Brain and spinal cord abscesses: treatment and prognosis

Treatment of abscesses of the brain and spinal cord

Treatment of cerebral abscesses can be conservative and surgical. The method of treatment depends primarily on the stage of development of the abscess, its size and localization.

In the stage of formation of the encephalitic focus (the duration of the anamnesis is up to 2 weeks), as well as with small (<3 cm in diameter) abscesses, conservative treatment is indicated. The usual tactic is empirical antibiotic therapy. Some surgeons prefer stereotactic biopsies for the final verification of the diagnosis and isolation of the pathogen.

Abscesses indicative of an increase in intracranial pressure and a dislocation of the brain, as well as those located near the ventricular system (pus breakthrough into the ventricular system often becomes fatal) are considered absolute indications for surgery. With traumatic abscesses located near the foreign body, surgical intervention also becomes a method of choice, since such an inflammatory process can not be cured conservatively. Indications for surgery are also fungal abscesses, although the prognosis in this situation is extremely unfavorable regardless of the method of treatment.

With abscesses located in vital and deep structures (brainstem, visual hillock, subcortical nuclei), direct surgical intervention is contraindicated. In such cases, the method of choice can be a stereotaxic method - puncture of the abscess and its emptying with a single or repeated (through a catheter installed for several days) by rinsing the cavity and introducing antibacterial drugs.

Severe somatic diseases are not considered an absolute contraindication to surgical intervention, since a stereotaxic operation can be performed under local anesthesia.

Patients in an extremely serious condition (terminal coma), any surgical intervention is contraindicated.

Principles of drug treatment of abscesses of the brain and spinal cord

Empirical (before the result of sowing or when it is impossible to identify the pathogen), antibiotic therapy must cover the maximum possible spectrum of pathogens. Therefore, the following algorithm is used.

• Patients without craniocerebral trauma or neurosurgical intervention in the history of prescribing the following drugs simultaneously:
  • vancomycin (adults - 1 g 2 times a day in / in, children - 15 mg / kg 3 times a day);
  • cephalosporin III generation (eg, cefotaxime);
  • metronidazole (adults - 30 mg / kg per day for 2-4 injections, children - 10 mg / kg 3 times a day).
• Patients with posttraumatic abscesses metronidazole are replaced with rifampicin at a dose of 9 mg per 1 kg of body weight 1 time per day inside.
• In patients with immunodeficiency (other than HIV), the most likely causative agent of cerebral abscess is Cryptococcus neoformans, less often Aspergillus spp. or Candida spp. In this regard, they are prescribed amphotericin B at a dose of 0.5-1.0 mg / kg per day intravenously or liposomal amphotericin B - 3 mg / kg per day intravenously with a gradual increase in the dose to 15 mg / kg per day. In the case of disappearance of the abscess according to the data of neuroimaging methods, fluconazole is administered 400 mg / day orally up to 10 weeks, and then patients are transferred to a constant maintenance dose of 200 mg / day.
• In patients with HIV, the most likely causative agent of brain abscess is Toxoplasma gondii, so in the empirical treatment of such patients sulfadiazine with pyrimethamine is used.

If a culture of the pathogen is obtained, the treatment is changed taking into account the antibioticogram. With sterile sowing continue empirical antibiotic therapy.

The duration of intensive antibiotic therapy is at least 6 weeks, after which it is advisable to prescribe oral antibacterial drugs for another 6 weeks.

The use of glucocorticoids leads to a decrease in severity and a faster reverse development of the fibrous capsule of the abscess, which is good with adequate antibiotic therapy, but otherwise can cause the spread of the inflammatory process beyond the primary focus. Therefore, the appointment of glucocorticoids is justified only with the increasing edema and dislocation of the brain, in other cases the question requires discussion.

Surgical treatment of abscesses of the brain and spinal cord

The main method of treatment of the majority of brain intracerebral abscesses is currently simple or supply-and-out drainage. The essence of the method is to install a catheter into the cavity of the abscess, through which pus is evacuated and antibacterial drugs are introduced. If possible, a second catheter with a smaller diameter is installed in the cavity for a few days, infusion of the washing solution is carried out through it (0.9% sodium chloride solution is usually used, the effectiveness of adding antibacterial drugs to it is not proved). Abscess drainage implies mandatory antibiotic therapy (first empirical, then - taking into account the sensitivity of the isolated pathogen to antibiotics).

An alternative method is the stereotaxic aspiration of the abscess contents without the installation of drainage. The advantage of the method is a lower risk of secondary infection and more lenient requirements for the qualification of medical personnel (monitoring the functioning of the inflow and outflow system requires special knowledge and close attention). However, when using this method, in about 70% of cases, repeated aspiration is necessary.

With multiple abscesses, the focus is primarily on drainage, the most significant in the clinical picture, or the most dangerous for complications (brain dislocation, pus penetration into the ventricular system, etc.).

When subdural abscesses or empyema drainage is used, the supply-and-extract system is not used.

The operations of total abscess removal together with the capsule, without opening the abscess, are not currently used due to high traumatic conditions. Exceptions are fungal and nokardioznye (caused by Nocardia asteroides, less often Nocardia brasiliensis) abscesses that develop in immunodeficient patients. Radical removal of abscesses in such situations somewhat improves survival.

Surgical treatment of epidural abscesses is the same as in osteomyelitis.

Forecast

The prognosis for abscesses of the brain depends on many factors. Of great importance is the ability to determine the pathogen and its sensitivity to antibacterial drugs, which allows for directional pathogenetic therapy. An important role in the outcome of the disease is the reactivity of the organism, the number of abscesses, the timeliness and adequacy of therapeutic measures.

The lethality with brain abscesses is about 10%, disability is about 50%. Almost a third of surviving patients develop epileptic syndrome.

Subdural empyema is prognostically less favorable than brain abscesses, since the absence of the purulent foci boundaries indicates either a high virulence of the pathogen or an extremely low resistance of the patient. The lethality for subdural empyema is about 50%. In fungal empyema in immunodeficient patients, it approaches 100%.

Epidural abscesses and empyema usually have a favorable prognosis. Infection almost never penetrates through the intact solid medulla, and the sanation of the osteomyelitis focuses can eliminate epidural empyema.

[1], [2], [3], [4], [5]