Intracranial abscess

CEREBRAL ABSCESS (contd) Management:

1. Antibiotics

Commence i.v. antibiotics on establishing the diagnosis (prior to determining the responsible organism or its sensitivities). Antibiotics are selected for their ability to cross the blood-brain barrier. The ease with which they penetrate the abscess capsule remains uncertain. Use combined therapy:

- PENICILLIN 4 mega-units q.i.d. - to cover streptococcus

- METRONIDAZOLE 1 g q.i.d. - to cover anaerobic organisms

- CHLORAMPHENICOL 500 mgs q.i.d. - to cover all other organisms

(or third generation cephalosporin e.g. cefotaxime 2 g q.i.d. or ceftriaxone 2-4 g/day) In immunocompromised patients - see page 494.

Later determination of the organism and its sensitivities permits alteration to more specific drugs. Intravenous antibiotics should continue for 2-3 weeks followed by oral medication for a further 3-4 weeks.

2. Abscess drainage Various methods exist:

Primary excision of the whole abscess including the capsule (standard treatment of cerebellar abscess)

Burr hole aspiration is simple and relatively safe. Persistent reaccumulation of pus despite repeated aspiration requires secondary excision. Primary excision removes the abscess in a single procedure, but carries the risk of damage to surrounding brain tissue. Open evacuation of the abscess contents requires a craniotomy, but minimises damage to surrounding brain.

3. Treatment of the infection site

Mastoiditis or sinusitis requires prompt operative treatment, otherwise this acts as a persistent source of infection.

Steroids help reduce associated oedema but they may also reduce antibiotic penetration and impede formation of the abscess capsule. Their value in management remains controversial. Conservative management: In some situations the risks of operative intervention outweigh its benefits. In those patients, treatment depends on i.v. antibiotics.

Indications: - small deep abscesses, e.g. thalamic (although stereotactic aspiration may help).

- multiple abscesses.

- early 'cerebritic' stage.

Prognosis

The use of CT scanning in the diagnosis and management of intracranial abscesses and the recognition and treatment of pathogenic anaerobic organisms have led to a reduction in the mortality rate from 40% to 10%. In survivors, focal deficits usually improve dramatically 346 with time. Persistent seizures occur in 50%.

Burr hole aspiration of pus, with repeated aspirations as required.

Evacuation of the abscess contents under direct vision, leaving the capsule remnants.

Burr hole aspiration of pus, with repeated aspirations as required.

Evacuation of the abscess contents under direct vision, leaving the capsule remnants.

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