Drainage of Severe Brain Abscesses(2 Cases)

Encapsulated and free pus in the substance of the brain tissue following an acute purulent infection is known as brain abscess, and which is uncommon. The brain abscess arise either as direct extention from infections within the cranial cavity or as hematogenous metastasis from infections elsewhere in the body. Since 1945, the antibiotics associated use of steroid and mannitol have been available for the treatment of brain abscess, and the result are very hopeful. The common method of surgical treatment are consist of excision and drainage and the problem of the best operative procedure has been disputed on the many neurosurgical literatures for many years. Recently we had treated 2 cases of severe otogenic brain abscesses with semicomatose patient by drainage, and good was the result compared with the other literatures. Result; 1. One case with semicoma recovered completely without any neurologic sequelae, and the other case recovered with visual disturbance. 2. The best operative procedure for the severe brain abscess considered a drainage.

The Clinical Consideration for Intracranial Epidural Abscess

The intracranial epidural abscess is a not indenpendent disease which is practically always secondary to osteitis or osteomyelitis of overlying bone. Also it was developed from complication of frontal sinusitis, middle ear or mastoiditis, incomplete debridement of compound comminuted depressed fracture and post-operative complications. Occasionally it was derived from dural sinus thrombophlebitis especially cavernous sinus. It was frequently developed frontal and temporal region. We have experienced 5 cases of intracranial epidural abscesses for this one year. Followings are the results ; 1. The causes were complication of compound depressed fracture, chronic osteomyelitis and post-operative complications. 2. The usual symptom was headache, fever and increased lethargy. 3. The laboratory findings of CBC were the increased WBC count and ESR. The CSF findings revealed occasionally increased the cell count and sugar. 4. The pus culture revealed proteus, coliform bacilli and paracolon bacili. 5. Treatment was surgical removal of overlying diseased bone, drainage of the purulent materials and instillation of antibotics irrigation. 6. The prognosis of the 5 cases of the intracranial epidural abscess was good. There was not appeared any complication or sequelae.

The Clinical Consideration for the Acute Subdural Hematoma

Acute subdural hematoma is commonly occurred by severe or minor head injury, which is encountered to neurosurgeons and needed the emergency operation. But the mortality rate of the acute subdural hematoma is still very high(60-90%) in spite of the recently advanced neuroradiology. Neurosurgery and anesthesiology the authors had managed 50 cases of acute subdural hematomas, confirmed surgically, during 24 months from march 1971 to march 1973 and observed clinically. Followings are the results. 1. The male sex was predominantly high in incidence, 6 to 1. the age incidence was high in the 3 rd decade to 5 th decade which is in vigorous social activity. 2. The most common mode of the head injury was the traffic accident in 35 of 50 cases. 15 cases were from other injuries. 3. The level of consciousness of the acute subdural hematoma was various from drowsy consciousness to coma. The lucid interval was developed in 18% of those. 44 cases showed papillary change. 39(88.6%) of these were ipsilateral mydriasis. In 23 of 50 cases had motor disturbance and 78.2% of 23 cases showed contralateral hemiplegia or hemiparesis. The papillary change and hemiplegia were valuable to know the side of hematoma. 4. One of the best diagnostic procedure for the acute subdural hematoma was the angiography. The authors performed the carotid angiography before surgery in all cases. The avascular zone of the angiographic finding was crescentic form in 71.4% of all and the most common site was the parietotemporal region, but rare in the posterior fossa in one case. 5. The mortality rate was 46%. the high mortality was observed in the condition of the old age, persistant coma after surgery, bilateral mydriatic fixed pupil, concomitant profound brain damage and brain swelling. 3 cases of non survival which were in the persistant coma after surgery were died of the complication of severe decubital ulcer, septicemia, pneumonia and cachexia. 6. In 27 survival cases, the hemiplegia, oculomotor palsy, organic dementia and epilepsy were observed as sequelae, which were progressively recovered. 9 of 27 cases were completely recovered to normal social life. But the epilepsy and organic dementia were falt to be the worst sequelae remaining the problem.

A Case of the Metastatic Hepatocellular Hepatoma to the Skull

The majority of metastatic lesions involving the skull arise from carcinoma of the breast and lung. Bone metastass from a wide speculum of malignant neoplasms may be discussed in general as osteoblastic or osteoclastic in type. In osteoblastic from there are carcinoma of the prostate, carcinoma of the breast, carcinoma of the urinary bladder and rarely hypernephroma and cholangiocellular hepatoma. Osteoclastic metastass are characteristically produced by carcinoma of the lung, uterus, gastrointestinal tract, and thyroid and malignant melanoma, and rarely hepatocellular hepatoma, Osteoclastic or osteolytic lesions are much more frequent. Osteolytic metastass to the skull typically present as multiple radiolucenices with ill-defined margin. Metastases may affect any portion of the skull, not only the calvaria but also the base. Recently we experienced a rare case of metastatic hepatocellular carcinoma to the skull. A 51 year old Korean male was admitted to the Dept. of neurosurgery, on Jan. 18, 1975. Patient had complained of headache and mass on the right frontoparietal region for ca 6 weeks and motor weakness on the left extremities for 2 weeks prior to admission. No jaundice and weight loss were complained. The mass on the right frontoparietal region had increased its size gradually and showed adult fist in its size on admission. Neurological examination on admission disclosed that the adult-fist sized mass on the right frontoparietal region was non-tender and palpated soft, and deep tendon reflexes were hyperactive, on the left, and Lt. Superficial reflexes were diminished. No spasticity was noted, and left grasping power was markedly weak. Hypersthesia was felt on the left of the body. No icterus was found. Nor palpable liver neither spleen was found. No tenderness on the abdomen and no palpable masses were noted. Complete blood cell counting was normal. The blood chemistry including the liver function test revealed normal except increased alkaline phosphatase(10.5 Bodansky units). (-feto-protein was negative. Urinalysis and stool examination were normal. X-ray films of simple skull series revealed multiple radiolucencies with ill-defined margins on the right fronto-parietal bone. Right carotid angiograms showed the left square shifting of the right anterior cerebral artery to the left and compressed downward the Rt. Middle cerebral artery, and abnormal vessels in tumor mass were supplied by only the Rt. External carotid artery extracranially and intracranially. Liver scanning was normal. A decompression craniectomy was performed. Extracranially the tumor mass was brownish yellow and soft, which seemed to be the lipoma in character. The skull bone was destroyed multiply. Intracranilly same mass was found. They were removed totally without any bleeding. The operation was finished in usual way, and biopsy was attempted. The post-operative course was usual one except no recovery of the neurologic deficit for 2 weeks. Microscopic examination revealed a metastatic hepatocelluar hepatoma.