Complete recovery from an apparent brain abscess treated without neurosurgery. The importance of early CT scanning

Management of abducens palsy in patients with petrositis

Our objective was to discuss the management and outcome of abducens nerve palsy in patients with Gradenigo's syndrome. In a retrospective analysis of patients with Gradenigo's syndrome at a tertiary-care center in Houston, Texas, from 1987 to 1995, we identified 2 patients with Gradenigo's syndrome, both female. One had bilateral involvement, so that the total was 3 ears. Both patients had complete recovery of their abducens nerve palsy. In 2 ears with chronic mastoiditis, sixth nerve palsies failed to respond to medical therapy alone, but resolved after mastoidectomy with drainage of the petrous apex. We recommend that patients with Gradenigo's syndrome and evidence of chronic mastoiditis be treated with aggressive medical and surgical care.

Brain abscess in childhood--long-term experiences

A retrospective evaluation was performed on 28 cases of paediatric brain abscess (male: female ratio 2.5:1; mean age 9.4 years; range 2.8-16 years) diagnosed between 1967 and 1987. In 46%, congenital cyanotic heart disease was identified as a predisposing factor, likewise sinusitis, otitis media or mastoiditis in 29% and immunodeficiency in 11%. Pathogenesis remained unclear in 14%. Initial symptoms and signs were predominantly nonspecific; loss of consciousness occurred in 32% of cases, neurological deficit and seizures each in 25%. Since the availability of CT, both diagnostic delay after hospital admission and mortality were substantially reduced: mean delay from 8.4 to 3.0 days, and mortality from 23% to 0%. Seventeen patients (61%) had follow up examinations 9.6 years (mean) after the acute illness (range 1-21 years). Neurological sequelae were diagnosed in 35% of cases, epilepsy in 29%, epileptic potentials during EEG in 12%, and CNS scars in 50%. Psychological testing revealed no statistically significant differences compared to normal populations. CNS scars, and epilepsy and/or epileptic potentials were more common after excision (7 patients) when compared to patients treated by aspiration and/or antibiotics alone (21 patients). It is concluded that excision of brain abscess should be avoided whenever possible. Therapy of choice consists of the administration of adequate antibiotics with or without CT-guided needle aspirations.

Effect of dexamethasone on various stages of experimental brain abscess

Rats were inoculated with staphylococcus aureus to produce cerebral abscesses and treated with either antibiotic or dexamethasone and with antibiotic plus dexamethasone at sequential stages of abscess formation. Antibiotic alone shortened the cerebritis stage, accelerated the encapsulation and affected the bacterial clearance in the abscess centre when it was started early in the course of cerebritis. Dexamethasone impaired the lymphocytic and fibroblastic responses and delayed the collagen deposition as well as suppressed the efficacy of antibiotic. However, it did not halt entirely the encapsulation and did reduce the associated cerebral oedema.

Treatment of intracranial abscesses associated with sinusitis in children and adolescents

We retrospectively reviewed the management of intracranial abscesses associated with sinusitis in 13 children and adolescents by reviewing medical records and computed tomography (CT) scans of a consecutive case series. The mean duration of follow-up was 4.5 years with a range of 1.3 to 8.6 years, and the setting was a major metropolitan children's hospital providing primary as well as tertiary care. All patients received antibiotics (most commonly chloramphenicol, 75 to 100 mg/kg/day, in combination with oxacillin, 150 to 200 mg/kg/day) to which the sinus and intracranial organisms are susceptible. Surgical drainage of loculated infection was done for patients with acute neurologic symptoms or signs and for those patients whose abscesses enlarged during medical therapy. Three patients underwent immediate drainage of intracranial abscesses because of acute neurologic signs and symptoms. Sequential CT scans demonstrated enlargement of the intracranial abscesses in the remaining 10 patients. This apparent failure of medical management could not be explained by duration of symptoms before therapy, size of lesion, choice of antibiotics, or use of steroids. No child was successfully treated with antibiotics alone. Successful management consisted of antibiotic therapy combined with surgical drainage of loculated infection. This approach to therapy is preferred for all children with intracranial abscess associated with sinusitis.

Treatment by aspiration of brain abscesses

Sixteen patients, with a total of 18 abscesses, were treated by aspiration and systemic antibiotic therapy, to which antiepileptic prophylaxis and corticosteroids were added. Diagnosis of the abscesses and monitoring of their evolution relied principally upon computed tomography; this technique was also used per-operatively when aspirating small abscesses. Bacteriological examinations were positive in all our cases and a polymicrobial flora was found in half of these. One or, eventually, two aspirations within the same week were sufficient, in most cases, to promote healing. Nevertheless, in three patients, the abscesses, however sterilized, did not show any volume reduction, probably because of adhesions to the dura mater, of a large part of the abscess surface area. One patient died from concomitant cardiac disease and one patient remained seriously disabled. Epilepsy was observed as a sequela, in six patients. This study emphasizes the role of neuroradiological and bacteriological examinations, whilst surgery may be restricted, in most cases, to a simple aspiration.

Rapidly growing head circumference as an isolated presenting symptom of brain abscesses in an infant

A rapid and excessive enlargement in occipito frontal circumference (OFC) as the only manifestation of multiple cerebral abscesses in infancy is extremely rare. A 2-month-old asymptomatic infant presenting with increasing OFC is described. Surgical drainage of the cerebral abscesses followed by prolonged antibiotic therapy resulted in complete recovery.

Clinical stages of human brain abscesses on serial CT scans after contrast infusion. Computerized tomographic, neuropathological, and clinical correlations

The authors describe a classification of human brain abscesses into stages of development as demonstrated on computerized tomography (CT) scans. The results of CT staging of 14 human brain abscesses are compared with the previously published findings in an experimental brain abscess model developed by the same authors. The CT criteria for categorizing brain abscesses into cerebritis and capsule stages were based on the pattern of contrast enhancement and the time-density curve of enhancement obtained from sequential CT scans after contrast infusion. Using these CT criteria, it was possible to accurately categorize all 14 brain abscesses into cerebritis and capsule stages. Histological examination of surgical and autopsy specimens provided immediate confirmation of the abscess stage in six patients. Indirect staging, based on surgical findings and/or subsequent autopsy findings, was possible in eight patients. Corticosteroid administration greatly reduced contrast enhancement in the cerebritis stage, but had little effect in the capsule stage. A systematic approach utilizing CT for establishing the diagnosis, staging, and treatment planning of brain abscess is proposed.