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"Emergency medicine" 7 (70) 2015

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Surgical Aspects in the Treatment of Brain Abscesses

Authors: Yasharov Yu.A., Tsymbaliuk V.I.
State Institution «Institute of Neurosurgery named after acad. A.P. Romodanov of National Academy of Medical Sciences of Ukraine», Kyiv, Ukraine

Categories: Medicine of emergency

Sections: Clinical researches

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Summary

Цель исследования. Оценка эффективности различных методов хирургического лечения пациентов с абсцессами головного мозга.
Материалы и методы. Авторами было проанализировано 242 случая абсцессов головного мозга у больных из 6 областей Украины за период с 2000 по 2014 г. Все пациенты проходили клинико-инструментальное исследование: анализ анамнестических данных, неврологическое обследование, общеклинические анализы крови, осмотр отоневролога, нейроофтальмолога, КТ- или МРТ-исследование. Всем больным производили культуральное исследование содержимого абсцессов.
Результаты. Все хирургические вмешательства, произведенные в нашем исследовании, можно разделить на следующие виды: тотальное удаление, пункция и дренирование абсцессов, пункционный метод без применения нейронавигации, с использованием рамочной или безрамочной навигации, комбинированный метод.
Выводы. Следует подчеркнуть важность в выборе метода лечения предпочтений конкретного нейрохирурга и оснащенность операционной. Стереотаксические методы лечения в настоящее время являются методом выбора, особенно при глубинно расположенных абсцессах и абсцессах, расположенных в функциональных зонах. При многокамерных абсцессах, абсцессах, вызванных анаэробной флорой, при посттравматических абсцессах с наличием инородных тел, а также в клиниках с ограниченными ресурсами полное удаление абсцесса может быть подходящим методом для лечения абсцессов головного мозга.

Мета дослідження. Оцінка ефективності різних методів хірургічного лікування пацієнтів з абсцесами головного мозку.
Матеріали та методи. Авторами було ­проаналізовано 242 випадки абсцесів головного мозку у хворих із 6 областей України за період із 2000 по 2014 рік. Усі пацієнти проходили клініко-інструментальне дослідження: аналіз анамнестичних даних, неврологічне обстеження, загальноклінічні аналізи крові, огляд отоневролога, нейроофтальмолога, КТ- або МРТ-дослідження. Усім хворим проводили культуральне дослідження вмісту абсцесів.
Результати. Всі хірургічні втручання, зроблені в нашому дослідженні, можна розділити на такі види: тотальне видалення, пункція та дренування абсцесів, пункційний метод без застосування нейронавігації, з використанням рамкової або безрамкової навігації, комбінований метод.
Висновки. Необхідно підкреслити важливість у виборі методу лікування переваг конкретного нейрохірурга та оснащеність операційної. Стереотаксичні методи лікування тепер є методом вибору, особливо при глибинно розташованих абсцесах і абсцесах, розташованих у функціональних зонах. При багатокамерних абсцесах, абсцессах, викликаних анаеробною флорою, при посттравматичних абсцесах із наявністю сторонніх тіл, а також у клініках з обмеженими ресурсами повне видалення абсцесу може бути підходящим методом для лікування абсцесів головного мозку.

Objective of the study. Evaluating the effectiveness of various methods of surgical treatment of patients with brain abscesses.
Materials and methods. The authors analyzed 242 cases of brain abscesses in patients from 6 regions of Ukraine for the period from 2000 to 2014. All patients underwent clinical and instrumental examination: analysis of anamnestic data, neurological examination, general clinical blood tests, examination by otoneurologist, neuroophthalmologist, computed tomography and magnetic resonance imaging. In all patients, culture-based analysis of abscess contents has been carried out.
Results. All types of surgical interventions made in this study can be divided into the following types: total removal, puncture and drainage of abscesses, puncture method without the use of neuronavigation, by means of a framework or frameless navigation, combined method.
Conclusions. The importance of neurosurgeon preferences and operating-room equipment should be stressed when choosing a method of treatment. Stereotactic treatments are currently the method of choice, especially in deep abscess, and abscesses located in functional areas. In multilocular abscesses, abscesses caused by anaerobic flora, in posttraumatic abscesses with the presence of foreign bodies, as well as in clinics with limited resources, the complete removal of an abscess may be a suitable method for the treatment of brain abscesses.


Keywords

абсцесс головного мозга, стереотаксическая хирургия, краниотомия.

абсцес головного мозку, стереотаксична хірургія, краніотомія.

brain abscess, stereotactic surgery, craniotomy.

Research purpose

Efficacy evaluation of various methods of surgical treatable of patients with brain abscess.

Introduction

Brain abscess is considered intraparenchymal collection of pus surrounded by capsule. 
Brain abscess may be the result of infection, as in ENT diseases, transfer infection by hematogenous way from the primary site of infection, after a traumatic brain injury or due to surgery. Often there are abscesses in which focus of infection can not be identified.
Achievements in microbiological methods of diagnostics, broad-spectrum antibiotics, computer and magnetic resonance imaging have led to significant success in the diagnosis and treatment of brain abscesses over the past decades. But despite all the advances, this disease continues to represent a serious and potentially life-threatening state in the present time.
Despite achievements in diagnosis and treatment, the incidence of brain abscess continues today at a relatively stable level.
Thus, in developed countries, the incidence of brain abscesses varies from 1-2% of all intracranial pathology, whereas in developing – up to 8%.
In the pre-computer era mortality was 22,7-45%, whereas currently only 0-20%.
The widespread use of CT and MRI in recent times greatly improved the diagnosis, surgical planning and treatment outcomes of patients with brain abscess.
Computer and Magnetic resonance imaging allows to "see" an abscess, to perform differential diagnostics with metastatic, multiforme glial tumors of a high degree of anaplasia, parasitic diseases (toxoplasmosis), radium necrosis, hematoma resorption phase, and to determine the stage of disease.
In the treatment of brain abscess requires an integrated approach that includes both drug therapy and surgery.

Methods and subjects

The authors analyzed 242 cases of brain abscesses in patients from 6 regions of Ukraine for the period from 2000 to 2014.
All patients underwent clinical and instrumental studies: analysis of the anamnesis data, neurological examination, general clinical blood tests, inspection by otoneurologist, neurophthalmologist, CT or MRI. All patients were inspected with the help of cultural testing. 

Results and discussions

When choosing a method of treatment of prevalent tactics of surgical treatment in combination with antibiotic therapy. From 242 persons there were operated 233 patients (96.3%), not operated on only 9 persons (3.7%).
All types of surgical interventions performed in this study can be divided into the following types: 1. The total removal of abscesses with the capsule. 2. Puncture and drainage of abscess. 3. Puncturing method without the use of navigation systems, "by hand", without installing drains. 4. Operations using the frame or frameless navigation as the removal and the puncture. 5. The combined method: the first stage of a puncture or drainage, as a second stage - deleting abscess with capsule.
In the first place by the number of performed surgeries: total removal of the abscess. 113 surgical interventions were performed  (46.7% of the patients studied). The mortality rate was 7.96%.
The second highest number of underlying surgeries: drainage of brain abscess. It performed 80 such surgical interventions, which accounted for 33% of all cases analyzed. The mortality rate was 13.8%.
The next method of treatment is associated with navigation techniques. So with the help of frameless neuronavigation operated on 11 patients, 10 patients produced surgery with stereotactic aspiration of brain abscesses. Deaths were not.
Puncture method "by hand" was performed in 15 cases (6.2%). Mortality was 20%.
In our research the most appropriate ways of surgical treatment were: stereotactic techniques and total removal of abscesses
When stereotactic treatments were performed mortality in our research is zero. Though it is impossible not to notice a careful selection of patients for this type of treatment. There was no patient with indicators Glasgow outcome scale less than 11 points.
I would like to emphasize the importance of the particular preferences of the neurosurgeon in the selection of treatment, also plays an important role when choosing equipment operating tactics surgery.

Conclusions

Stereotactic treatments are currently the method of choice, especially when abscess located deep and in the functional areas.
When multicompartment abscess, abscesses caused by anaerobic flora, posttraumatic abscesses with the presence of foreign matters, as well as in clinics with limited resources, the complete removal of an abscess may be a suitable method for the treatment of brain abscesses. Besides, there were no deaths.

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