BRAIN ABSCESS A brain abscess is a collection of pus, immune cells, and other material in the brain, usually from

a bacterial or fungal infection. Causes Brain abscesses commonly occur when bacteria or fungi infect part of the brain. Swelling and irritation (inflammation) develop in response to this infection. Infected brain cells, white blood cells, live and dead bacteria, and fungi collect in an area of the brain. Tissue forms around this area and creates a mass. While this immune response can protect the brain by isolating the infection, it can also do more harm than good. The brain swells. Because the skull cannot expand, the mass may put pressure on delicate brain tissue. Infected material can block the blood vessels of the brain. The germs that cause a brain abscess can reach the brain through the blood. The source of the infection is often not found. However, the most common source is a lung infection. Less often, a heart infection is the cause. Germs may also travel from a nearby infected area (for example, an ear infection or a tooth abscess) or enter the body during an injury (such as a gun or knife wound) or neurosurgery. In children with congenital heart disease or a blood vessel birth defect, such as those with Tetralogy of Fallot, infections are more able to reach the brain from the intestines, teeth, or other body areas. The following raise your risk of a brain abscess: A weakened immune system (such as in AIDS patients) Chronic disease, such as cancer Drugs that suppress the immune system (corticosteroids or chemotherapy) Right-to-left heart shunts, usually the result of congenital heart disease Symptoms Symptoms may develop slowly, over a period of 2 weeks, or they may develop suddenly. They may include:

Changes in mental status Confusion Decreasing responsiveness Drowsiness Eventual coma Inattention Irritability Slow thought processes Decreased movement Decreased sensation Decreased speech (aphasia) Fever and chills Headache Language difficulties Loss of coordination Loss of muscle function, typically on one side Seizures Stiff neck Vision changes Vomiting Exams and Tests A brain and nervous system (neurological) exam will usually show signs of increased intracranial pressure and problems with brain function. Tests to diagnose a brain abscess may include: Blood cultures Chest x-ray Complete blood count (CBC) Head CT scan Electroencephalogram (EEG) MRI of head Testing for the presence of antibodies to organisms such as Toxoplasma gondii and Taenia solium A needle biopsy is usually performed to identify the cause of the infection. Treatment A brain abscess is a medical emergency. Pressure inside the skull may become high enough to be life threatening. You will need to stay in the hospital until the condition is stable. Some people may need life support. Medication, not surgery, is recommended if you have: Several abscesses (rare)

A small abscess (less than 2 cm) An abscess deep in the brain An abscess and meningitis Shunts in the brain for hydrocephalus (in some cases the shunt may need to be removed temporarily or replaced) Toxoplasma gondii infection in a person with HIV Antibiotics will be prescribed. Antibiotics that work against a number of different bacteria (broad spectrum antibiotics) are most commonly used. You may be prescribed several different types of antibiotics to make sure treatment works. Antifungal medications may also be prescribed if the infection is likely caused by a fungus. Immediate treatment may be needed if an abscess is injuring brain tissue by pressing on it, or there is a large abscess with a large amount of swelling around that it is raising pressure in the brain. Surgery is needed if : Increased pressure in the brain continues or gets worse The brain abscess does not get smaller after medication The brain abscess contains gas (produced by some types of bacteria) The brain abscess might break open (rupture) Surgery consists of opening the skull, exposing the brain, and draining the abscess. Laboratory tests are often done to examine the fluid. This can help identify what is causing the infection, so that more appropriate antibiotics or antifungal drugs can be prescribed. The surgical procedure used depends on the size and depth of the abscess. The entire abscess may be removed (excised) if it is near the surface and enclosed in a sac. Needle aspiration guided by CT or MRI scan may be needed for a deep abscess. During this procedure, medications may be injected directly into the mass. Certain diuretics and steroids may also be used to reduce swelling of the brain.

Outlook (Prognosis) If untreated, a brain abscess is almost always deadly. With treatment, the death rate is about 10 - 30%. The earlier treatment is received, the better. Some patients may have long-term neurological problems after surgery. Possible Complications Brain damage Meningitis that is severe and life threatening Return (recurrence) of infection Seizures When to Contact a Medical Professional Go to a hospital emergency room or call the local emergency number (such as 911) if you have symptoms of a brain abscess. Prevention You can reduce the risk of developing a brain abscess by treating any disorders that can cause them. Have a follow-up examination after infections are treated. Some people, including those with certain heart disorders, may receive antibiotics before dental or urological procedures to help reduce the risk of infection. Alternative Names Abscess - brain; Cerebral abscess; CNS abscess

PAYHOPHYSIOLOGY : Brain abscesses may be single or multiple. Each abscess begins as a microscopic focus of septic, microvascular injury, usually within white matter or at the gray-white junction. Growth of bacteria within this focus produces a localized encephalitis or "cerebritis," which undergoes liquefaction (Britt and Enzmann 1983; Enzmann et al 1983; Pendlebury et al 1989). The developing abscess elicits an inflammatory response of lymphocytes and polymorphonuclear leukocytes, with localized, frequently intense cerebral edema. Over time, an abscess capsule forms, consisting of both fibrotic and gliotic elements. The abscess capsule tends to be thickest on its cortical surface and thinnest medially, causing the abscess to expand toward and rupture into the ventricular system (Kastenbauer et al 2004). Death in brain abscess may result from tonsillar herniation, caused by the mass effect of the abscess and its surrounding cerebral edema, or from rupture of the abscess into the ventricular system. Brain abscesses most frequently arise following hematogenous dissemination of organisms from distant sites of infection. The most common associated systemic infections are chronic lung infections, in particular bronchiectasis and lung abscess, and acute bacterial endocarditis (Greenlee and Mandell 1973; Bleck and Greenlee 2000; Kastenbauer et al 2004). Brain abscess is particularly likely in conditions in which a right-to-left cardiac shunt allows organisms to move directly from the venous circulation into left-sided systemic circulation. For this reason, children with cyanotic congenital heart disease are at particular risk for hematogenous brain abscess (Cole et al 2012; Ozsurekci et al 2012), as are patients with hereditary hemorrhagic telangiectasia (Tabakow et al 2005; Galitelli et al 2006a; 2006b; Sell et al 2008; Corre et al 2011). Rarely, brain abscess may also complicate pulmonary arteriovenous fistulae not associated with hereditary hemorrhagic

telangiectasia or in the setting of a patent foramen ovale (Kawano et al 2009). Less frequently, brain abscesses result from spread of organisms through emissary veins during sinusitis, otitis, or mastoiditis (Bleck and Greenlee 2000). Historically, otitis represented the major pericranial infection associated with brain abscess; at present, however, brain abscess is more frequently associated with frontal, ethmoidal, and sphenoidal sinusitis (Kastenbauer et al 2004), and the most common site of brain abscess is the frontal lobe (Roche et al 2003). Less frequent causes of brain abscess include penetrating trauma, neurosurgical procedures, facial infections, and dental sepsis (Kastenbauer et al 2004). A single case report lists brain abscess as a complication of tongue piercing (Herskovitz et al 2009). Brain abscesses of hematogenous origin are most common in the distribution of the middle cerebral artery, followed by those of the anterior cerebral artery and posterior circulation (Kastenbauer et al 2004). Abscesses arising from frontal and ethmoidal sinusitis are most commonly located within the frontal lobe (Bleck and Greenlee 2000). Sphenoid sinusitis may cause frontal or temporal lobe abscesses. Infections of the middle ear or mastoid may spread through emissary veins into the middle fossa to cause temporal lobe abscesses or into the posterior fossa to cause cerebellar abscess (Bleck and Greenlee 2000; Kastenbauer et al 2004).