Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 56, Num. 1, 2008, pp. 13-16

Neurology India, Vol. 56, No. 1, January-March, 2008, pp. 13-16

Original Article

Endoscopic management of brain abscesses

Yadav YadRam, Sinha Mallika, Neha, Parihar Vijay

Neurosurgery Unit, NSCB Government Medical College, Apex Hospital and Research Centre, Jabalpur, Madhya Pradesh
Correspondence Address:105 Nehru Nagar, Opposite Medical College, Jabalpur - 482 003, Madhya Pradesh, yadavyr@yahoo.co.in

Date of Acceptance: 17-Jan-2008

Code Number: ni08003

Abstract

Keywords: Brain abscess, endoscopic treatment, minimally invasive technique

Treatment of brain abscess is still a subject of controversy. Craniotomy with primary extirpation and resection of the abscess membrane, ^{[1],[2],[3],[4],[5]} burr hole craniotomy and aspiration of pus with or without insertion of a drain, ^[1],[6] stereotactic aspiration, ^[1],[7],[8] ultrasound-guided aspiration, ^[9] medical management, ^[1] endoscopic aspiration ^[10],[11] and stereotactic endoscopic aspiration ^[12],[13] are different therapeutic approaches. However, simple therapeutic approaches like twist drill/burr hole aspiration with or without insertion of a drain are also quite effective. Endoscopic method has advantage of allowing direct visualization of abscess cavity. Completeness of aspiration can also be assessed. ^[10],[11] Perioperative bleeding can be controlled, which may not be possible in stereotactic or any other guided aspirations. We are reporting our results of 24 cases of endoscopic aspiration.

Materials and Methods

Results

This is a prospective study of 24 patients of brain abscesses treated between January 2004 and January 2007. There were 16 male and 8 female patients. Their ages ranged between 6 and 58 years. There were 23 patients of chronic otitis media and one of congenital cyanotic heart disease. At the time of admission to the Neurosurgery Unit, GCS was 3 in one patient, 13 in two cases and 14-15 in 21 cases. All the patients underwent endoscopic surgery. There were 14 cerebellar, 8 temporal and one frontal and thalamic abscess each. Operating time ranged from 30 to 60 min (average 42 min). All the patients recovered completely except one who died (GCS 3). There was no recurrence in any case. There was no complication related to procedure. Microorganisms were demonstrated in 11 (45%) patients; streptococcal was most frequent (62%); mixed infection occurred in 29% of abscesses. Stay in Neurosurgery Unit ranged from 7 to 12 days. Mastoid surgery was done as a separate procedure after endoscopic surgery during the hospital stay. The follow-up period ranged between 6 and 42 months.

Discussion

The results of endoscopic treatment of brain abscesses in our series were found to be safe and effective. Other authors too have advocated the use of endoscopy in brain abscesses. Fritsch et al. ^[10] have suggested that the neuro-endoscopic treatment of brain abscesses has additional advantages as compared to stereotactic aspiration. It allows more complete drainage and lavage. Gajdhar and Yadav ^[11] have concluded that the endoscopic aspiration of thalamic abscess appears to be a safe and effective method of treatment. They have also stressed that the direct visualization of abscess cavity is possible and the completeness of evacuation can be assessed. Bleeding during surgery can be controlled by endoscopic technique. ^[11] Multiloculated abscesses can be better treated by endoscopic technique if the facility of neuro-navigation is available. This facility was not available in our operation theatre. Moreover, we did not manage multiloculated abscesses by endoscopic method. Although endoscopic approach has advantages over conventional techniques, including better visualization, completeness of aspiration, treatment of multiloculated abscess and control of bleeding, there is no controlled study available for comparison of results.

Sharma et al. ^[1] have reviewed the concerned literature and found that the lavage with endoscopic stereotactic evacuation may cut down indications of excision of brain abscesses in future. They expected that a trend of adequate drainage of brain abscess via minimally invasive surgery is emerging. Hellwig et al . ^[12] emphasized that endoscopic stereotactic technique, as a minimally invasive neurosurgical method, can be used for the treatment of brain abscess. Hellwig et al. ^[13] concluded that the results of endoscopic stereotaxy in brain abscess were encouraging as compared to the conventional microsurgical techniques and pure stereotactic techniques.

The results of treatment in our series were related to the condition of patients before surgery; all our patients in GCS 13-15 survived with good results while a patient in GCS 3 died. Similar results were also seen in other endoscopic series of Fritsch and Manwaring ^[10] and of Hellwig et al . ^[12] . Ortega-Martinez et al . ^[6] have observed 6.7% overall mortality in three treatment groups-non-surgical, catheter drainage-aspiration and surgical excision. Mortality was higher in patients with low levels of consciousness and age over 70 years. Ciurea et al . ^[9] have observed 11.86% mortality in repeated puncture and aspiration group.

There was no recurrence in any case in our series. Low recurrence in our series could be due to complete aspiration of abscess cavity under vision. Ciurea et al . ^[9] have observed 18.64% recurrence in their series (repeated puncture and aspiration group). Ozkaya et al . ^[4] have observed recurrence in 7.6% cases after the combined approach (mastoidectomy and abscess removal through the same sitting) as compared to 75% patients with recurrence after separate procedures (mastoidectomy followed by the cranial procedure within 7 days). Boviatsis et al. ^[7] have observed recurrence in 8.33% cases after CT-guided stereotactic aspiration. Kutlay et al. ^[14] have observed 0% recurrence rate in 13 patients treated with stereotactic aspiration and antibiotic treatment combined with hyperbaric oxygen therapy. Kurschel et al. ^[15] also did not have any recurrence after a mean follow-up of 21 months (range from 7 to 72 months) with hyperbaric oxygen therapy in five children with brain abscess. Atiq et al. ^[16] have recorded 66% complications like hemi-paresis, seizure, hydrocephalus and mental retardation. High complication in this series was due to late diagnosis and high percentage of cyanotic congenital heart disease (37%). They have also observed 3.3% bleeding (1/30) in children with brain abscesses. Kaplan et al. ^[17] have observed that bleeding in brain abscess can occur due to inflammation or damage of the fragile neovasculature of the abscess wall. Hypoxia caused by Fallot′s tetralogy or other congenital heart diseases facilitates the damage of these vessels. These damaged blood vessels bleed due to lack of any supportive tissues. Post-operative bleeding can occur in blind aspirations or stereotactic aspirations. ^[11] There was no bleeding in our series.

Sharma et al. ^[1] have stressed that stereotactic aspiration of all the locculi of multiloculated abscess can be done in single or staged aspiration. Nakajima et al. ^[8] have suggested stereotactic aspiration for brainstem abscess. Boviatsis et al. ^[7] have emphasized that CT-guided stereotactic aspiration of brain abscess helps achieve all treatment goals as it drains the content of the abscess, reduces mass effect and confirms diagnosis. CT-guided stereotactic aspiration is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia. Ciurea et al. ^[9] have reviewed the current concepts of management of brain abscesses, with particular emphasis on the use of real-time CT or ultrasound-guided operative techniques and found that these modalities are very useful in the management on brain abscess.

Simple techniques like twist drill/burr hole aspiration with or without insertion of a drain are also quite effective. Ortega-Martinez et al. ^[6] have suggested that burr hole drainage-aspiration should be used as the first mode of treatment due to its advantage of shorter admission time together with its high efficacy and low morbidity.

Excision is required in large superficial abscesses resistant to multiple aspirations, post-traumatic abscess with a foreign body or fistula and multiloculated abscess of nocardia or actinomycotic etiology. ^[1] Nowoslawska et al. ^[2] have suggested craniotomy in children above 3 years of age with mature abscesses of the central nervous system. Bhand ^[5] suggested that appropriate antibiotic therapy and complete removal of abscess along with excision of capsule could reduce mortality and neurological deficits from brain abscess.

Confirmation of diagnosis and monitoring of treatment response with magnetic resonance spectroscopy may allow greater number of patients to be managed with medical treatment in future. ^[1] Reddy et al. ^[18] have suggested that diffusion-weighted imaging has high sensitivity and specificity for the differentiation of brain abscess from other non-abscess intracranial cystic lesions.

We used infant feeding tube for aspiration. Husain et al . ^[19] used angiographic catheter for aspiration of intraventricular and juxtaventricular cysts or solid lesions for aspiration, lesion removal and biopsy. Infant feeding tube is simple, cheap, effective and easily available, but its softness may cause it to bend and cause some difficulty while negotiating through the working channel. Angiographic catheter is stiffer, has wide internal diameter because of a thin wall and can be twisted as desired before introduction into the working channel. Therefore, it seems to be better than infant feeding tube.

Strength and limitation

This is the largest series on endoscopic management of brain abscesses. One limitation of endoscopic technique is that the vision is poor to start with. It is difficult in multiloculated abscesses, but stereotactic, ultrasound or other image-guided surgery can overcome this difficulty. We could not report multiloculated cases because of non-availability of navigation methods in our operation theatre.

Summary

References

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