In the past several years a concensus approach has been reached in diagnosis and therapy of brain abscess. The ease and accuracy of evaluation of intracranial lesions afforded by third generation computerized tomography scanners has lead to reliable, quick, non-surgical diagnoses and monitoring which is relatively non-invasive. The use of multiple agent, increased spectrum, antimicrobials has resulted in acceptable reduced morbidity and mortality. This has decreased the need for therapeutic surgical intervention. The non-surgical approach was preceded by several other modes of management which were acceptable in their time. During the past 21 years, 17 patients have been under the care of one or more of the above authors. A review of these cases is presented with instructive and informative histories. A knowledge of past therapeutic modalities and their attendant complications compared with present medical therapy assures an acceptance of the latter as the method of choice. A search of the general literature shows wide acceptance in other fields; however, no reference could be found in the recent otolaryngological literature to support a non-surgical approach.
A NUMBER of observers have reported untoward reactions following lumbar puncture in patients with tumors of the brain or with increased intracranial pressure due to other causes.* These untoward reactions have been attributed to temporal lobe herniation or herniation of the cerebellar tonsils. In some of the cases death is reported to have occurred immediately from presumed compression of vital centers, and in others a train of symptoms have developed which are presumed to indicate a more gradual compression.The statement is frequently seen that lumbar puncture is dangerous and is contraindicated whenever papilledema is present. This conclusion is reached on the basis of untoward reactions in individual cases, and to our knowledge there has not been an analysis of the results in a large series of cases. This study was undertaken in order to determine the frequency of untoward reactions in a large series of patients with tumors of the brain on whom a lumbar puncture was performed. MATERIALAll of the available brain tumor cases (965) at the Neurological Institute of New York, from January, 194S, to July, 1953, were reviewed ; only those patients who had lumbar puncture performed prior to arteriography, air studies, or surgery were included. A total of 401 histologically verified cases were available for this study, with the exception of 15 brain stem neo¬ plasms that were verified by surgery or air studies.For this survey, the status of all the patients was carefully evaluated from the time of the lumbar puncture until arteriography, air studies, or surgery. A careful search was made for the presence of symptoms or signs indicating an adverse effect of the lumbar puncture, with special attention to signs of temporal lobe herniation or herniation of the cerebellar tonsils. Particular attention was given to the following : third nerve involvement as evidenced by pupillary dilatation or extraocular muscle paralysis ; changes of the blood pressure, pulse, respirations, and tempera¬ ture; the appearance of convulsions; decerebrate rigidity; changes in the state of consciousness, and unexpected progression in neurologic deficit. RESULTSDivision of the cases according to the anatomical location and histologie type is shown in Table 1. There were 164 tumors in the anterior fossa, 140 in the middle fossa, 74 in the posterior fossa, 10 in the sellar and parasellar region, and 13 multiple metastatic lesions. The general histologie distribution of these cases followed that reported in other large series of cases of brain tumors.From the Neurological Institute of the Presbyterian Hospital, New York.References 1 through 5. Downloaded From: http://archneurpsyc.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/25/2015
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