury, paranasal sinus, otogenic infection, and congenital heart disease. Widespread availability of computerized tomography scan and stereotactic procedures has led to earlier diagnosis and minimally invasive management of BA. Although the earlier reported high incidence of BA in developing countries (8% of all intracranial space occupying lesions) is diminishing, it is still a major problem (2). In addition, resistant strains, because of inappropriate use and overuse of antibiotics and opportunistic infections in immunocompromised patients, have raised unique problems in the management of BA. In their article, Nathoo et al. presented a retrospective analysis of a large series of 973 cases of BA treated during a 20-year period
Key words 䡲 Brain abscess 䡲 Cranial infections 䡲 Health care 䡲 Otogenic 䡲 Paranasal 䡲 Sinusitis 䡲 Trauma
612
Abbreviations and Acronyms BA: Brain abscess
www.SCIENCEDIRECT.com
(1983-2002) at the 106-bed Wentworth Hospital, Durban, South Africa, the sole public sector neurosurgical referral center for the province of KwaZulu-Natal, until its closure in December 2002. The vast majority of the patients were male and young. Otorhinogenic and post-traumatic injury were common etiologic factors and nearly 90% of the BA were located in the supratentorial compartment. Surgical drainage was the main stay of treatment and nearly 75% of patients had a good outcome. The fact that 130 patients died shows the gravity of the problem. It was reassuring to learn that the incidence of BA reduced over time. The supratentorial BA was approached by either burr hole or limited craniotomy and drained. The infratentorial abscess was drained after a suboccipital craniectomy. Patients were initially started on a triple antibiotic therapy (empirically)—penicillin, chloramphenicol, and metronidazole— until the sensitivity report and then changed appropriately. The investigators have to be congratulated for their efforts and presenting in detail their experience, which will be useful to any neurosurgeon interested in the subject. Of particular importance is their recommendation for eradication of the primary source or ear, nose, and throat procedures under the same anesthesia. Although desirable, it is neither always possible nor mandatory to do the ear, nose, and throat procedure under the same anesthesia. What is, however, important is early eradication of the primary source, lest BA recurs. It is important to mention that the data presented pertains to the 20th century. Many advances have taken place. An empiric triple antibiotic regimen, as practiced then, is rarely used today (especially chloramphenicol); open drainage of abscess into “strategically placed sodium hypochlorite soaked gauze” is of historic interest and has no place in modern neurosurgery
Department of Neurosurgery and Gamma Knife Centre, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India To whom correspondence should be addressed: Basant Kumar Misra, M.Ch. [E-mail: [email protected]] Citation: World Neurosurg. (2011) 75, 5/6:612-613. DOI: 10.1016/j.wneu.2011.01.037
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.01.037
PERSPECTIVES
today. Although frame-based stereotactic drainages were performed in the investigators’ series in only 3.2% of patients, some form of image guidance is almost routine today while draining BAs. Many advances in neuroimaging, especially the newer magnetic resonance imaging sequences and magnetic resonance spectroscopy provides a clue to the pathologic type of BA, fungal, mycobacterial, or other, to initiate early chemotherapy.
REFERENCES 1. Antunes ACM, Franciscatto AC, Modkovski R, De Avila TT: BA. In: Kalangu KKN ed. Essential Practice of Neurosurgery. Nagoya: Access Publishing Co. Ltd.; 2009:1350-1362. 2. Bhatia R, Tandon PN, Banerji AK: Brain abscess—an analysis of 55 cases. Int Surg 58:565-568, 1973. 3. Canale DJ: William Macewen and the treatment of brain abscess revisited after one hundred years. J Neurosurg 84:133-142, 1996.
In spite of the newer antibiotics and advances in neuroimaging, the most critical factor in the decrease of incidence of BA and improvement in the outcome of treatment is improvement in the socioeconomic status and healthcare facility in the community and early diagnosis with a contrast enhanced computerized tomography scan. The investigators have to be congratulated for highlighting these issues. It would have been better, however, if the article had not been so long!
4. Dandy WE: Treatment of chronic abscesses of the brain by tapping. Preliminary note. JAMA 87:14771478, 1926. 5. Heineman HS, Braude AI, Osterholm JL: Intracranial suppurative disease. Early presumptive diagnosis and successful treatment without surgery. JAMA 218: 1542-1547, 1971. 6. Sambasivan M, Ramamurthi B: Pyogenic infections. In: Ramamurthi B, Tandon PN, eds. Textbook of Neurosurgery, 2nd ed. New Delhi: Churchill Livingstone; 1996:447-467.
WORLD NEUROSURGERY 75 [5/6]: 612-613, MAY/JUNE 2011
Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Citation: World Neurosurg. (2011) 75, 5/6:612-613. DOI: 10.1016/j.wneu.2011.01.037 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Published by Elsevier Inc.
www.WORLDNEUROSURGERY.org
613