Iranian Journal of Clinical Infectious Disease 2010;5(4):231-234

Iranian Journal of Clinical Infectious Diseases

2010;5(4):231-234
2010 IDTMRC, Infectious Diseases and Tropical Medicine Research Center



Brain abscess; epidemiology, clinical manifestations
and management: A retrospective 5-year study
Mehdi Besharat
1*
, Frahad Abbasi
2

1
Infectious Diseases and Tropical Medical Research Center, Shahid Beheshti Medical University, Tehran, Iran
2
Bushehr University of Medical Sciences, Bushehr, Iran

ABSTRACT
Background: Infections involving the cerebrum are true neurosurgical emergency that require rapid diagnosis and
appropriate surgical and medical intervention to achieve good clinical outcome. Brain abscess is one of most common
forms of intracranial pyogenic infections. Bacterial infections of the nervous system are often challenging for the
treating physician.
Patients and methods: In this study we evaluated 41 patients with brain abscess in Loghman hospital during 2002-
2009. Demographic features, predisposing factors, clinical manifestations, laboratory data and managements were
evaluated.
Results: Totally, 53.6% of patients were 15-29, 26% were 30-49 and 17% were 50-70 years old. The most frequently
encountered clinical manifestations were headache (92.6%) and nausea and vomiting (73.1%). Predisposing condition
leading to brain abscess were sinusitis (9.2%), otitis (12%), CSF rhinorrhea (2.4%), mastoiditis (7.2%), neurosurgery
(17%) and endocarditis (2.4%), and finally 20% had no risk factor. Mean duration of disease was 13 days. For 80% of
patients surgical intervention was performed. Mortality rate was 12%. A total of 9.7% of patients admitted with
diagnosis of brain abscess were finally diagnosed as acute demyelinating encephalomyelitis (ADEM).
Conclusion: In spite of improvement in diagnosis and treatment of patients with cerebral abscess, mortality is still high.
Factors related to patient underlying diseases and the delay in commencement of antibiotic treatment were associated
with increased mortality.

Keywords: Abscess; Brain; Intracranial; Management.
(Iranian Journal of Clinical Infectious Diseases 2010;5(4):231-234).


I NTRODUCTI ON
1
A brain abscess is a focal, intracerebral
infection that begins as a localized area of
cerebritis and develops into a collection of pus
surrounded by a well-vascularized capsule (1).
Intracranial abscesses remain a significant health-
care problem in developing countries. Despite

Received: 13 July 2010 Accepted: 17 October 2010
Reprint or Correspondence: Mehdi Besharati, MD.
Infectious Diseases and Tropical Medical Research Center,
Shahid Beheshti University of Medical Sciences, Tehran, Iran.
E-mail: m_besharat@live.com
advances in imaging and antibiotic treatment, brain
abscess is still encountered occasionally. Various
aerobic and anaerobic bacteria have been reported
as causative agents of brain abscess (2). Accurate
assessment of therapeutic response in patients with
brain abscess is essential to direct appropriate
therapy (3). Brain abscesses are mainly caused by
either direct or indirect inoculation of gram
positive bacteria including Staphylococcus aureus
or Streptococcus species into the central nervous
BRIEF REPORT
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232 Brain abscess
Iranian Journal of Clinical Infectious Disease 2010;5(4):231-234
system (4). In this study, we evaluated
demographics, clinical manifestations and
management of brain abscesses in our hospital.

PATI ENTS and METHODS
The aim of this study was to evaluate
epidemiological and clinical aspects of brain
abscess. In this descriptive retrospective study we
evaluated 41 patients who were admitted to
Loghman hospital with diagnosis of brain abscess
during 2002-2009. Demographic information,
predisposing factors, clinical manifestations,
laboratory data and management including medical
and surgical interventions were evaluated.

RESULTS
In our setting, 53.6% of patients aged 15-29,
26% aged 30-49 and 17% aged 50-70 years. The
mean age was 32 years old. Brain abscess was
detected more commonly in men than women
(75.6% vs. 24.4%). Clinical manifestations were as
follow: headache (92.6%), nausea and vomiting
(73.1%), meningeal signs (17%), drowsiness
(12%), decreased level of consciousness (9.7%),
fever (9.7%), urinary and fecal incontinency
(7.3%), visual disturbance (7.3%) and chills
(4.8%).
Abnormal laboratory indices were leukocytosis
in 31%, ESR>40 in 73.3% and CRP 3+ in 73.3% of
patients.
Predisposing conditions leading to brain abscess
were sinusitis (9.2%), otitis (12%), CSF rhinorrhea
(2.4%), mastoiditis (7.2%), previous neurosurgical
procedures (17%) and endocarditis (2.4%). Totally,
20% of our patients had no risk factor. Mean
duration of disease was 13 days.
All patients had undergone CT scan with and
without contrast. Abscesses were located in frontal,
parietal and temporal lobes.
Totally, 7.3% of patients were HIV positive.
For 52% of patients surgical interventions were
achieved. We prescribed a combination of
intravenous ceftriaxone, metronidazole and
vancomycin. Meanwhile, 7.3% of patients received
pyrimethamin and sulfadiazine. Staphylococcus
aureus, Pseudomonas aeruginosa and Klebsiella
were the most commonly cultured organisms.
Mortality rate was 12%. Totally, 9.7% of
patients admitted with the diagnosis of brain
abscess, were finally diagnosed acute
demyelinating encephalomyelitis (ADEM).

DI SCUSSI ON
Brain abscess is a focal, intracerebral infection
that begins as a localized area of cerebritis and
develops into a collection of pus surrounded by a
well-vascularized capsule (5). Infection involving
the cerebrum is a true neurosurgical emergency
that requires rapid diagnosis and appropriate
surgical and medical intervention to achieve good
clinical outcome. Microorganisms can reach the
brain by several different mechanisms (6). The
most common pathogenic mechanism of brain
abscess formation is spread from a contiguous
focus of infection, most often in the middle ear,
mastoid cells, or paranasal sinuses (7). Other
mechanisms of brain abscess formation are
hematogenous dissemination to the brain (8) and
trauma (9). Brain abscess is cryptogenic in about
20% of patients (10). The clinical course of brain
abscess may range from indolent to fulminant (5).
Common signs and symptoms of brain abscess are
headache, mental status changes, focal neurologic
deficits, fever, seizures, nausea and vomiting,
nuchal rigidity and papilledema (11).
Neuroimaging plays a crucial role in the diagnosis
and therapeutic management of neurologic
infections (12). With the advent of computed
tomography and magnetic resonance imaging, it is
now possible to detect an infectious process early
in its course and follow the response to therapy (6).
Recent advances in neuroimaging have resulted in
a marked decrease in morbidity and death due to
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Besharat M. et al 233
Iranian Journal of Clinical Infectious Disease 2010;5(4):231-234
brain abscesses. The advent of computed
tomography-guided stereotaxy has reduced
morbidity in patients with deep-seated abscesses.
Empirical therapy is best avoided in the present
era, particularly given the availability of
stereotactic techniques for aspiration and
confirmation of diagnosis (13). Early pus samples,
obtained by biopsy or surgical resection, are
needed to establish a certain bacteriological
diagnosis and initiate appropriate intravenous
antibiotics (14). In patients with a bacterial brain
abscess of unclear pathogenesis, empirical therapy
with vancomycin, metronidazole, and a third- or
fourth-generation cephalosporin (cefotaxime or
ceftriaxone, or ceftazidime or cefepime if P.
aeruginosa is suspected) is recommended pending
culture results (11). Despite advances in surgical
techniques in the management of the brain abscess,
long-term antibiotics are as crucial to cure as the
initial surgical procedure itself (15). Most patients
with bacterial brain abscess require surgical
management for optimal therapy. The two
procedures available are aspiration of the abscess
after bur hole placement and complete excision
after craniotomy (16). Decompression with
stereotactically guided aspiration, antibiotic
therapy based on results of pus culture, and
repeated aspirations if indicated from results of
periodic CT follow-up scans seem to be the most
appropriate treatment modality for brain abscesses
(17).

ACKNOWLEDGEMENT
We would like to thank our staff in Infectious
Diseases and Tropical Medical Research Center.

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