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the basal ganglia or thalamus, and resolving cerebral hemorrhage or infarction Sometimes only surgical exploration will settle the issue, but one must be cautious in interpreting the stereotactic biopsy if only in ammatory and gliotic tissue is obtained, since these changes may appear in the neighborhood of either abscess or tumor Treatment During the stage of cerebritis and early abscess formation, which is essentially an acute focal purulent encephalitis, intracranial operation accomplishes little and probably adds only further injury and swelling of brain tissue and possibly dissemination of the infection Some cases can be cured at this stage by the adequate administration of antibiotics Even before bacteriologic examination of the intracerebral mass, certain antibiotics can be given 20 to 24 million units of penicillin G and either 4 to 6 g of chloramphenicol, or metronidazole, a loading dose of 15 mg/kg followed by 75 mg/kg every 6 h These drugs are given intravenously in divided daily doses Metronidazole is so well absorbed from the gastrointestinal tract that it can be taken orally, 500 mg every 6 h This choice of antimicrobial agents is based on the fact that anaerobic streptococci and Bacteroides are likely to be the preponderant causative organisms Evidence of staphylococcal infection can be presumed if there has been recent neurosurgery or head trauma or a demonstrable bacterial endocarditis with this organism These circumstances call for the use of a penicillinaseresistant penicillin, such as nafcillin, 15 g every 4 h intravenously In patients sensitive to penicillin, or if methicillin-resistant staphylococci are isolated or known to be common as local nosocomial organisms, the drug of choice is vancomycin 1 g every 12 h, the dose being adjusted to maintain a serum concentration of 20 to 40 mg/mL and trough levels of 10 mg/mL Abscesses due to bacteria of oral origin do not respond well to any of these regimens because of the frequency of gram-negative organisms; a third- or fourthgeneration cephalosporin, such as cefotaxime, 2 g every 4 h intravenously, is then recommended In all cases, several weeks of treatment are advised The initial elevation of intracranial pressure and threatening temporal lobe or cerebellar herniation should be managed by the use of intravenous mannitol and dexamethasone, 6 to 12 mg every 6 h If improvement does not begin promptly, it becomes necessary to aspirate the abscess stereotactically or remove it by an open procedure for precise etiologic diagnosis (Gram s stain and culture) The decision regarding aspiration or open removal of the abscess is governed by its location and the course of clinical signs and by the degree of mass effect and surrounding edema as visualized by repeated scans Only if the abscess is solitary, super cial, and well encapsulated or associated with a foreign body should total excision be attempted; if the abscess is deep, aspiration performed stereotactically and repeated if necessary is currently the method of choice If the location of the abscess is such that it causes obstructive hydrocephalus for example, in the thalamus adjacent to the third ventricle or in the cerebellum it is advisable to remove or aspirate the mass and to drain the ventricles externally for a limited time While it has been our practice to recommend either complete excision for posterior fossa and fungal abscesses or aspiration if they are deep, there is still a lack of unanimity as to the optimal surgical approach It is customary to instill antibiotics into the abscess cavity following aspiration, but the ef cacy of this treatment is dif cult to judge The combination of antimicrobial therapy and surgery has greatly reduced the mortality from brain abscess The least satis-. uwp barcode generator Generate Barcode and QR code in Windows Universal app ...
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