BRAIN ABSCESS M.RASOOLINEJAD, MD DEPATMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE

BRAIN ABSCESSBRAIN ABSCESS

M.RASOOLINEJAD, MDM.RASOOLINEJAD, MDDEPATMENT OF INFECTIOUS DISEASEDEPATMENT OF INFECTIOUS DISEASE

TEHRAN UNIVERSITY OFTEHRAN UNIVERSITY OFMEDICAL SCIENCEMEDICAL SCIENCE

BRAIN ABSCESSBRAIN ABSCESS

Focal Focal & &

Suppurative Process Suppurative Process in Brain Parenchymain Brain Parenchyma

Anatomical Relationships of the MeningesAnatomical Relationships of the Meninges

•BoneBone

•Dura MaterDura Mater

•ArachnoidArachnoid

•Pia MaterPia Mater•BrainBrain

•Epidural AbscessEpidural Abscess

•Subdural EmpyemaSubdural Empyema

•MeningitisMeningitis

EPIDEMIOLOGYEPIDEMIOLOGY•Uncommon intracranial infectionsUncommon intracranial infections

•Incidence 1:100,000/yearIncidence 1:100,000/year

•Predisposing conditions: Paranasal SinusitisPredisposing conditions: Paranasal Sinusitis Otitis MediaOtitis Media Dental infectionsDental infections

•Immunocompromised ptsImmunocompromised pts Uncommon org Uncommon org(T.gondii, Aspergillus spp, Nocardia spp, …)(T.gondii, Aspergillus spp, Nocardia spp, …)

ETHIOLOGYETHIOLOGYAA brain abscess may develop:brain abscess may develop:1.1.Direct spread from a contagious cranial of infectionsDirect spread from a contagious cranial of infections( ( Paranasal sinusitis, Otitis media, Mastoiditis,…..)Paranasal sinusitis, Otitis media, Mastoiditis,…..)

2. 2. Following head trauma or Neurological procedureFollowing head trauma or Neurological procedure

3. 3. Hematogenous spread from remote site of infHematogenous spread from remote site of inf

4. 4. No obivious primary source of inf ( 20-30% )No obivious primary source of inf ( 20-30% ) (Cryptogenic brain abscess )(Cryptogenic brain abscess )

ETHIOLOGYETHIOLOGYMost common organisms are :Most common organisms are :•Paranasal sinusitis:Microaerophilic &Paranasal sinusitis:Microaerophilic & Anaerobic strepAnaerobic strep Haemophilus sppHaemophilus spp Bacteroides sppBacteroides spp Fusobacterium sppFusobacterium spp•Dental infections: Streptococci sppDental infections: Streptococci spp PrevetellaPrevetella ProphyromanasProphyromanas

ETHIOLOGYETHIOLOGYMost common organisms are :Most common organisms are :Otitis media & Mastoiditis:Otitis media & Mastoiditis: StreptococciStreptococci Bacteroides sppBacteroides spp P. aeroginosaP. aeroginosa EnterobacteriaceaeEnterobacteriaceaeHematogenous: S. ViridanceHematogenous: S. Viridance S. AureousS. AureousNeurosergical procedure & open head traumaNeurosergical procedure & open head trauma::(S. aureous, Enterobactericeae, P. aeroginosa)(S. aureous, Enterobactericeae, P. aeroginosa)

SOURSE OF BRAIN ABSCESSSOURSE OF BRAIN ABSCESS•Frontal lobe:Frontal lobe: Frontal & Ethmoidal & Sphenoidal sinusesFrontal & Ethmoidal & Sphenoidal sinuses Dental infectionsDental infections

•Temporal lobeTemporal lobe: : Middle ear, Mastoid, Maxillary sinusesMiddle ear, Mastoid, Maxillary sinuses

•Cerebellum & Brain Stem: Middle ear & MastoidCerebellum & Brain Stem: Middle ear & Mastoid

•Posterior Frontal or Parietal lobes:Posterior Frontal or Parietal lobes: Middle Cerebral ArteryMiddle Cerebral Artery Gray- White matterGray- White matter Often multipleOften multiple

PATHGENESISPATHGENESIS•Bacterial invasion of brainBacterial invasion of brain (Parenchyma )(Parenchyma )•Preexisting or concomitant :Preexisting or concomitant : Ischemia &Ischemia & Necrosis & Necrosis & Hypoxia of brain tissueHypoxia of brain tissue

PATHGENESISPATHGENESIS4 Stages Brain Abscess formation:4 Stages Brain Abscess formation:

Early cerebritis ( days 1 to 3 )Early cerebritis ( days 1 to 3 )

Prevascular infiltration of inflammatory cellsPrevascular infiltration of inflammatory cells

Central core of coagulative necrosis Central core of coagulative necrosis

Marked edema surrounds the lesionsMarked edema surrounds the lesions

Stage 1 Stage 1

Early CerebritisEarly Cerebritis

Early cerebritisEarly cerebritis


Late cerebritis ( days 4 to 9 )Late cerebritis ( days 4 to 9 ) Pus formation ( necrotic center )Pus formation ( necrotic center ) Macrophages & Fibroblastrs Macrophages & Fibroblastrs Thin capsule Thin capsule ( Fibroblast & Reticular fibers )( Fibroblast & Reticular fibers ) Marked edema around the lesions Marked edema around the lesions

Stage 2Stage 2

Late CerebritisLate Cerebritis


Early Capsule formation ( days 10 to13 )Early Capsule formation ( days 10 to13 ) Capsule formationCapsule formation

Ring-enhancing capsule ( Imaging )Ring-enhancing capsule ( Imaging )

Stage 3Stage 3

Early Capsule formationEarly Capsule formation


Stage 4 Stage 4 Late Capsule formation ( > 14 days )Late Capsule formation ( > 14 days ) Well formed necrotic centerWell formed necrotic center Dense peripheral collagenous capsuleDense peripheral collagenous capsule No cerebral edemaNo cerebral edema Marked gliosis & reactive astrocytesMarked gliosis & reactive astrocytes Gliosis Gliosis Seizures Seizures

CLINICAL PRESENTATIONSCLINICAL PRESENTATIONSBrain abscess presents as an Brain abscess presents as an Expanding Intracranial massExpanding Intracranial mass

Headache > 75%Headache > 75% Constant, Dull, Constant, Dull, Aching sensationAching sensation Hemicranial or General Hemicranial or General Progressive Progressive Refractory RefractoryFever: 50% & Low gradeFever: 50% & Low gradeSeizure: New onset Seizure: New onset Focal or GeneralizedFocal or Generalized

CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

Increased Intracranial Pressure:Increased Intracranial Pressure:•PapilledemaPapilledema•NauseaNausea•VomitingVomiting•DrowsinessDrowsiness•ConfusionConfusionMeningismus:Meningismus:•When it has ruptured into When it has ruptured into Ventricle or subarachnoid spaceVentricle or subarachnoid space


Focal neurologic deficit > 60%Focal neurologic deficit > 60%•Frontal lobeFrontal lobe Hemiparesis Hemiparesis Mental status, DrowsinessMental status, Drowsiness

•Temporal lobeTemporal lobe Dysphasia DysphasiaUpper homonymous quadrantanopiaUpper homonymous quadrantanopiaIpsilateral headacheIpsilateral headache


Focal neurologic deficit > 60%Focal neurologic deficit > 60%•Cerebellar Cerebellar Nystagmus, Ataxia Nystagmus, Ataxia Dysmetria, vomiting Dysmetria, vomiting

•Brain stemBrain stem Facial weakness, Facial weakness,Fever, Hemiparesis, Dysphagia,Fever, Hemiparesis, Dysphagia,Vomiting, Headache, Fever Vomiting, Headache, Fever

DIAGNOSISDIAGNOSISNEUROIMAGING STUDIESNEUROIMAGING STUDIES

•Brain CT- ScanBrain CT- Scan•MRI ( Early cerebritis, Posterior Fossa)MRI ( Early cerebritis, Posterior Fossa)•Steriotactic Needle aspirationSteriotactic Needle aspiration•Lumbar puncture Lumbar puncture Risk of Herniation Risk of Herniation•CSF CSF Non Specific Non Specific•Peripheral leucocytosis: 50%Peripheral leucocytosis: 50%•Elevated ESR: 60%Elevated ESR: 60%

Left parietal abscessLeft parietal abscess

Marked edemaMarked edema

Ring EnhancementRing Enhancement

Multiple abscess in a 6 years old boyMultiple abscess in a 6 years old boy

Presumed source of polymicrobial abscessPresumed source of polymicrobial abscess

Cerebellar AbscessCerebellar Abscess

Mixed Abscess LocationMixed Abscess Location

T. Gondii EncephalitisT. Gondii Encephalitis



TREATMENTTREATMENTSURGICOMEDICAL SURGICOMEDICAL

•Aspiration Or Open DrainageAspiration Or Open Drainage•Empirical Combination Empirical Combination Antimicrobial TherapyAntimicrobial Therapy•Duration: 6 to 8 wks IVDuration: 6 to 8 wks IV•Prophylactic Anticonvulsant Prophylactic Anticonvulsant TherapyTherapy•GlucocorticoidsGlucocorticoids( Severe Edema & ICP )( Severe Edema & ICP ) •Serial CT-Scan or MRISerial CT-Scan or MRI

ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPYOtitis media Otitis media && Mastoiditis: Mastoiditis:Metronodazole Metronodazole && 3 3rdrd Cephalosporin Cephalosporin

Sinusitis:Sinusitis:Metronidazole Metronidazole && 3 3rdrd Cephalosporine Cephalosporine

Dental Sepsis:Dental Sepsis:Penicillin & MetronidazolePenicillin & Metronidazole

ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPYPenetrating trauma Penetrating trauma &&Neurosurgury:Neurosurgury:Vancomycin Vancomycin && 3 3rdrd Cephalosporin Cephalosporin

Bacterial endocarditis:Bacterial endocarditis:Vancomycin & Gentamycin Vancomycin & Gentamycin Nafcilline (Oxacillin) & Ampicillin Nafcilline (Oxacillin) & Ampicillin & Gentamycin& GentamycinUnknown: Unknown: Vancomycin Vancomycin && Metronidazole Metronidazole && 33rdrd Cephalosporin Cephalosporin

PROGNOSISPROGNOSIS

Successfully treatment Successfully treatment Good prognosisGood prognosis

Seizures are a Seizures are a common complication 70%common complication 70%

THETHEENDEND

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BRAIN ABSCESS M.RASOOLINEJAD, MD DEPATMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE