Brain Abscess

What is brain abscess?

Focal collection within brain

parenchyma
Pathogenesis?

Direct
20-60% of the cases
Focal abscess
Hematogenous
Multiple abscesses
No identifiable souces in 20-40% of the cases
Primary sources in direct spread
and distribution of abscess
Otitis media inferior temporal lobe and
cerebellum
Frontal or ethmoid sinuses frontal lobe
Dental caries frontal lobe
Foreign bodies - bullet
Primary sources
hematogenous spread
Chronic pulmonary infections lung abscess
and empyema
Skin infection
Intrabdominal and pelvic infection
Bacterial endocarditis
Cyanotic congenital heart disease most
common in children
Microbiology

Clues to the primary source

Anaerobics

Usually mouth flora

May be from pelvic or intraabdominal
infections multiple abscesses
Examples anaerobic streptococci,
bacteroides species, fusobacterium
Aerobics
Gram positive
Staphylococcus aureus neurosurgery and trauma
Streptococcus milleri proteolytic enzymes that cause
necrosis
Others viriddans streptococci, microaerophilic streptocci
Gram negative
Usually from trauma or neurosurgery
Klebsiella pneumoniae, Pseudodomonas species, E. coli,
and Proteus species
Immunocompromised hosts?

Opportunistic infections
Toxoplasma gondii
Listeria
Fungi Aspergillus, cryptococcus
neoformans, coccidiodidides immitis,
Candida albicans
Immigrants

Parasites
Cysticercosis 85% of brain infection in
Mexico city
Symptoms?

Headache most common

Neck stiffness
Associated with occipital abscess
Abscess leaks into lateral ventricle
Altered mental status cerebral edema
Vomiting increased intracranial pressure
Physical finding?
Fever not very reliable, since only 45-50% present
Focal neurological deficit days or weeks after
onset of headache
Seizure
25% of the cases
May be first manifestation of brain abscess
Grand mal in frontal infection
Third or sixth cranial palsy increased intracranial
pressure
Papilledema cerebral edema
Tests?

CT scan with contrast

MRI with gadolinium diethylenetriamine
Lumbar puncture
Contraindicated
Analysis
WBC < 500/mm3 with predominately lymphocytes
WBC > 1,000/mm3 consistent with meningitis but not
improved with antibiotics, consider MRI for ruptured
abscess
Treatment options?

Antibiotics 6 to 8 weeks
Surgical drainage
Antibiotics?
Penicillin G aerobic and anaerobic streptococci
from mouth flora
Metronidazole against anaerobes but not aerobes,
good intralesional penetration
Ceftriaxone or cefotaxime Enterobacteraciae,
particular chronic ear infection
Ceftazidime neurosurgery and p. aeruginosa
Oxacillin or nafcillin head trauma or neurosurgery,
mainly staphylococcus aureus coverage
Vancomycin MRSA
Aminoglycosides poor blood brain barrier, not use
Indications for surgical
drainage?
No clinical improvement within a week
Depressed sensorium
Increased intracranial pressure
Progressive increase in the ring diameter of
the abscess
Surgical approach

Needle aspiration
Prefer approach because of less neurological
deficit
Under ultrasound or CT guided
Surgical excision
More neurological deficit
Prefer in traumatic abscess, particularly with
foreign body,and encapsulated fungal abscess
Advantages: shorten antibiotics to 2 to 4 weeks
and less relapse
Steroid use?

Mainly for mass effect

Disadvantages
Reduce contrast enhancement on CT scan
Slow capsule formation
Increase risk of rupture
Decrease penetration of antibiotics
Complications

Neurological deficits commonly seizure with

frontal lesion
Poor prognosis mortality rate up to 30%
Rapid progression of the infection
Severe mental changes
Rupture into ventricle