Mamelak A N, Mampalam T J, Obana W G, Rosenblum M L
Department of Neurological Surgery, University of California, San Francisco.
Neurosurgery. 1995 Jan;36(1):76-85; discussion 85-6. doi: 10.1227/00006123-199501000-00010.
Bacterial brain abscesses occur in approximately 1500 to 2500 patients each year in the United States. Multiple abscesses have been noted in 10 to 50% of these patients. The goal of this study was to better define the roles of surgery and medical management in patients harboring multiple brain abscesses and to develop an algorithmic approach to the treatment of these complex patients. Between 1976 and 1992, 16 patients with multiple brain abscesses were treated by a single physician (M.L.R.). The ages of the patients ranged from 1.5 to 73 years (median, 47 yr). In all patients, a diagnosis of multiple abscesses was made by computed tomography (15 patients) or magnetic resonance imaging (1 patient) brain scans. The number of abscesses per patient ranged from 2 to 30, and the abscesses were located in all regions of the brain. Thirteen received a combination of antibiotics and surgical drainage, and three received antibiotics only. Surgery was performed on abscesses larger than 2.5 cm or on those situated in critical areas of the brain or causing significant mass effect. Excision and open aspiration via craniotomy and stereotactic aspiration were analyzed on the basis of the location of the lesion and infecting organism. Any abscess that enlarged after 2 weeks of antibiotics or that failed to shrink after 3 to 4 weeks of antibiotics was again aspirated or excised. Forty-three surgical procedures were performed in 13 patients, and 8 (62%) of the patients operated on required more than one surgical procedure. No significant morbidity was observed in any of the surgical procedures. Antibiotics were administered intravenously for an average of 6 to 8 weeks and were adjusted according to organism type and sensitivity to antibiotics. One patient (6%) died, and the remaining 15 patients had resolution of all abscesses and good neurological recovery within 6 months. On the basis of these results, we propose a combined surgical and medical approach to the treatment of patients with multiple brain abscesses. We recommend the aggressive surgical drainage of all abscesses larger than 2.5 cm in diameter, combined with 6 to 8 weeks of intravenous antibiotics. Biweekly computed tomography or magnetic resonance imaging is necessary to closely monitor patients for evidence of abscess growth or failure to resolve despite antibiotics, prompting another operation. The application of this combined approach should yield cure rates of more than 90% in patients with multiple brain abscesses, a result similar to that expected when treating patients with solitary lesions.
在美国，每年约有1500至2500名患者发生细菌性脑脓肿。这些患者中有10%至50%被发现有多个脓肿。本研究的目的是更好地明确手术和药物治疗在患有多个脑脓肿患者中的作用，并制定一种针对这些复杂患者的治疗算法。1976年至1992年间，16例患有多个脑脓肿的患者由同一位医生（M.L.R.）进行治疗。患者年龄从1.5岁至73岁不等（中位数为47岁）。所有患者均通过计算机断层扫描（15例）或磁共振成像（1例）脑部扫描确诊为多个脓肿。每位患者的脓肿数量从2个至30个不等，且脓肿位于脑内各个区域。13例患者接受了抗生素与手术引流相结合的治疗，3例患者仅接受了抗生素治疗。对于直径大于2.5厘米的脓肿、位于脑关键区域的脓肿或引起明显占位效应的脓肿进行手术。根据病变位置和感染病原体对开颅切除及开放穿刺抽吸和立体定向抽吸进行了分析。任何在使用抗生素2周后增大或在使用抗生素3至4周后未缩小的脓肿再次进行抽吸或切除。13例患者共进行了43次外科手术，其中8例（62%）接受手术的患者需要不止一次外科手术。在任何一次外科手术中均未观察到明显的并发症。抗生素静脉给药平均持续6至8周，并根据病原体类型和对抗生素的敏感性进行调整。1例患者（6%）死亡，其余15例患者在6个月内所有脓肿均消退且神经功能恢复良好。基于这些结果，我们提出一种针对患有多个脑脓肿患者的手术与药物联合治疗方法。我们建议对所有直径大于2.5厘米的脓肿进行积极的手术引流，并联合6至8周的静脉抗生素治疗。每两周进行一次计算机断层扫描或磁共振成像，以密切监测患者，查看是否有脓肿增大或尽管使用了抗生素但仍未消退的迹象，如有则需再次手术。应用这种联合治疗方法，多个脑脓肿患者的治愈率应超过90%，这一结果与治疗单发病变患者时预期的结果相似。
