A Canadian National Survey of the Neurosurgical Management of Intracranial Abscesses

Abstract

Objective: Intracerebral abscess is a life-threatening condition for which there are no current, widely accepted neurosurgical management guidelines. The purpose of this study was to investigate Canadian practice patterns for the medical and surgical management of primary, recurrent, and multiple intracerebral abscesses. Methods: A self-administered, cross-sectional, electronic survey was distributed to active staff and resident members of the Canadian Neurosurgical Society and Canadian Neurosurgery Research Collaborative. Responses between subgroups were analyzed using the Chi-square test. Results: In total, 101 respondents (57.7%) completed the survey. The majority (60.0%) were staff neurosurgeons working in an academic, adult care setting (80%). We identified a consensus that abscesses >2.5 cm in diameter should be considered for surgical intervention. The majority of respondents were in favor of excising an intracerebral abscess over performing aspiration if located superficially in non-eloquent cortex (60.4%), located in the posterior fossa (65.4%), or causing mass effect leading to herniation (75.3%). The majority of respondents were in favor of reoperation for recurrent abscesses if measuring greater than 2.5 cm, associated with progressive neurological deterioration, the index operation was an aspiration and did not include resection of the abscess capsule, and if the recurrence occurred despite prior surgery combined with maximal antibiotic therapy. There was no consensus on the use of topical intraoperative antibiotics. Conclusion: This survey demonstrated heterogeneity in the medical and surgical management of primary, recurrent, and multiple brain abscesses among Canadian neurosurgery attending staff and residents.1

Update and approach to patients with brain abscess

“…The neurosurgical approach to treatment of brain abscess may differ substantially from surgeon to surgeon and hospital to hospital [3 ▪ ,8 ▪ ,33,34,51 ▪ ,52 ▪ ]. A diameter above 2 or 2.5 cm is often referenced as a rule of thumb to carry out aspiration or excision of brain abscess although stereo-tactic navigation allows for accurate targeting of abscesses as small as 1 cm in diameter [51 ▪ ].…”

“…The neurosurgical approach to treatment of brain abscess may differ substantially from surgeon to surgeon and hospital to hospital [3 ▪ ,8 ▪ ,33,34,51 ▪ ,52 ▪ ]. A diameter above 2 or 2.5 cm is often referenced as a rule of thumb to carry out aspiration or excision of brain abscess although stereo-tactic navigation allows for accurate targeting of abscesses as small as 1 cm in diameter [51 ▪ ]. It appears that this pragmatic and somewhat arbitrary threshold has been broadly adopted after discussion in publications by an influential group of neurosurgeons in the 1980s and 1990s without specific data demonstrating an association between abscess size and neurosurgical or overall outcome [53–55].…”

“…20% of cases [8 ▪ ]. Analyses of outcome according to aspiration or excision are heavily confounded by differences in study periods and populations as well as accessibility of the brain abscess [51 ▪ ,52 ▪ ,60]. Excision should be prioritized in fungal brain abscess and may be considered in other (recurrent) abscesses located superficially in noneloquent areas or in the cerebellum [8 ▪ ,51 ▪ ,61,62].…”