Brain – Abscess & Management

8/16/2019 Brain – Abscess & Management

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Brain –Abscess &

Management


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Introduction

• Brain abscess – localsuppurative processin brain parenchyma

•Subdural empyema –collection of pusbetween dura andarachnoid membranes

• ~ 0.! of autopsyseries

• ~ " in "0#000 hospitaladimissions


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Epidemiology

• Frequency (US)

- $he prevalence of brain abscess inpatients with A%S is '# so the overallrate has thus '

- $he fre(uency of fungal brain abscesshas ' ) fre(uent administration of

BSAM# immunosuppressive agents#and corticosteroids.


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• Internationally

- signi*cant problem in developingcountries.

- predisposing factors vary in di+erentparts of the world

• Mortality/Morbidity

- %ntro of AM# imaging studies ) rate ,• Sex

- more common in males


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• Age

- Brain abscesses occur more fre(uently inthe *rst - decades of life.

- predisposing cause of subdural empyemain young children is bacterial meningitis#

- a decrease in meningitis due to

the Haemophilus infuenzae vaccine hasreduced the prevalence in young children.


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Pathophyiology

• caused by intracranial in/ammationwith subse(uent abscess formation.

• most fre(uent intracranial locationsin descending order of fre(uency1 2

• frontal)temporal3 frontal)parietal3partial 3cerebellar 3 occipital lobes

• %nfection may enter the intracranialcompartment directly or indirectlyvia 4 routes


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!" #ontiguou uppurati$e %ocu(&''* o% cae)

-. $his direct route of intracraniale5tension is

more commonly associated withsubacute and

chronic otitic infection andmastoiditis than

with sinusitis.


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+" ,rauma (!* o% cae)

-. $rauma that causes an open s6ullfracture allows organisms to seeddirectly in the brain.

-. Brain abscess can also occur as acomplication of intracranial surgery#and foreign body# such as pencil tip#lawn dart# bullets# and shrapnel.

-. 7ccasionally brain abscess can

develop after trauma to the face.


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-" .ematogenou pread %rom aditant %ocu (+'* o% cae)

-. more commonly multiple andmultiloculated and are fre(uentlyfound in the distribution of themiddle cerebral artery.

-. a8w 9:# endocarditis# 9;%#neutropenia# transplantation# :%<infection


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Preentation

• .itory

- =84 of patients# S5 present for =w orless

>ever

:eadache >ocal ?eurologice*cit


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• Mental status changes may indicatecerebral edema1 ) @!

• Seiures ) =)4!

• ?ausea and vomiting ) -0!• ?uchal rigidity ) =!

• apilledema ) =!

- A suddenly worsening headache# followed by

emerging signs of meningismus# is often a8w

rupture of the abscess.


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Phyical

• ;ow)grade or high)grade fever

• ersistent

headache oftenlocalied1

• rowsiness89onfusion8Stupor

• Ceneral or focalseiures

• ?ausea andvomiting

• >ocal motor or

sensoryimpairments

• apilledema

• Ata5ia• :emiparesis

• ?ec6 sti+ness


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• 9erebellar abscess ) ?ystagmus# ata5ia#vomiting# and dysmetria

• Brainstem abscess ) >acial wea6ness#

headache# fever# vomiting# dysphagia# andhemiparesis

• >rontal abscess ) :eadache# inattention#drowsiness# mental status deterioration#motor speech disorder# hemiparesis withunilateral motor signs# and grand malseiures


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• $emporal lobe abscess ) :eadache#ipsilateral aphasia if in the dominanthemisphere1# and visual defects

• 7ccipital abscess) ?ec6 rigidity


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#aue

• redominant organisms include thefollowing2

- Staphylococcus aureus

- Aerobic# anaerobic# and microaerophilicstreptococci# including alpha)hemolyticstreptococci and Streptococcus

anginosus milleri1 group Streptococcusanginosus# Streptococcus constellatus#and Streptococcus intermedius1


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- revotella and >usobacterium speciesand B

ragilis

- Dnterobacteriaceae Klebsiella pneumoniae, Escherichia coli# androteus species1

- seudomonas species

- 7ther anaerobes


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i0erential iagnoi

• Bacterial meningitis

• Brain cancer primary or metastatic1

• 9ryptococcosis

• 9ysticercosis

• Dpidural Abscess

• >ocal encephalitis

• Mycotic aneurysm• Septic cerebral emboli causing infarction

• Septic dural sinus thrombosis


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1or2up

• 3aboratory tudie

!)4outine tet

-) 9B9 count with di+erential and platelet count

-) DSEF elevated in up to =84 of patients-) Serum 9)reactive protein 9E1 or Gestergren

sedimentation rate

-) Serological tests for some pathogens eg#serum immunoglobulin C antibodies# 9S>polymerase chain reaction H9EIfor Toxoplasma1


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- Blood cultures at least =F preferablybefore antibiotic usage1

- Moderate leu6ocytosis is present#and the DSE and 9E level aregenerally elevated.

- Serum sodium levels may be low

because of inappropriate antidiuretichormone production.

- latelet counts may be high or low.


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Imaging tudie

#, can M4I


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7ther tet

• D9C

- occasionally reveals a focus of highvoltage

with slow activity.

- %t is nonspeci*c and rarely of value in

con*rming the diagnosis.- $his is the least accurate procedure

in the diagnostic evaluation.


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Staging

• $he early stage of the infection *rstJ)"- d1 is called cerebritis and isassociated with edema.

• ?ecrosis and li(uefaction occur after=)4 wee6s# and the lesion becomesgradually surrounded by a *brotic

capsule


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,reatment

• Medical #are

- Before the abscess has becomeencapsulated and localied# antimicrobial

therapy# accompanied by measures tocontrol increasing intracranial pressure# isessential.

- 7nce an abscess has formed# surgical

e5cision or drainage combined withprolonged antibiotics usually -)K w61remains the treatment of choice.


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• Surgical care

- Surgical drainage provides the mostoptimal therapy.

- $he procedures used are aspirationthrough a bur hole and completee5cision after craniotomy.

- $hese procedures are also diagnosticand provide material that can guideantimicrobial therapy.


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- ?eedle aspiration is the preferredand the

most commonly used procedure andis often

performed using a stereotacticprocedure with

the guidance of ultrasound or 9$scanning


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#omplication

• :emiparesis

• 9ranial nerve palsy

• :ydrocephalus

• %ntellectual and behavioral disorders

• Ata5ia

• Spasticity•


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Prognoi

• Mortality has declined since theintroduction of 9$ and ME% and thedevelopment of newer surgical

techni(ues.• Mortality rate is about "!.

• $he mortality is higher in

immunocompromised# those who hada transplant# and those with brainstem or deep hemispheric abscesses.


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Eeferences

• Manipal Manual of Surgery -th Ddition1

• Medscape

• Surgery ?otes for MBBS by Andre $an

Brain – Abscess & Management

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