[Intracranial abscess and empyema: neurosurgical management]. / Abcès et empyèmes intracrâniens: prise en charge neurochirurgicale.

Brain abscesses and empyemas are severe infections with lethal outcomes in the case of inappropriate treatment. The files of 34 patients with brain abscesses, and nine with intracranial empyemas treated over eight years (1990-1997) were analyzed retrospectively. Cases were evaluated for treatment and compared with data from the literature. Patients with brain abscess underwent either aspiration of the lesion through a burr hole (79.5% of the cases), or craniotomy and excision (8.8% of the cases); 11.7% were treated only with antibiotics. The operative mortality was 2.9% and the outcome was satisfactory in 85% of patients. These results are in agreement with data from the literature. Prognosis is strongly related to the initial clinical status. Current methods of treatment include surgical aspiration of large abscesses with a mass effect, and are usually associated with a poor clinical status. Excision is suggested whenever aspiration procedures have failed, or in the presence of foreign material or fungal abscess. Medical treatment is indicated for small and deeply located abscesses in patients with satisfactory clinical states. Empyemas in our series were treated with burr hole and pus aspiration. The mortality rate was 11%, and 62.5% of the patients made a good recovery. In agreement with other reported studies, the method of treating subdural empyema is much less significant than an aggressive early drainage of the infection. Although brain abscesses and empyema remain a significant neurosurgical concern, aggressive treatment can result in an excellent outcome in the majority of patients.

[C.T. scan and traumatic intracranial haematoma without clinical signs (author's transl)]. / Tomodensitométrie et hématomes intracrániens post-traumatiques sans manifestation clinique.

Patients having sustained head injuries were investigated by computerized axial tomography, a few hours after trauma. 24 conscious patients had large traumatic lesions: epidural haematoma, acute subdural haematoma and cerebral attrition. 12 had no focal sign and were well conscious or very slightly drowsy. 12 were slightly drowsy and/or had focal signs but these signs were very discrete in contrast with the huge lesions seen on the CT Scan. This seems to confirm that an epidural haematoma expands very early after the head injury, and, in any case, that it does exist during the free interval. From a practical view point, computerized tomography may greatly improve the treatment of patients who, other-wise, would have been operated upon in comatose state. This study is not a prospective one, it does not lead to any statistical value. But it points out the usefulness of CT Scan after severe head injury especially of conscious patients, above all if there is a skull fracture.

[Should the aneurysms of Osler's disease be investigated and operated on prior to hemorrhage?]. / Faut-il rechercher et opérer les anévrismes de la maladie d'Osler avant l'hémorragie?

Neurologic accidents are today the first cause of mortality following bacterial endocarditis through ischemia or mycotic aneurysm rupture. Authors propose a protocol management by complete cerebral angiography and CT scan as soon as the least neurologic sign appears. A headache is the most frequent of these signs. 35 patients were explored during 3 years and 10 treated surgically. These authors conclude that: mycotic aneurysm must be detected aneurysm with subarachnoid haemorrhage must be operated on as soon as possible. With unruptured aneurysm, surgical decision is more difficult: sequential angiography after excision of the most dangerous aneurysm, demonstrates that an aneurysm can appear, enlarge, diminish or spontaneously resolve. Carrying on with this protocol should allow an answer to this question.

[Neurosurgical aspects of Rendu-Osler disease. Apropos of 6 recent cases and review of the literature]. / Aspects neurochirurgicaux de la maladie de Rendu-Osler. A propos de 6 cas récents et revue de la littérature.

Six patients with neurological complications in Rendu-Osler-Weber disease were reviewed. There were 4 patients (3 int the same family) with a brain abscess, one patient with a brain abscess and a spinal cord subarachnoid hemorrhage, one patient with a recurrent intracerebral hemorrhage due to a vascular malformation. The infectious complications are related to the presence of pulmonary arterio-venous fistula, which should be treated, whenever diagnosed. Because of the potentially severe outcome of these neurological complications of the Rendu-Osler-Weber disease, screening of the patient's relatives is highly recommended.

[Subdural empyema. Apropos of 17 cases]. / Empyèmes sous-duraux. A propos de 17 cas.

Seventeen patients with subdural empyema were treated from 1985 to 1993. These included 13 males and 4 females with 11 patients aged between 12 and 30 years old. Sinusitis was found to be the primary source of infection in 16 cases. The clinical presentation was classic and the preoperative diagnosis was established on the first CT in 12 cases. In the remaining cases a second or third CT was necessary to demonstrate the empyema, 24 to 48 hours later. Surgical management was first made by burr holes with a small craniectomy in 15 cases. A large craniotomy was performed in 2 patients. Soft catheter drainage was carried out in 6 cases, 9 patients received surgical treatment once (3) or twice (6). Two patients, operated on while in a coma (stage IV of Bannister scale) died and one patient survived with severe disability (operated at stage III). The others (14) made a good recovery (6 in grade A and 8 in grade B of Mauser). These results were compared with those in the literature and we concluded that the mean factor of prognosis is the level of consciousness at the time of initial treatment. In most of the cases, burr holes or a small craniotomy, carried out on the basis of CT or MRI data, are the easiest and most effective method of surgical treatment.

Brain abscess due to Bacillus macerans following a penetrating periorbital injury.

We report a case of a brain abscess due to Bacillus macerans and Clostridium sp. following a penetrating periorbital injury by a wooden branch. Intracranial penetration by and retention of a foreign body were not suspected initially, and neurological symptoms developed only 2.5 months later. Previously reported cases of brain abscesses due to Bacillus species are reviewed.