Improved management of multiple brain abscesses: a combined surgical and medical approach.

Bacterial brain abscesses occur in approximately 1500 to 2500 patients each year in the United States. Multiple abscesses have been noted in 10 to 50% of these patients. The goal of this study was to better define the roles of surgery and medical management in patients harboring multiple brain abscesses and to develop an algorithmic approach to the treatment of these complex patients. Between 1976 and 1992, 16 patients with multiple brain abscesses were treated by a single physician (M.L.R.). The ages of the patients ranged from 1.5 to 73 years (median, 47 yr). In all patients, a diagnosis of multiple abscesses was made by computed tomography (15 patients) or magnetic resonance imaging (1 patient) brain scans. The number of abscesses per patient ranged from 2 to 30, and the abscesses were located in all regions of the brain. Thirteen received a combination of antibiotics and surgical drainage, and three received antibiotics only. Surgery was performed on abscesses larger than 2.5 cm or on those situated in critical areas of the brain or causing significant mass effect. Excision and open aspiration via craniotomy and stereotactic aspiration were analyzed on the basis of the location of the lesion and infecting organism. Any abscess that enlarged after 2 weeks of antibiotics or that failed to shrink after 3 to 4 weeks of antibiotics was again aspirated or excised. Forty-three surgical procedures were performed in 13 patients, and 8 (62%) of the patients operated on required more than one surgical procedure. No significant morbidity was observed in any of the surgical procedures. Antibiotics were administered intravenously for an average of 6 to 8 weeks and were adjusted according to organism type and sensitivity to antibiotics. One patient (6%) died, and the remaining 15 patients had resolution of all abscesses and good neurological recovery within 6 months. On the basis of these results, we propose a combined surgical and medical approach to the treatment of patients with multiple brain abscesses. We recommend the aggressive surgical drainage of all abscesses larger than 2.5 cm in diameter, combined with 6 to 8 weeks of intravenous antibiotics. Biweekly computed tomography or magnetic resonance imaging is necessary to closely monitor patients for evidence of abscess growth or failure to resolve despite antibiotics, prompting another operation. The application of this combined approach should yield cure rates of more than 90% in patients with multiple brain abscesses, a result similar to that expected when treating patients with solitary lesions.

Unilateral hydrocephalus in adults.

The authors report 14 cases of unilateral hydrocephalus in adults. Headache was the most common presenting symptom. Unilateral hydrocephalus was documented in each patient with computed tomography scans; magnetic resonance imaging was also used in seven patients in the latter part of the series. Unilateral hydrocephalus was caused by tumor (seven patients), venous angioma (one patient), ependymal cyst (one patient), postinflammatory gliosis (one patient), and was idiopathic in four patients. The primary surgical treatment was craniotomy with fenestration of the septum pellucidum, which relieved symptoms in eight of nine patients for whom long-term follow-up data were available.

Intraoperative ultrasound imaging of the entire brain through unilateral exploratory burr holes after severe head injury: technical note.

A portable ultrasound unit with a 3.5-MHz probe allows accurate imaging of both cerebral hemispheres and partial imaging of the posterior fossa through unilateral exploratory burr holes or a craniotomy. In patients with clinical signs of transtentorial herniation after severe head injury, this unilateral technique can detect extraaxial and intraparenchymal mass lesions more accurately than is possible with bilateral exploratory burr holes.

The proliferative activity of neurilemomas.

Twenty-one patients with neurilemomas (15 intracranial and 6 intraspinal) received a 1-hour intravenous infusion of 5-bromodeoxyuridine (BrdU), 200 mg/m2 before tumor removal, to label S-phase tumor cells. Excised tumor specimens were stained by the indirect immunoperoxidase method with anti-BrdU monoclonal antibodies to determine the BrdU labeling index, or percentage of S-phase cells. The BrdU labeling index ranged from 0.1% to 3.1% (mean, 0.9%). The BrdU labeling index was greater than 1.5% in four of the 21 tumors (three trigeminal and one spinal). One acoustic tumor in a patient with neurofibromatosis type 1 had a labeling index of 1.3%, which was the highest among the acoustic tumors. The BrdU labeling indices did not correlate with the patient's age, tumor size, or the duration of signs and symptoms. There was no significant difference between the BrdU labeling indices of Antoni type A and Antoni type B tissue. The low BrdU labeling index of most of the intracranial neurilemomas coincides well with the slow growth of these tumors. As the BrdU labeling index may reflect growth potential of individual tumors, it could be used to guide the follow-up patients with incompletely resected tumor.

Nonoperative treatment of spinal epidural infections.

Spinal epidural infections were diagnosed before the onset of neurological deficits in six patients and treated nonsurgically. The diagnosis was based on the clinical presentation and on the results of myelography and computerized tomography scanning. Positive cultures were obtained from blood in all six patients, from aspiration of a paraspinous infection in two, and from a skin abscess and a pulmonary empyema in one patient each. Staphylococcus aureus was the causative organism in five cases. All patients were treated with intravenous antibiotics and remained neurologically intact throughout the course of treatment. Five patients have had no recurrence of their symptoms. One patient eventually required surgery for persistent discitis.

Presentation of type I Chiari malformation after head trauma.

An unusual case of Type I Chiari malformation that became symptomatic after closed head injury is reported. The patient manifested transient upper extremity weakness, persistent lower cranial nerve dysfunction, and cerebellar signs that slowly resolved. Magnetic resonance images showed tonsillar ectopia but no displacement of the brain stem or syringomyelia. Type I Chiari malformation should be included in the differential diagnosis of patients who present with upper extremity weakness, lower cranial nerve palsies, or cerebellar signs after trauma.

Neuronal changes in fetal cortex transplanted to ischemic adult rat cortex.

Fetal cortex from 16- and 17-day-old embryonic rats was transplanted into the parietal cortex of 12 adult rats rendered ischemic by temporary intraluminal occlusion of the middle cerebral artery. Ischemic injury in the host cortex adjacent to all nine surviving transplants was demonstrated with hematoxylin and eosin and cresyl violet strains. Nicotidamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemical studies revealed a normal number of NADPH-d-positive neurons, whereas acetylcholinesterase (AChE) staining revealed many more AChE-positive neurons in the transplants compared to the host parietal cortex. This could be due to: 1) selective survival of AChE neurons in the transplants compared to the host cortex; 2) increased expression of AChE in transplanted neurons; 3) induction of AChE in normally AChE-negative neurons; or 4) decreased transport of the AChE enzyme from the perikarya to fibers in surviving transplanted neurons. Many fibers positive for AChE and NADPH-d crossed between the host and transplant, although fiber density in the transplants was less than in normal host cortex. These results should encourage future investigation of whether similar transplants improve neurological function following experimental stroke.

Trends in the management of bacterial brain abscesses: a review of 102 cases over 17 years.

The records of 102 patients with brain abscesses treated over 17 years were analyzed. In recent years, cardiac and pulmonary causes were less frequent, the abscesses were smaller, and fewer patients were in poor neurological condition. There has been no significant change in the type or number of infective organisms or in the number of abscesses during the study period. Computed tomographic brain scanning was the most important factor in reducing the mortality rate from 41% to 4%. The patients were grouped according to the treatment received: excision (n = 46), aspiration (n = 33), or nonsurgical therapy (n = 17). Patients treated nonsurgically were more likely to have smaller abscesses and multiple lesions than were patients in the other two groups. There were no significant differences in the morbidity or mortality rates between treatment groups. Patients whose abscesses were excised had a significantly shorter course of antibiotics than the other patients. Organisms were identified in 85% of the cultures from surgical specimens. The use of preoperative antibiotics was significantly associated with sterile cultures; 30% of patients who received antibiotics preoperatively had sterile cultures, compared with only 4% of patients who did not receive such treatment. The mortality rate among all treated patients (the diagnosis of brain abscess was missed in 6 patients before computed tomographic scanning became routine) was significantly related to the initial neurological grade and the size of the lesion but not to age, sex, or the number of abscesses. Four of the 8 treated patients who died had congenital cyanotic heart disease; an aggressive surgical approach is recommended for such patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Transsphenoidal microsurgery for Cushing disease. A report of 216 cases.

We report cumulative results of the transsphenoidal microsurgical treatment of Cushing disease in 221 patients: 173 patients had selective adenomectomy, 25 had total hypophysectomy, 6 had partial hypophysectomy, and 12 had exploration only. Five patients were excluded from analysis because intraoperative technical difficulties precluded exposure of the pituitary gland. The selection of candidates for transsphenoidal exploration was based on endocrinologic criteria. Magnetic resonance imaging was the preferred radiologic test. Selective venous sampling of adrenocorticotropic hormone further refined the diagnosis when endocrinologic and radiologic procedures were not definitive. Remission of disease was achieved in 164 of 216 (76%) patients analyzed (95% CI, 69 to 81). Among patients with histologic confirmation of adenomas, the percentage having remission was significantly higher (P less than 0.001) in patients with microadenomas than in patients with macroadenomas and in patients with intrasellar adenomas than in patients with extrasellar extension of their adenoma or perforation of the sellar floor by adenoma (P less than 0.001). Five patients had an ectopic source of adrenocorticotropic hormone secretion. Two patients had diffuse pituitary hyperplasia. Complications occurred in 9.3% of the patients, including two deaths that were apparently unrelated to surgery (CI, 5.4 to 13). The results indicate that transsphenoidal surgery is the preferred treatment for most patients with Cushing disease.