Child’s Brain 1: 368-375 (1975)
Intracranial Abscess: Treatment by Continuous Catheter Drainage R obert G. Selker Department of Neurosurgery, University of Pittsburgh School of Medicine, and the Montefiore Hospital, Pittsburgh, Pa.
‘The uncomplicated cerebral abscess early recognized, accurately localized and promptly operated upon is one of the most satisfactory of intracranial lesions.’ MacEven 1893 Key Words. Abscess • Continuous catheter • Drainage Abstract. 15 children with brain abscesses were subjected to continuous catheter drainage as the procedure of choice for a solitary encapsulated abscess. Although many still advocate craniotomy and total excision, this series, coupled with the ex perience of others in the literature, leaves little doubt that catheter drainage alone is sufficient. The simplicity of creating a burr hole under local anesthesia, the ability to irrigate with antibiotics and then outline the cavity with contrast agents are but a few of the advantages of this method.
The treatment of a localized brain abscess has had a varied and inter esting history. Once considered a hopeless condition, M acE w en ’s [12] epic contribution demonstrated not only the feasibility of surgical inter vention, but with an extremely low mortality rate. During the intervening years, antibiotics, dehydrating agents, modern anesthesia and ncuroradiology have further modified the treatment and prognosis of these le sions. Thus, it is believed that the solitary brain abscess modestly encap sulated need not require craniotomy, transcortical incision and total re moval. Continuous catheter drainage with gradual shortening promotes
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Introduction
Selker
369
drainage, allows for irrigation with antibiotics if desired, permits outline of the capsule with radiopaque material and enhances collapse of the cap sule from the bottom, thereby denying the reaccumulation of purulent material.
15 children with solitary brain abscess were treated by catheter drainage and fol lowed for 1-13 years (table 1). They ranged from 3 months to 14 years of age with a variety of etiologies and sites. Congenital heart lesions accounted for the greatest percentage. All were subjected to the catheter drainage technique as the primary mode of therapy. Localization of the abscess was accomplished by angiography and brain scan. The diagnosis was established primarily from the history and clinical evaluation on admission. The procedure, most times carried out under local anesthesia, consisted of a sin gle burr hole placed over the site of the lesion. The dura was opened and sealed to the surrounding brain surface by electrocautery. A transcortical incision was effect ed in sufficient length to permit passage of a No. 10 red rubber catheter shortened to 10 cm and fitted to a metal stylet. An exploring needle was not passed first to lo cate the abscess, as has been the practice in some situations. The stylet-fitted cathe ter was passed primarily and upon encountering resistance was firmly inserted into the center of the mass. Withdrawal of the stylet as a rule produced a flow of puru lent material. On occasion, gentle aspiration was required to promote flow. When certain of the placement, a sterile safety pin was passed through the side wall of the catheter to mark its depth and to prohibit inward migration. When spontaneous flow of material ceased, gentle irrigation of the cavity was carried out with Bacitra cin® solution (50,000 U in 500 cm3 normal saline) in increments of 10 cm3, each time yielding an almost equal return. When the return had become clear to the point of appearing only turbid, 5 cm3 of air and 5 cm3 of pantopaque were placed into the abscess cavity, and the catheter was immediately clamped. A sterile dressing was placed and the patient was transferred to the x-ray department where brow-up. brow-down right and left horizontal, lateral and AP views were examined. Thus, each picture would outline the roof (air) and the floor (pantopaque) of each aspect of the cavity. Offshoots and daughter abscesses can in this manner be identified. Great care is exercised to be certain that the tip of the catheter is in the geometric center of the now outlined space. If it is not, the catheter is redressed and reposi tioned. In either case, the catheter is unclamped and allowed to drain freely into a large fluff dressing. Superimposition of the x-rays under a bright light dramatically outlines the size, shape and volume of the entire abscess cavity. The area between the pantopaque shadow and air contour is indicative of the remaining material to be drained (fig. 1). Daily irrigations are carried out with 5 cm3 increments of Bacitracin or other an tibiotic solutions until the return is clear. On the third and each subsequent day, the catheter position is shortened by 0.5-1 cm until the catheter is removed. Daily or every other day, x-rays are performed to note the size of the air shadow. Additional
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Methods and Procedure
370
St.1.K I R
Fig. 1. Air and pantopaque outline of abscess cavity. Note remaining material to be drained.
pantopaque can be added if necessary, but has only rarely been required. Intermit tent tapping of the abscess is not performed. Systemic antibiotics (penicillin and chloramphenicol) are instituted before surgery and continued for 3 weeks postoperatively. The antibiotic regimen is changed in accordance with the culture and subse quent antibiotic sensitivity reports. Following removal of the catheter, the patient is followed on a weekly basis as an outpatient. Brain scans are performed each visit, carefully looking for evidence of decrease in uptake. All patients were either personally interviewed by the author or contacted through family members and/or local family physicians to obtain follow-up data.
Results
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Of the 15 patients involved in this study, 2 died during open heart sur gery, 2 and 6 years postdrainage, and were neurologically intact at that time. One patient drowned 8 years after surgery but was reported to have been neurologically well at the time of her accident. Therefore, no mor tality accrued as a result of the surgery or the abscess. Four patients un derwent craniotomy. One done so because of an early insecurity concern-
Continuous Catheter Drainage of Intracranial Abscess
371
ing the leaving of the capsule in place, one because of a frank recurrence of symptoms and before we realized it was possible to drain an abscess a second time. The third patient underwent craniotomy to remove a foreign body in the abscess proper which could not be removed by drainage alone. The fourth patient had clot with the abscess cavity making com plete collapse of the abscess impossible. Although the average length of drainage was 11V» days, most were collapsed and completely drained in 6-7 days. One patient required re peat catheterization of the cavity and another required catheterization of a daughter abscess which did not communicate with the original cavity. It was, however, identified in the original pantopaque air contrast study. Follow-up brain scans and evaluations were made on most of the pa tients. Positive uptakes noted pre- and immediately postoperatively re turned to normal in approximately 6 weeks. Any additional cranial symp toms suggestive of recurrence were thus rapidly screened by this method after the initial 6-week period. The organism most often found was the microaerophilic streptococcus. Only four of the abscesses in this series were sterile. There were no sec ondary invading bacteria, even though the length of drainage in some of the patients was prolonged. The abscess material which was initially posi tive, showed no growth on subsequent culture attempts and is probably related to the use of the Bacitracin solution. Seizure activity was appreciated in six patients preoperatively. Four patients reported seizure activity during the réévaluation period, but were adequately controlled by medication. They were not the same patients presenting with a seizure. It is possible that the patient who died by drowning had a seizure in the water although there is no evidence to indi cate that to be the case. She was, however, taking anticonvulsant medica tion at the time of the accident.
During the 81 years since the manuscript of M acE wen [12] appeared, neurosurgeons have struggled with the problems of intracranial suppura tion. Antibiotics, sophisticated visualizing techniques for localization, modern anesthesia and dehydrating agents all have contributed to lessen ing this burden. There have been many methods of surgical intervention, all advocated with equal vigor [1-11, 13]. In general, the neurosurgical world is gradually acceding to the prophetic statement of D andy [4]:
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Discussion
Table I. Patient data
Site of abscess
Etiology
Pre-operative Follow-up status status
Days of drainage
Size cm3
Recur rence
Other surgical procedures
Cause of death
1
7
parietal (deep)
unde termined
papilledema intact Cheyne-Stokcs
23
35
no
no
-
9
2
51
frontal
unde termined
hemiparesis
intact
26
45
no
no
-
9
3
7
occipital
unde termined
lethargy visual field loss
intact
9
40
no
excision of drowned 8 capsule 8 years 10 days later later (no pus)
4
6
frontal
unde termined
papilledema
intact
6
40
yes
excised 13 days later (25 cm8 pus)
5
10
parietal
congenital heart
comatosed
visual field loss
8
60
no
no
died during open heart
6
30
40
no
no
-
4
7
25
no
no
—
13
31
parietal
unde termined
hemiparesis
retarded
7
5
left cerebellum
otitis
lethargic hemiparesis
intact
2
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6
Length of follow-up years
Selker
Age years
Patient No.
Tabic / (continued)
Site of abscess
Etiology
Preoperative status
Follow-up status
4.5
parietal
congenital heart
hemiparesis
intact
Days of drainage
Size cm3
Recurrence
Other surgical procedures
Cause of death
4
25
no
no
died during open heart
Length of follow-up years 2
9
14
parietal temporal (2 lesions)
congenital heart
visual field loss hemiparesis
visual field loss
7 10
30 75
no
no
-
11
10
14
occipital
congenital heart
visual field loss
intact
10
30
no
no
-
13
11
3
frontal
congenital heart
headache
intact
8
35
no
no
-
2
12
11
frontal
congenital heart
hemiparesis
intact
12
40
no
no
-
8
13
9
frontal
congenital heart
hemiparesis
intact
7 7
20 45
yes
no
-
2
14
11
occipital
congenital heart
decerebrate
visual field loss
5
35 no plus clot
craniotomy (clot)
-
2
15
4
frontal
foreign body
papilledema
intact
4
20
craniotomy removal of foreign body
-
1
1 Age is given in months.
no
Continuous Catheter Drainage of Intracranial Abscess
8
Age years
Ui - j
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Patient No.
Selker
the conclusion is inevitable that many patients so afflicted (brain ab scess) succumb from the effects of the treatment rather than from the ab scess itself.’ No longer is it necessary to tolerate the deliberate creation of a cerebral fungus or establish adhesions between cortex and meninges as a preliminary step. Similarly, it now seems unnecessary to subject most pa tients with a solitary encapsulated abscess to a full scale craniotomy, trans cortical incision and total extirpation. Intermittent tapping of an abscess cavity carries with it the ominous prospect of seeding viable organisms along the needle tract in otherwise uninvolved brain. The supposition that ‘tapping’ is a preliminary feature performed before craniotomy, has by this series and others been shown to be incorrect. Intermittent tapping, or single aspiration of the abscess cavity, does not permit total collapse and complete drainage of the cavity. Utilization of the technique described in this monograph has several advantages which are immediately apparent: (a) Total collapse of the capsule occurs from the bottom up, thereby precluding residual collection. (b) This technique negates the need for full scale craniotomy. A simple burr hole will suffice with only the passage of a catheter, disrupting less vital brain tissue. (c) The entire cavity can be outlined and the volume of remaining ma terial to be drained can be determined. This can be repeated at intervals during the catheterization process. (d) The content of the cavity is rendered sterile in most cases by irriga tion with antibiotics. (e) The procedure can be employed with local anesthesia, a point of some interest in the cyanotic congenital heart group of patients who are usually critically ill at the time of surgery. (f) The brain scan can be effectively utilized to determine the progno sis of the abscess currently under treatment and the possible formation of others during not only the convalescent period but at any time thereafter. Admittedly, this procedure, as any thus far published, has its greatest effect and usefulness in the solitary encapsulated abscess. However, con sidering the extensive use of antibiotics today, the decrease in sinus and otitic involvement and the emergence of the most common variety of ab scess that associated with congenital cardiac lesions, the greatest percen tage of abscesses seen clinically today can be managed by short-term con tinuous catheter drainage with a minimum of sequelae. Postoperative sei zure activity related to surgical intervention can be held to a minimum.
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374
Continuous Catheter Drainage of Intracranial Abscess
375
References
R obert G. Selker , Department of Neurosurgery, University of Pittsburgh School of Medicine, and the Montefiore Hospital, Pittsburgh, Pa. (USA)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
1 Bellar, D. J.; Sahar, A., and Praiss, I.: Brain abscess. J. Neurol. Neurosurg. Psychiat. 36: 757-768 (1973). 2 C arey, M. E.; C hou , S. N., and F rench , L. A.: Experience with brain abscess. J. Neurosurg. 36: 1-9 (1972). 3 C oleman, C. C.: Reduction of mortality of brain abscess by simple methods of treatment. Sth. med. J., Nashville 23: 484-487 (1930). 4 Dandy, W. E.: Treatment of chronic abscess of the brain by tapping. J. Am. med. Ass. 87: 1477-1478 (1926). 5 D owman, C. E.: The treatment of brain abscess by the introduction of protective adhesions between the brain cortex and the dura before the establishment of drainage. Archs Surg., Chicago 6: 747-754 (1923). 6 G arfield , J.: Management of supratentorial intracranial abscess. A review of 200 cases. Br. med. J. ii: 7-11 (1969). 7 G rant, F. C.: The mortality from abscess of the brain. J. Am. med. Ass. 99: 550-556 (1932). 8 Grant, F. C.: End-result in one hundred consecutive cases of brain abscess. Sur gery Gynec. Obstet. 75: 465-467 (1942). 9 King, J. E.: The treatment of brain abscess by unroofing and temporary hernia tion of abscess cavity with the avoidance of usual drainage methods. Surgery Gynec. Obstet. 29: 554-568 (1924). 10 LeBeau, J.: Radical surgery and penicillin in brain abscess. J. Neurosurg. 3: 359-374 (1946). 11 M ount , L. A.: Conservative surgical therapy of brain abscesses. J. Neurosurg. 7: 385-389 (1950). 12 MacEwen, W.: Pyogenic infective diseases of the brain and spinal cord (Maclehose, Glasgow 1893). 13 R izzoli, H. V.; M c Cun e , S., and Sherman, I.: Surgical management of metas tatic brain abscess. J. Neurosurg. 5: 372-384 (1948).
Intracranial Abscess: Treatment by Continuous Catheter Drainage R obert G. Selker Department of Neurosurgery, University of Pittsburgh School of Medicine, and the Montefiore Hospital, Pittsburgh, Pa.
‘The uncomplicated cerebral abscess early recognized, accurately localized and promptly operated upon is one of the most satisfactory of intracranial lesions.’ MacEven 1893 Key Words. Abscess • Continuous catheter • Drainage Abstract. 15 children with brain abscesses were subjected to continuous catheter drainage as the procedure of choice for a solitary encapsulated abscess. Although many still advocate craniotomy and total excision, this series, coupled with the ex perience of others in the literature, leaves little doubt that catheter drainage alone is sufficient. The simplicity of creating a burr hole under local anesthesia, the ability to irrigate with antibiotics and then outline the cavity with contrast agents are but a few of the advantages of this method.
The treatment of a localized brain abscess has had a varied and inter esting history. Once considered a hopeless condition, M acE w en ’s [12] epic contribution demonstrated not only the feasibility of surgical inter vention, but with an extremely low mortality rate. During the intervening years, antibiotics, dehydrating agents, modern anesthesia and ncuroradiology have further modified the treatment and prognosis of these le sions. Thus, it is believed that the solitary brain abscess modestly encap sulated need not require craniotomy, transcortical incision and total re moval. Continuous catheter drainage with gradual shortening promotes
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
Introduction
Selker
369
drainage, allows for irrigation with antibiotics if desired, permits outline of the capsule with radiopaque material and enhances collapse of the cap sule from the bottom, thereby denying the reaccumulation of purulent material.
15 children with solitary brain abscess were treated by catheter drainage and fol lowed for 1-13 years (table 1). They ranged from 3 months to 14 years of age with a variety of etiologies and sites. Congenital heart lesions accounted for the greatest percentage. All were subjected to the catheter drainage technique as the primary mode of therapy. Localization of the abscess was accomplished by angiography and brain scan. The diagnosis was established primarily from the history and clinical evaluation on admission. The procedure, most times carried out under local anesthesia, consisted of a sin gle burr hole placed over the site of the lesion. The dura was opened and sealed to the surrounding brain surface by electrocautery. A transcortical incision was effect ed in sufficient length to permit passage of a No. 10 red rubber catheter shortened to 10 cm and fitted to a metal stylet. An exploring needle was not passed first to lo cate the abscess, as has been the practice in some situations. The stylet-fitted cathe ter was passed primarily and upon encountering resistance was firmly inserted into the center of the mass. Withdrawal of the stylet as a rule produced a flow of puru lent material. On occasion, gentle aspiration was required to promote flow. When certain of the placement, a sterile safety pin was passed through the side wall of the catheter to mark its depth and to prohibit inward migration. When spontaneous flow of material ceased, gentle irrigation of the cavity was carried out with Bacitra cin® solution (50,000 U in 500 cm3 normal saline) in increments of 10 cm3, each time yielding an almost equal return. When the return had become clear to the point of appearing only turbid, 5 cm3 of air and 5 cm3 of pantopaque were placed into the abscess cavity, and the catheter was immediately clamped. A sterile dressing was placed and the patient was transferred to the x-ray department where brow-up. brow-down right and left horizontal, lateral and AP views were examined. Thus, each picture would outline the roof (air) and the floor (pantopaque) of each aspect of the cavity. Offshoots and daughter abscesses can in this manner be identified. Great care is exercised to be certain that the tip of the catheter is in the geometric center of the now outlined space. If it is not, the catheter is redressed and reposi tioned. In either case, the catheter is unclamped and allowed to drain freely into a large fluff dressing. Superimposition of the x-rays under a bright light dramatically outlines the size, shape and volume of the entire abscess cavity. The area between the pantopaque shadow and air contour is indicative of the remaining material to be drained (fig. 1). Daily irrigations are carried out with 5 cm3 increments of Bacitracin or other an tibiotic solutions until the return is clear. On the third and each subsequent day, the catheter position is shortened by 0.5-1 cm until the catheter is removed. Daily or every other day, x-rays are performed to note the size of the air shadow. Additional
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
Methods and Procedure
370
St.1.K I R
Fig. 1. Air and pantopaque outline of abscess cavity. Note remaining material to be drained.
pantopaque can be added if necessary, but has only rarely been required. Intermit tent tapping of the abscess is not performed. Systemic antibiotics (penicillin and chloramphenicol) are instituted before surgery and continued for 3 weeks postoperatively. The antibiotic regimen is changed in accordance with the culture and subse quent antibiotic sensitivity reports. Following removal of the catheter, the patient is followed on a weekly basis as an outpatient. Brain scans are performed each visit, carefully looking for evidence of decrease in uptake. All patients were either personally interviewed by the author or contacted through family members and/or local family physicians to obtain follow-up data.
Results
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
Of the 15 patients involved in this study, 2 died during open heart sur gery, 2 and 6 years postdrainage, and were neurologically intact at that time. One patient drowned 8 years after surgery but was reported to have been neurologically well at the time of her accident. Therefore, no mor tality accrued as a result of the surgery or the abscess. Four patients un derwent craniotomy. One done so because of an early insecurity concern-
Continuous Catheter Drainage of Intracranial Abscess
371
ing the leaving of the capsule in place, one because of a frank recurrence of symptoms and before we realized it was possible to drain an abscess a second time. The third patient underwent craniotomy to remove a foreign body in the abscess proper which could not be removed by drainage alone. The fourth patient had clot with the abscess cavity making com plete collapse of the abscess impossible. Although the average length of drainage was 11V» days, most were collapsed and completely drained in 6-7 days. One patient required re peat catheterization of the cavity and another required catheterization of a daughter abscess which did not communicate with the original cavity. It was, however, identified in the original pantopaque air contrast study. Follow-up brain scans and evaluations were made on most of the pa tients. Positive uptakes noted pre- and immediately postoperatively re turned to normal in approximately 6 weeks. Any additional cranial symp toms suggestive of recurrence were thus rapidly screened by this method after the initial 6-week period. The organism most often found was the microaerophilic streptococcus. Only four of the abscesses in this series were sterile. There were no sec ondary invading bacteria, even though the length of drainage in some of the patients was prolonged. The abscess material which was initially posi tive, showed no growth on subsequent culture attempts and is probably related to the use of the Bacitracin solution. Seizure activity was appreciated in six patients preoperatively. Four patients reported seizure activity during the réévaluation period, but were adequately controlled by medication. They were not the same patients presenting with a seizure. It is possible that the patient who died by drowning had a seizure in the water although there is no evidence to indi cate that to be the case. She was, however, taking anticonvulsant medica tion at the time of the accident.
During the 81 years since the manuscript of M acE wen [12] appeared, neurosurgeons have struggled with the problems of intracranial suppura tion. Antibiotics, sophisticated visualizing techniques for localization, modern anesthesia and dehydrating agents all have contributed to lessen ing this burden. There have been many methods of surgical intervention, all advocated with equal vigor [1-11, 13]. In general, the neurosurgical world is gradually acceding to the prophetic statement of D andy [4]:
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
Discussion
Table I. Patient data
Site of abscess
Etiology
Pre-operative Follow-up status status
Days of drainage
Size cm3
Recur rence
Other surgical procedures
Cause of death
1
7
parietal (deep)
unde termined
papilledema intact Cheyne-Stokcs
23
35
no
no
-
9
2
51
frontal
unde termined
hemiparesis
intact
26
45
no
no
-
9
3
7
occipital
unde termined
lethargy visual field loss
intact
9
40
no
excision of drowned 8 capsule 8 years 10 days later later (no pus)
4
6
frontal
unde termined
papilledema
intact
6
40
yes
excised 13 days later (25 cm8 pus)
5
10
parietal
congenital heart
comatosed
visual field loss
8
60
no
no
died during open heart
6
30
40
no
no
-
4
7
25
no
no
—
13
31
parietal
unde termined
hemiparesis
retarded
7
5
left cerebellum
otitis
lethargic hemiparesis
intact
2
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6
Length of follow-up years
Selker
Age years
Patient No.
Tabic / (continued)
Site of abscess
Etiology
Preoperative status
Follow-up status
4.5
parietal
congenital heart
hemiparesis
intact
Days of drainage
Size cm3
Recurrence
Other surgical procedures
Cause of death
4
25
no
no
died during open heart
Length of follow-up years 2
9
14
parietal temporal (2 lesions)
congenital heart
visual field loss hemiparesis
visual field loss
7 10
30 75
no
no
-
11
10
14
occipital
congenital heart
visual field loss
intact
10
30
no
no
-
13
11
3
frontal
congenital heart
headache
intact
8
35
no
no
-
2
12
11
frontal
congenital heart
hemiparesis
intact
12
40
no
no
-
8
13
9
frontal
congenital heart
hemiparesis
intact
7 7
20 45
yes
no
-
2
14
11
occipital
congenital heart
decerebrate
visual field loss
5
35 no plus clot
craniotomy (clot)
-
2
15
4
frontal
foreign body
papilledema
intact
4
20
craniotomy removal of foreign body
-
1
1 Age is given in months.
no
Continuous Catheter Drainage of Intracranial Abscess
8
Age years
Ui - j
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
Patient No.
Selker
the conclusion is inevitable that many patients so afflicted (brain ab scess) succumb from the effects of the treatment rather than from the ab scess itself.’ No longer is it necessary to tolerate the deliberate creation of a cerebral fungus or establish adhesions between cortex and meninges as a preliminary step. Similarly, it now seems unnecessary to subject most pa tients with a solitary encapsulated abscess to a full scale craniotomy, trans cortical incision and total extirpation. Intermittent tapping of an abscess cavity carries with it the ominous prospect of seeding viable organisms along the needle tract in otherwise uninvolved brain. The supposition that ‘tapping’ is a preliminary feature performed before craniotomy, has by this series and others been shown to be incorrect. Intermittent tapping, or single aspiration of the abscess cavity, does not permit total collapse and complete drainage of the cavity. Utilization of the technique described in this monograph has several advantages which are immediately apparent: (a) Total collapse of the capsule occurs from the bottom up, thereby precluding residual collection. (b) This technique negates the need for full scale craniotomy. A simple burr hole will suffice with only the passage of a catheter, disrupting less vital brain tissue. (c) The entire cavity can be outlined and the volume of remaining ma terial to be drained can be determined. This can be repeated at intervals during the catheterization process. (d) The content of the cavity is rendered sterile in most cases by irriga tion with antibiotics. (e) The procedure can be employed with local anesthesia, a point of some interest in the cyanotic congenital heart group of patients who are usually critically ill at the time of surgery. (f) The brain scan can be effectively utilized to determine the progno sis of the abscess currently under treatment and the possible formation of others during not only the convalescent period but at any time thereafter. Admittedly, this procedure, as any thus far published, has its greatest effect and usefulness in the solitary encapsulated abscess. However, con sidering the extensive use of antibiotics today, the decrease in sinus and otitic involvement and the emergence of the most common variety of ab scess that associated with congenital cardiac lesions, the greatest percen tage of abscesses seen clinically today can be managed by short-term con tinuous catheter drainage with a minimum of sequelae. Postoperative sei zure activity related to surgical intervention can be held to a minimum.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
374
Continuous Catheter Drainage of Intracranial Abscess
375
References
R obert G. Selker , Department of Neurosurgery, University of Pittsburgh School of Medicine, and the Montefiore Hospital, Pittsburgh, Pa. (USA)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 5/14/2018 5:11:33 PM
1 Bellar, D. J.; Sahar, A., and Praiss, I.: Brain abscess. J. Neurol. Neurosurg. Psychiat. 36: 757-768 (1973). 2 C arey, M. E.; C hou , S. N., and F rench , L. A.: Experience with brain abscess. J. Neurosurg. 36: 1-9 (1972). 3 C oleman, C. C.: Reduction of mortality of brain abscess by simple methods of treatment. Sth. med. J., Nashville 23: 484-487 (1930). 4 Dandy, W. E.: Treatment of chronic abscess of the brain by tapping. J. Am. med. Ass. 87: 1477-1478 (1926). 5 D owman, C. E.: The treatment of brain abscess by the introduction of protective adhesions between the brain cortex and the dura before the establishment of drainage. Archs Surg., Chicago 6: 747-754 (1923). 6 G arfield , J.: Management of supratentorial intracranial abscess. A review of 200 cases. Br. med. J. ii: 7-11 (1969). 7 G rant, F. C.: The mortality from abscess of the brain. J. Am. med. Ass. 99: 550-556 (1932). 8 Grant, F. C.: End-result in one hundred consecutive cases of brain abscess. Sur gery Gynec. Obstet. 75: 465-467 (1942). 9 King, J. E.: The treatment of brain abscess by unroofing and temporary hernia tion of abscess cavity with the avoidance of usual drainage methods. Surgery Gynec. Obstet. 29: 554-568 (1924). 10 LeBeau, J.: Radical surgery and penicillin in brain abscess. J. Neurosurg. 3: 359-374 (1946). 11 M ount , L. A.: Conservative surgical therapy of brain abscesses. J. Neurosurg. 7: 385-389 (1950). 12 MacEwen, W.: Pyogenic infective diseases of the brain and spinal cord (Maclehose, Glasgow 1893). 13 R izzoli, H. V.; M c Cun e , S., and Sherman, I.: Surgical management of metas tatic brain abscess. J. Neurosurg. 5: 372-384 (1948).
