Intracranial Suppuration at the Brazzaville Academic Hospital

Background: Intracranial suppurations (ICS) due to banal germs are medical-surgical emergencies, despite their little removed frequency. Represented by abscesses and empyemas, their management has been improved by the combined contributions of new diagnostic and therapeutic methods. Objective: Appreciate the management of intracranial suppurations banal germ in our service. Material and methods: A retrospective study of 41 cases of intra-cranial suppurations was conducted at Brazzaville University Hospital, from January 2007 to June 2019. Diagnostic, therapeutic and evolution aspects have been studied. Results: They are divided into 24 empyemas, 8 abscesses and 9 associations abscess-empyema. The average age was 20.2 years old in general. The male predominance is noted in all groups. The sex ratio is 3.1 for all of these intracranial suppurations (ICS). They frequently complicated Oto-Rhino-Laryngology (ORL) infections (41.4%). The clinic was mostly represented by the Bergman’s triad 51.2%, followed by headache 14.6% and seizures 12.2%. The lesions were predominant in supratentorial 97.5%. Frontal location was found in 67.4%. Germs were isolated in 29.4% of samples. There were 5 Streptococci, 3 Staphylococci and 2 Gram-negative Bacilli. The medico-surgical treatment indicated in 80.5% combined often probabilistic tri-antibiotherapy with the evacuation of the pus by the trepano-puncture. Evolution under this treatment was marked by healing in 90.2%. The lethality was 9.7%. Conclusion: The pursuit of the improvement of these infections requires the adequate treatment of their gateways, most of them loco-regional.


Introduction
Intracranial suppurations (ICS), represented by abscesses and empyemas, are se-Neuroscience & Medicine rious affections [1] [2]. Those due to banal germs are medico-surgical emergencies that have seen their prognosis improved by the combined contributions of new antibiotic molecules and new medical imaging techniques, namely Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) [1] [2]. The latter made it possible to make early diagnosis of lesion and topography; to see their evolutionary stage, but also because of their safety, to improve their surveillance. These have made it possible to make an early diagnosis of lesions, to specify their topographies and their evolutionary stage, but also to improve their surveillance.
In Africa in general and south of the Sahara in particular [3] [4] [5], several publications have been made on this subject. The results include: young age of patients, frequency of the ORL origin front door, delayed diagnosis, low percentage of isolated germs, and trepano-puncture as the most common surgical treatment.
Through this study, we hope to contribute to a better knowledge of these affections, by relating their particularities in our environmental and professional context, as several African teams had done before us.

Material and Method
This is a retrospective study, going from June 2007 to June 2019 (12 years In terms of lesions found in medical imaging, these patients were classified into three groups: that of abscesses, empyemas and the group of associations (abscess-empyema). The epidemiological, clinical, paraclinical, therapeutic and evolutionary data collected on Office 2013 Excel were analyzed. Epidemiological data related to age, sex and gateway, diagnostic elements were clinical (delay between onset of signs and diagnosis, clinical signs) and paraclinical (results of morphological examinations and bacteriology of pus). Therapeutically, this was the antibiotic therapy used and the type of surgical treatment performed. The results were appreciated in terms of lethality and healing. The cured patients were without or with sequelae. The patients cured without sequelae were those who had a normal neurological examination and those with sequelae had a persistence of neurological signs more than three months after treatment.
For this study, we obtained the favourable opinion of the National Ethics Commission.

Epidemiological Data
Of the 2050 hospitalized patients in 12  Male dominance is noted in all groups. The sex ratio is 3.1 for all of these ICS, 3 for empyema ( Figure 1), 2 for abscess and 3.5 for Associations ( Figure 2).

Clinical Data
The delay between onset of symptoms and diagnosis was, on average, 28.3 days.

Para-Clinical Data
The morphological assessment was made of CT alone in 37 cases (90%), MRI alone in 3 cases (7.3%) and the combination of the two examinations in 2 cases (4.8%). Three patients had two CTs because of worsening clinical condition.
Lesions were mostly supratentorial. Table 2 gives the different locations.
Overall, single lesions accounted for 63.4% and multiples for 36.6%.

Therapeutic and Evolutionary Data
The treatment instituted was exclusively medical for the 8 cases The evolution following the treatment is recorded in Table 4.

ICS are rare but still serious conditions, especially in Africa [3] [4] [5].
Affected subjects generally have an average age of less than 30 years. This age is even lower in the patients of associations group (14.1 years). The male predominance found in our study is noted in many studies [3] [4] [5] [6], except that of Diallo [7] in Mali.
This is often the complications of loco-regional infections that include sinusitis infections are the most common cause with a rate identical to that of scalp and facial infections (29.2%). These sinusitis are also the first entry into the studies of Broalet [4], Ouiminga [6] and Diallo [7]. Miniar [8] ranks them in first position with meningitis. For Boumediane [9], Sichiziya [10], Idowu [11], Nathoo [12], it is mainly otitis. Traumatic causes were found only in 4.9% of cases, unlike Sichiziya [10] and Kabré [5] who found them in first position with respectively   [9]. It was followed by fever, and headache with 14.6%, seizures of 12.2% and fever and consciousness disorder in 9.7% each.
The place of modern morphological examinations in the diagnosis of ICS is unanimously recognized. CT alone, often gave the diagnosis. Diagnosed doubts had MRI prescribed in 2 patients. These examinations revealed a predominance of empyemas over abscesses and the association of the two lesions. This distribution is found by Broalet [4] but, contrary to that Code [3]. Their location is almost exclusively supratentorial with a predominance of the head office, alone or associated with other regions. This observation is made by almost all authors.
However, Anwary [14] finds, in his study, a significant proportion of infratentorial sites equal to those of the intracranial parietal regions.
While HIV-acquired immunodeficiency has allowed outbreaks of some ICS such as cerebral toxoplasmosis, it has not been observed in ICS with banal germs. HIV serology was positive in only 5.2% of cases and Broalet [4] in 12 patients found no positive serology. The leukocytosis, the acceleration of the sedimentation rate and the increase in C-reactive protein reported by some authors [6] [10], and found during our study (almost 3 times out of 4), constitute for us, Gram-negative Bacilli in 2 cases. Streptococcus isolated in 5 cases was the most found germ, followed by Staphylococcus (3 cases). The anaerobic germs had not been isolated. The low rate of positivity of bacteriological examinations and the prevalence of Gram positive Cocci were noted by Ba [3] and Ouiminga [6] in Senegal, as well as Miniar [8] in for the evacuation of pus. This is the trepano-puncture used by many authors [3] [19]. The bony opening has been widened in the empyema, to facilitate that of the dura mater. The operative revisions used the same operative technique. The excision of the hull has not been practiced in our series. Boumediane [9] and Hassani [20] justify it in recurrences and cases of intra-cavitary foreign body, which we did not have. The stereotactic puncture that Hassani [20] reported in 34.15% and by Chaoui quoted by Hassani in 59.1%, was not practical because it was not available. The treatment of the infection origin is imperative to avoid recurrences [1]. Preventing these infections seems to us to be the best option.
Indeed, the action on the sources of these infections, largely represented by ORL infections, will reduce these ICS. Despite our medical practice in the area of certain diseases such as malaria, we must know how to evoke these ICS in some patients as noted Kabré [5]. Early management of these conditions will limit the treatment to the medical component essentially.
Under this treatment, healing without sequelae was noted in 70.7%. Those with sequelae accounted for 19.5% of epilepsy (12.2%) who was predominating.
The mortality was 9.5%. This evolution of our patients and, reported by most authors, confirms the benefit brought by the triple contribution of novelties in medical imaging techniques, antibiotic molecules and surgical techniques.

Study Strengths and Limitations
The study identified the problems related to the management of intra cranial suppuration in Brazzaville. These difficulties are useful bases to initiate the change of this support.
The limit of the study was especially its retrospective character.

Conclusion
CIS is still a health problem in Africa because of its worrying lethality. Complication of loco-regional and remote infections, adequate treatment of these sources can significantly reduce their morbidity and mortality.

Author's Contributions
L Boukassa designed and wrote the manuscript, OB Ngackosso and SB Kinata Bambino collected the data, HE Ekouele Mbaki dealt with statistical aspects.