Elsevier

World Neurosurgery

Volume 76, Issue 5, November 2011, Pages 431-436
World Neurosurgery

Peer-Review Report
A Review of Brain Abscess Surgical Treatment—78 Years: Aspiration versus Excision

https://doi.org/10.1016/j.wneu.2011.03.048Get rights and content

Objective

The literature regarding surgical treatment of brain abscess was reviewed from 1990 to (and including) 2008 to supplement a previous literature review from 1930 to 1990.

Methods

The Ovid Medline database 1950–2009 with the year range limited to 1990–2009 was used to identify all articles relating to brain abscess. The results were compared with a previously published review from 1930–1990 by the senior author.

Results

The original finding was confirmed that the high mortality from aspiration in the pre-computer tomography era decreased dramatically after computer tomographic scanning became available. In the present review, the mean mortality for aspiration post-1990 was 6.6% for publications with more than five patients. With surgical excision by craniotomy, the mean mortality in the same period was 12.7%.

Conclusions

The present review suggests that aspiration may be the first surgical choice in patients with supratentorial parenchymal brain abscesses.

Introduction

Brain abscesses are a common occurrence in the developed world with an incidence of up to 2% of all space occupying lesions. They are even more common in developing countries, with an incidence of up to 8% (17). Brain abscesses are almost always secondary to a focus of suppuration elsewhere in the body and can develop from a local source (e.g., after head trauma) or from a distant site by hematogenous spread (6, 20, 21). Patients usually present with symptoms of increased intracranial pressure including headaches, vomiting, seizures, or specific neurological deficits related to the abscess location (8).

Brain abscesses carried a high mortality rate in the pre-computerized tomographic (CT) scanning era; however, with the introduction of CT scanning in the 1970s, the rate decreased dramatically. The use of this scanning technique with respect to brain abscesses has helped improve many aspects of the management of these lesions due to earlier detection, localization, and guidance during surgical treatment. CT scanning has been increasingly used in this field, and there has been a noticeable decline in the use of excision by craniotomy as a standard treatment, and currently the preferential method is surgical aspiration, which is usually image-guided or stereotactic (8). Other aspects of management of patients with brain abscesses include targeting the causative organism by intravenous antibiotic therapy initially and also the treatment of hydrocephalus and/or seizures (18). The role of surgery includes the management of clinical deterioration, neurological deficits, when mass effect is present, when multiple abscesses are in accessible locations, and if confirmation of diagnosis is required. As with many other conditions, surgery is only considered when benefits outweigh the risks (18).

Craniotomy has been shown to be superior to aspiration in subdural empyema (16). In contrast, the use of aspiration for brain abscess, in preference to excision, is still a disputed topic. Several factors determine the choice of aspiration or excision of the abscess, including chances of success and adverse effects after surgery (18). Aspiration has a multitude of indications, whereas excision of abscess is recommended when aspiration and medical management has failed, and if the abscess is large and located superficially. Excision is said to have a particularly poor outcome when the abscess is deep seated, if there is cerebritis involved, and also if multiple abscesses are present. However, excision does reduce recurrence and may limit the occurrence of seizures (18).

Currently, conservative-only treatment in patients with brain abscess is being researched, and with the increasing use of better imaging techniques, medical management alone might increase in the future (18). However, an up-to-date review comparing survival rates of patients after aspiration or excision of brain abscesses is needed to determine whether the trend noticed since the introduction of CT guidance has continued, and to investigate the evidence behind recommending aspiration above excision.

The aim of the present study was to conduct a literature review using the Ovid database to add to previous knowledge about the surgical treatments of brain abscess, and to discuss which technique is associated with the highest survival rates—whether it is aspiration or excision.

Section snippets

Methods

A literature search was performed using Ovid Medline database 1950–2009, with the year range limited to 1990–2009. The key words used were “brain abscess” and “aspiration” or “excision.” Text reviews were excluded, and all case reports, case series, and retrospective analyses were included in the results. Two researchers conducted the literature review and were able to discuss data collection methods and ensure that the search was conducted in the same way and any errors that were overlooked by

Results

Using the search terms and limits 278 results were identified. Once text reviews and any articles where surgical treatments had not been used were excluded, 195 results remained in the study. However, an additional 27 results of the 195 could not be used because of lack of data within the article regarding mortality after each surgical procedure, language barriers, or inability to trace the article. Thus, 168 articles could be included in the present review.

Fifty-seven results (of the remaining

Discussion

Our results show that between 1990 and 2008, aspiration of brain abscess has a lower mortality rate compared with excision when outliers were excluded (6.6% mean mortality with aspiration, 12.7% mean mortality with excision). When comparing these rates with data from the period between 1930 and 1990 using the distribution on the graphs (Figures 5 and 6), aspiration showed a significant reduction in mean mortality rate but excision showed only a slight reduction (13). When comparing the results

Recommendations

Further analyses can be conducted into differences in mortality between single aspiration, repeated, stereotactic aspiration and drainage, and mortality in patients receiving a combination of aspiration and excision of abscess. Average mortality can be compared between those patients who received only aspiration and those who only had excision. Future research can compare mortality between medical management and surgical techniques. The comparison of survival rates for excision (Figure 6)

Conclusions

In keeping with previous hypotheses, it was found in this literature review that aspiration of brain abscess carries a lower overall mortality rate compared with excision (when looking at non-case reports). Also, the introduction of CT scanning has led to a significant reduction in mortality rates associated with surgical aspiration of abscess. However, CT imaging has not impacted in the same way on mortality rates after surgical excision of brain abscess. In contrast, case reports showed an

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    Nathoo et al.9 and Cavuşoglu et al.14 found greater mortality with excision, although Nathoo et al.’s study was biased with a disproportionate amount of immunocompromised patients in the excision group. Ratnaike et al.12 found that in the post-CT era, excision carried a greater mortality rate than did aspiration, with the caveat that the investigators did not account for baseline or immunocompromised states, abscess location, depth, or radiologic grade. The overall mortality rate of our study of 11.5% was within the previously reported range for surgical excision and aspiration.

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Conflict of interest statement: Drs. Ratnaike, Das, and Gregson declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Dr. Mendelow is the Director of the Newcastle Neurosurgery Foundation LTD and has received honoraria from Codman, Novo Nordisc and Stryker.

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