History of Management of Brain Abscesses in Children

Understanding of Disease

  • Trepanation – second century: The first surgical attempts to treat intracranial purulent collections are attributed to Galen, who as early as the second century used trepanation and trephination to drain pus under the skull.
  • 1752 – first report of management of otic origin abscess: Morand is recognized to be the first to operate successfully on an intracranial abscess of otic origin in 1752 (92).
  • 1872 – report on management of posttraumatic brain abscess: In 1872 Weeds reported the successful drainage of a posttraumatic brain abscess (92).
  • 1876 – Macewen first diagnosed abscess: In 1876 Macewen made the first diagnosis of a brain abscess in a child on the basis of symptoms and the results of a neurological examination. A left frontal lobe abscess was found at the postmortem examination after the family had refused surgery.
  • 1893 – Macewen’s review of abscesses: In 1893 Sir William Macewen’s monograph represented a comprehensive review of 19th-century knowledge about brain abscesses.  His monograph discussed the surgical anatomy, pathology, symptoms, intracranial sinuses, and treatment of abscesses including an emphasis on prevention by aggressive treatment of otitis media and mastoiditis (95).
Sir William Macewen (1848-1924):

 

  • Poorly documented: Only 38 pediatric cases were identified in a review of the world medical literature between 1875 and 2001 (37).

Technological Development

  • CT scan: Prior to the introduction of CT scans, the delay in diagnosis contributed to high rates of death and complications. CT scanning has aided in the diagnosis of brain abscesses, and the introduction of antibiotics has assisted in their management (98, 129). Mortality rates for children with brain abscesses in a U.S. series dropped from 31% to 5.6% with the advent of CT scans (112).
  • MRI: The introduction of MRI has provided even greater anatomical detail and, similar to the effects of CT scans, has contributed to earlier diagnosis and better localization of the lesion (51).
  • Improved culturing techniques: With the improvement of microbiological laboratory techniques, anaerobic bacteria are now more commonly (40–100% of cases) detected (12, 110).
  • Antibiotics: A fundamental step in the treatment of intracranial pyogenic conditions is the development of antibiotic treatment introduced in the mid-20th century with drugs such as penicillin or chloramphenicol. Prior to the antibiotic era, the mortality rate ranged from 40–60%. With the advent of antimicrobial agents, improved culturing techniques, and imaging modalities leading to earlier detection and better surgical localization, current death rates have been reported in the 4–12% range (30, 36, 98).
  • Medical treatment alone: Successful treatment of brain abscesses with medical therapy alone was first reported in 1971. Since that report, medical treatment has proven to be an effective modality in select patients (67).

Surgical Technique

  • Progressive minimalization in management: Several techniques have been described to drain intracerebral abscess, including tube drainage, marsupialization, excision, and tapping with aspiration. This last procedure was advocated by Dandy as a minimally invasive procedure and has been refined in the modern era with the use of stereotactic techniques.
  • Stereotaxis: Neurological sequelae from cerebral abscesses have declined from 16–52% in most large series before 1975 to about 4–27% in series published after 1975. The use of stereotactically guided aspiration, with its limited damage to the surrounding brain, is believed to be responsible for some of this improvement (30, 117).
  • Endoscopy: Neuroendoscopy has been described in the treatment of brain abscesses in children. The advantage of the modality is that it allows for complete aspiration of the cavity and irrigation under direct visualization (52).