Brain abscess

Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal bone, epidural abscess) or remote (lung, heart, kidney etc.) infectious sources within the brain tissue. The infection may also be introduced through a skull fracture following a head trauma or surgical procedures. Brain abscess is usually associated with congenital heart disease in young children. It may occur at any age but is most frequent in the third decade of life.

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Features

The symptoms of brain abscess are caused by a combination of increased intracranial pressure due to a space-occupying lesion (headache, vomiting, confusion, coma), infection (fever, fatigue etc.) and focal neurologic brain tissue damage (hemiparesis, aphasia etc.). The most frequent presenting symptoms are headache, drowsiness, confusion, seizures, hemiparesis or speech difficulties together with fever with a rapidly progressive course. The symptoms and findings depend largely on the specific location of the abscess in the brain. An abscess in the cerebellum, for instance, may cause additional complaints as a result of brain stem compression and hydrocephalus. Neurological examination may reveal a stiff neck in occasional cases (erroneously suggesting meningitis). The famous triad of fever, headache and focal neurologic findings are highly suggestive of brain abscess but are observed only in a minority of the patients.

Pathophysiology

Brain abscesses are usually polymicrobial in nature.

The most common organism recovered from cultures is the bacterium Streptococcus. However, a wide variety of other bacteria (Proteus, Pseudomonas, Pneumococcus, Meningococcus, Haemophilus), fungi and parasites may also cause the disease. Fungi and parasites are especially associated with immunocompromised patients. Organisms that are most frequently-associated with brain abscess in patients with AIDS are Mycobacterium tuberculosis, Toxoplasma gondii and Cryptococcus neoformans, though in infection with the latter organism, symptoms of meningitis generally predominate.

Bacterial abscesses rarely (if ever) arise de novo within the brain. There is almost always a primary lesion elsewhere in the body that must be sought assiduously, because failure to treat the primary lesion will result in relapse. In cases of trauma, for example in compound skull fractures where fragments of bone are pushed into the substance of the brain, the cause of the abscess is obvious. Similarly, bullets and other foreign bodies may become sources of infection if left in place. The location of the primary lesion may be suggested by the location of the abscess: infections of the middle ear result in lesions in the middle and posterior cranial fossae;^[1] congenital heart disease with right-to-left shunts often result in abscesses in the distribution of the middle cerebral artery^[2][3]; and infection of the frontal and ethmoid sinuses usually results in collection in the subdural sinuses.

Diagnosis

The diagnosis is established by a computed tomography (CT) (with contrast) examination. At the initial phase of the inflammation (which is referred to as cerebritis), the immature lesion does not have a capsule and it may be difficult to distinguish it from other space-occupying lesions or infarcts of the brain. Within 4-5 days the inflammation and the concomitant dead brain tissue are surrounded with a capsule, which gives the lesion the famous ring-enhancing appearance on CT examination with contrast (since intravenously applied contrast material can not pass through the capsule, it is collected around the lesion and looks as a ring surrounding the relatively dark lesion). Lumbar puncture procedure, which is performed in many infectious disorders of the central nervous system is contraindicated in this condition (as it is in all space-occupying lesions of the brain) because removing a certain portion of the cerebrospinal fluid may alter the concrete intracranial pressure balances and cause a part of the brain tissue to move out of the skull (brain herniation).

Ring enhancement may also be observed in cerebral hemorrhages (bleeding) and some brain tumors. However, in the presence of the rapidly progressive course with fever, focal neurologic findings (hemiparesis, aphasia etc) and signs of increased intracranial pressure, the most likely diagnosis should be the brain abscess.

Treatment

The treatment includes lowering the increased intracranial pressure and starting intravenous antibiotics (and meanwhile identifying the causative organism mainly by blood culture studies).

Surgical drainage of the abscess remains part of the standard management of bacterial brain abscesses. The location and treatment of the primary lesion also crucial, as is the removal of any foreign material (bone, dirt, bullets, and so forth).

There are a few exceptions to this rule: Haemophilus influenzae meningitis is often associated with subdural effusions that are mistaken for subdural empyemas. These effusions resolve with antibiotics and require no surgical treatment. Tuberculosis can produce brain abscesses that look identical to bacterial abscesses on CT imaging and surgical drainage or aspiration is often necessary to make the diagnosis, but once the diagnosis is made no further surgical intervention is necessary.

Prognosis

Once an almost always fatal disease before the CT era. If the abscess is treated before the person goes into a coma then the death rate has been estimated from 5% to 20%. Early treatment and the patients overall health has an effect on prognosis. Other factors include: antibiotic resistance or the abscess location. An abscess deep within the brain is more difficult to treat than others.

References

1. ^ Macewan W (1893). Pyogenic Infective Diseases of the Brain and Spinal Cord. Glasgow: James Maclehose and Sons. 
2. ^ Ingraham FD, Matson DD (1954). Neurosurgery of Infancy andChildhood. Springfield, Ill: Charles C Thomas. 
3. ^ Raimondi AJ, Matsumoto S, Miller RA (1965). "Brain abscess in children with congenital heart disease". J Neurosurg 23: 588–95.