ABSCESSES of the brain, arising from infection of the paranasal sinuses or mastoid infection, are usually single, first passing through a stage of septic encephalitis, followed by encapsulation. If the infection of the brain is caused by highly virulent organisms, a rapid necrosis of the brain tissues may follow, and encapsulation does not take place. Treatment of an abscess of this type nearly always fails. It is the purpose of this paper to discuss some of the important features of brain abscess and to describe a method of treatment which, in the author's hands, has given fairly satisfactory results. It is probable that the technic of operation for brain abscess will be further refined, and that reduction of the present mortality rate will be accomplished by applying different methods of operative treatment to different types of abscess. The size of the abscess, its subcortical depth, and the density of the capsule must all be taken into consideration in deciding whether or not drainage should be employed, and, if used, the selection of the point in the abscess wall into which the drainage material is to be placed. Multiple, metastastic abscesses are not considered, as they are rarely amenable to surgical treatment. Brain abscesses arising from infection of the frontal sinuses usually develop in the adjacent frontal lobe. Those arising from aural infections are found either in the adjacent temporal lobe or the cerebellar hemisphere of the corresponding side. McEwen found cerebellar abscesses more frequently than those of the cerebral hemispheres. In a series of 31 cases of encapsulated brain abscess, we have recorded only three cases in which the abscess was located in the cerebellum. While abscesses may result from penetrating wounds of the brain, or even from untreated scalp lacerations without fracture of the skull, it is rare for abscess of the brain to follow a primary acute infection either of the frontal sinuses or of the mastoid. It evidently requires a considerable period for infection to break down the barriers which exist between the inflammation of the bony cavities and the brain. It is generally believed that a transfer of infection from the sinuses, or mastoid, to the brain takes place through the blood vessels which enter the brain adjacent to the infected bone. Infected thrombi form in these vessels, and, by retrograde propagation, the infection enters the white substance, in which the blood supply is poor and the level of resistance to infection is low. In this stage, the inflammation of the brain in the region of the infected vein is diffuse, but tending to become encapsulated, provided the virulence of the organism is not overwhelming. It is thought that about three weeks are required for the abscess to become encapsulated. During the early stage of abscess formation, that is, during the stage of septic encephalitis, high temperature, chilly feeling, and evidence of systemic sepsis are present.
Eighty-two percutaneous enterostomies were performed at three institutions with the Cope suture anchor for stomach or jejunal wall stabilization during alimentation tube placement. The anchors were successfully placed into the stomach or jejunum in 81 cases. Early in the series, two anchors were misplaced, with no sequelae. There were no other complications at the time of placement. In all successful cases, excellent immobilization of the viscus was achieved. Tract dilation and tube placement were easily performed, and there were no guidewire or tube dislodgments.
The purpose of this paper is to discuss the operative treatment of chronic encapsulated abscess of the brain and to report the results of operation in a small series of abscesses of this type. In view of the high mortality, any method of operation for brain abscess should be carefully scrutinized to exclude technical errors, which may not only prevent the eradication of a localized suppuration, but actually spread the infection to uninvolved regions of the brain. It is generally appreciated that the principles utilized in the successful treatment of abscess in other regions of the body must be radically modified in operations for brain abscess. An unfailing adherence to these principles in the treatment of the various types of abscess of the brain will often convert a walled-off, more or less quiescent lesion into a rapidly fatal septic encephalitis, the most frequent terminal complication of an unsuccessful operation for
The Amplatz retrievable inferior vena cava filter was designed to be used as either a permanent indwelling filter or a short-term, percutaneously removable filter. The authors placed 52 filters in 52 patients. No deaths occurred as a result of filter placement or usage. Follow-up in 42 (81%) patients included inferior vena cavography (n = 31), computed tomography (n = 4), duplex ultrasound (n = 4), and autopsy (n = 3). Inferior vena cava thrombosis was found in seven (17.5%) of the 40 previously nonobstructed venae cavae studied. Two patients with caval thrombosis required a second filter to prevent embolization of thrombus that had extended to the lung side of the first filter. No clinically evident pulmonary emboli after filter placement have been noted. Six filters were successfully retrieved or repositioned percutaneously. The relatively high rate of caval thrombosis with extension above the filter may be due to a higher trapping efficiency or to filter geometry. The role of this filter in the treatment of deep venous thrombosis and pulmonary emboli is unclear.
Fracture of the skull involving the paranasal sinuses and mastoids is important mainly because it exposes the brain to infection. Less serious effects are paralysis of cranial nerves and facial deformity from displacement or loss of bone fragments. Fractures of the skull, whether of the vault or base or, as they usually are, of the two in combination, frequently produce serious damage to the brain, and the brain injury should receive primary consideration. Fracture of a paranasal sinus is often only a minor effect of an injury which damages important regions of the brain at the base of the skull and severely macerates the cerebral cortex by the indriven fragments of an associated compound fracture of the vault. Consideration of the sinus fracture in serious cases of head trauma must at times be postponed or even entirely abandoned in favor of a management which gives the patient the best chance
