Never go to sleep on undrained pus: a retrospective review of surgery for intraparenchymal cerebral abscess

Abstract

Cerebral abscess is an emergency requiring urgent drainage via craniotomy or burrhole aspiration. We examine whether initial method of drainage affects outcome and important characteristics in patients with cerebral abscess. This is a retrospective analysis of 62 patients operated on in our unit with a loculated infected cerebral collection in the years 2003-2007 inclusive. Full statistical analysis was performed using data appropriate tests. Burrhole and craniotomy groups were evenly matched with no difference in any demographic factors. Surgical method made no difference to rate of re-operation (p = 0.276), antibiotic duration (p = 0.648), discharge GCS (p = 0.509), length of stay (p = 0.647) or GOS (p = 0.968). There was a trend to worsened outcome with delay to surgery (p = 0.132) with delayed patients requiring longer hospital stays (p< or = 0.005). Patients requiring a longer antibiotic duration had worse outcomes (p < or = 0.005). Surgical method did not have a significant effect on outcome, so burrhole aspiration with its advantages in terms of speed and scale of surgery should be strongly considered. Delay had an adverse affect, so operation should be as expeditious as possible whenever the differential diagnosis includes abscess, diagnosis of which may be aided by advanced magnetic resonance imaging techniques.

Pyogenic brain abscess, a 15 year survey

“…However, in multivariate analysis only GCS at admission, the presence of co-morbidities and intraventricular rupture of brain abscess were significant predictors of outcome. Additional predictors previously reported to be associated with a poor outcome, namely fever (>38.5°C), diagnostic delay and advanced age were not associated with adverse outcome in our material [4-6]. The presence of leucocytosis was associated with adverse outcome (GOS≤ 3) in 29% of patients compared to 11% without (p=0.039), however, as the outcome was equivalently poor (33% with GOS≤ 3) in the 15 patients with missing values for leukocytes, this predictor was excluded from analysis.…”

“…Diagnostic delay has generally been believed to be a key contributing factor to the severity and outcome of brain abscess [6,27]. In our study, the majority of patients presented with uncharacteristic symptoms and diagnosis was frequently delayed.…”

“…The highest mortality rates have been reported in case-series with a high proportion of non-surgically managed patients [9,15], primarily reflecting the overall poor prognosis of patients with severe septic shock, meningitis, multiple abscesses and/or staphylococcal infections. In contrast, case series with a high proportion of surgically managed streptococcal abscesses tend to have a much better overall outcome [6,14,19,23]. …”

The proteome of pus from human brain abscesses: host-derived neurotoxic proteins and the cell-type diversity of CNS pus

“…We conclude that leukocytic antibacterial proteins, which have known neurotoxic effects, likely contribute actively to the tissue destruction inherent in brain abscess formation. This conclusion underscores the importance of rapid evacuation of brain abscesses, 35 because leukocytic proteins may cause brain damage even after antibiotic treatment is begun.…”

Culture-negative Brain Abscess with <i>Streptococcus intermedius</i> Infection with Diagnosis Established by Direct Nucleotide Sequence Analysis of the 16S Ribosomal RNA Gene

“…Streptococcus intermedius is a member of the Streptococcus anginosus group (SAG). Several retrospective reviews and case reports have mentioned S. intermedius as a significant pathogen among the SAG species in the development of brain abscess (2)(3)(4)(5). However, no studies have compared S. intermedius brain abscess with abscess caused by other SAG members or other bacteria.…”