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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