Dr. Amanj Burhan
specialist Neurosurgeon
4/13/2015
Brain Abscess
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INCIDENCE:
ETIOLOGY
MICROBIOLOGY
PATHOGENESIS
CLINICAL PRESENTATION
DIAGNOSIS
MANAGEMENT
OUTCOME
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INCIDENCE
• Is 1-2% of SOL in brain (USA)
• Is 8% (INDIA)
• Decreased incidence (because of antibiotic
and improved life)
• Lastly increased incidence because of
opportunistic infection in immune
compromised patient .
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ETIOLOGY
1.Infection :
From PNS ,middle ear and mastoid
Characterized by solitary and located superficially
Infection spread by either direct or through veins(thrombophlibitis of
diploic vein)
PNS (frontal and temporal lobe )
Middle ear (temporal lobe)
mastoid (temporal lobe and cerebellum)
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2. Heamatogenous
•hematogenous dissemination microorganism from remote site of
infection
•The abscess are multiple and deeply located
•Mostly located in the frontal and parietal lobe?
•Primary foci include (skin pustule ,pulmonary infection ,
diverticulitis …etc.
•In Cyanotic cong. Heart dis. Brain abscess is leading cause of
mortality and morbidity
•Most common type of CHD. Is TOF 50%
•Brain abscess in CHD are generally solitary
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3. Penetrating trauma :
A. Penetrating trauma are seen occur soon or
after years from trauma.
Contaminated bone fragments and debris
provide anidus for infection
Bullet cause brain abscess or not ?
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B. Basal skull fracture with CSF leak and
meningitis cause post traumatic abscess
• Brain abscess from penetrating trauma is
preventable or not?
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4.Previous craniotomy
Because of :
A. Introduce of M.O.at time of surgery
B. Spread of M.O. intracranialy through the wound
C. Bone flap infection
5. Immune compromised person
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MICROBIOLOGY
•Otogenic and dental infection caused by
anaerobic organism
•Sinusitis caused by staph aureus, aerobic
streptococci
• CHD caused by strep. SPP.
•In immune deficiency caused by fungus
•In AIDS by toxoplasma gondi
•Incidence of –ve culture is 25-30%
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PATHOGENESIS AND HISTOPATHOLOGY OF
BRAIN ABSCESS
• Preceding antibody formation there is an area
of necrosis which is seeded by bacteria
• Brain abscess formation are 4 stages
1.stage I:early cerebritis (day 1 to day 3)
characterized by necrotic tissue ,local
inflammatory response, marked edema This
stage there is no demarcation between the
lesion and surrounding brain
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2.stage two (late cerebritis)(day 4-10):
characterized by : pus , maximum edema
3.stage three (early encapsulation)(day10—13)
Capsule limits spread of infection
Capsule develops slowly in medial wall of abscess?
4.Stage four: late capsule stage ( day 14 and on )
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• Clinical presentation :
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Occur in majorities in the first 2 decades of life
Males more affected ( cause is unknown )
adults depend on immune status
Infants : increase in head circumference , bulging fontanel ,
separation of cranial sutures , vomiting , irritability , seizures
• Signs of IICP and FND :
1. Edema
2. Cerebral tissue destruction
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• Symptoms :
1. Head ache ( 90 %)
2. Change in conscious level ( 60 %)
3. FND ( 60 %)
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Parietal lobe : hemiparesis
Temporal lobe : dysphasia
Cerebellar : ataxia and nystagmus
4.Fever (more than 50 %)
5. Nausea and vomiting ( 50 %)
6. Seizure ( 50 %)
7.Papilledema and meningismus
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Laboratory findings
1. WBC : normal or mild increase
2. ESR : increase in 90%
3. CSF : not specific
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Opening pressure
Protein
Glucose
Culture
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4. radiological characteristic of brain abscess
1. Brain CTS with contrast
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ring enhancement
Multi loculation
Multiplicity
Finding of gas
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• MRI :
• T1 :
• necrotic center ( hypointence)
• Capsule ( hyperintence)
• Edema ( hypointence)
• T2 :
• necrotic center ( hyperintence)
• Capsule ( hypointence)
• Edema ( hyperintence
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Management
1. Antibiotic therapy :
• Antibiotic is mandatory and should given
• Antibiotics depends on C/S
• Imperial treatment depend on the etiology
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Sinusitis : ( penicillin + metronidazole )
Otitis : ( penicillin + metronidazole + 3rd generation cephalosporin)
Metastatic abscess :(metronidazole + 3rd generation cephalosporin)
Post traumatic abscess ( vancomycin)
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• Advantage of antibiotic therapy
• Small size
• Deep seated
• Multiple
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2. Aspiration :
• Advantages :
1. Confirm diagnosis
2. Remove of purulent material
3. Provide environment for antibiotics to work
4. Provide immediate relief of IICP
• Stereotactic guided aspiration
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3.Excision of brain abscess
• Advantages
1. Traumatic abscess ( contain foreign body and bone fragment )
2. Fungal abscess
3. Gas containing abscess
• Disadvantages
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Follow up
• CT weekly during antibiotic therapy
• And then monthly CT
• 2-3 week decrease size of abscess
• 3-4 months complete resolution of abscess
• 6-9 months no residual contrast
enhancement
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Outcome of abscess :
Mortality influenced by ( herniation , rupture of
abscess to the ventricle , clinical course of the
patient, type of abscess, neurological state of
patient at time of diagnosis)
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1. Long term morbidity : ( seizure , FND,
Cognitive dysfunction)
2. Recurrence: ( 5-10%) causes ( inadequate
antibiotic therapy, incorrect choice of AB,
presence of foreign body , failure to eradicate
source of the abscess)
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