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Brain Abscess
Definition
A brain abscess is defined as an intraparenchymal
infection caused by bacteria, mycobacteria, fungi, protozoa,
or helminthes that evolve to an encapsulated purulent
1,2
collection .
can also view the sinuses, middle ears, and orbits to search
2
for a potential source of infection .
Epidemiology
A brain abscess is a rare disease. The incidence of
brain abscess was 1.3/100,000 per year. The male to
3
female ratio was approximate 3:1 .
Pathophysiology
Brain abscesses are serious, life-threatening conditions.
Despite advances in diagnostic imaging, surgical
interventions, and antimicrobial treatment, the mortality
(5.9% to 20%) and morbidity rate of brain abscess remain
high. Approximately 35% children with brain abscesses do
1,4
not return to their predisease state after treatment .
Brain abscesses are mostly related to the invasion of
infectious organisms that were transmitted from an infection
5
focus in other part of the body . Spreading of infection from
a remote site can occur through contiguity (close proximity)
6
or via the blood stream .
The most common predisposing conditions for brain
abscess are infections from contiguous foci such as otitis
media or mastoiditis, sinusitis, meningitis, and odontogenic
foci. Thirty three percent of brain abscess are resulted from
hematogenous
spread.
Common
sources
for
hematogenous
spread
are
pulmonary
infection,
gastrointestinal tract, congenital heart diseases, and
endocarditis. Fourteen percent are resulted from
1,7
penetrating head injuries . Eighteen percent of the
8
abscesses are due to unknown origin .
Brain abscesses begin with a local infection that evolves
into a collection of pus surrounded by a well vascularized
9
capsule . Approximately 80% of brain abscesses are
10
located in the cerebral hemisphere .
Approximately 50% - 76% of the causative organisms of
3,7
brain abscesses are streptococci . Other causative
organisms include anaerobic bacteria, staphylococci, gram11,12
negative bacteria, and fungus
.
Diagnostic Tests
Computerized tomography (CT) scan, magnetic
resonance imaging (MRI), completed blood count, blood
culture, echocardiogram, and teeth examination are the
most common tests for diagnosing brain abscess and to
2
detect the source of infection .
In laboratory tests, signs of infection such as
leukocytosis, elevated C-reactive protein concentration,
and elevated erythrocyte sedimentation rate may be
8
revealed . Blood cultures are useful to detect the source of
1
microorganism from hematogenous spread .
Computerized tomography is non-invasive and has a
sensitivity of 95% - 99%. It is used to identify the location
and size of the abscess and any mass effect. A CT scan
A CT scan showing the brain abscess (arrow)
Magnetic resonance imaging is able to demonstrate
more anatomical detail and has better resolution than CT
13
scan . Magnetic resonance imaging is useful to detect
14
early cerebritis and alterations of the blood brain barrier . It
is also able to differentiate brain abscess from brain tumor
15
or infarcts .
A T-2 MRI showed a brain abscess (arrow) with
cerebral edema
Lumbar punctures are frequently performed when
patients are suspected to have concomitant meningitis
and/or ventriculitis. Cultures of the CSF obtained from
lumbar puncture may grow the microorganism responsible
14
for the brain abscess . Lumbar punctures should not be
performed when patients have increased intracranial
16
pressure in order to prevent cerebral herniation .
Manifestations
The classic triad presentation for brain abscess are
1,2,3
headache, fever, and neurological deficits . However,
12
only 20% of patients present with the classic triad .
Approximately 30% of patients with brain abscess are
17
apyrexia .
Manifestations of brain abscess can vary based on the
location and size of the abscess. The most common
presentations include headache, fever, nausea and
vomiting, seizures, motor or sensory dysfunction, visual
2,4,7,12
field deficits, memory loss, and personality changes
.
Treatment Options
The treatment choice for brain abscess depends on
different factors. It includes the signs and symptoms of the
patient, the number, size, and location of the abscess, and
18
health condition of the patient . Treatment options include
12,16
medical treatment, and surgical intervention
.
Medical treatment involves administration of antibiotic,
antiepileptic agent, and corticosteroid therapy. Medical
treatments are appropriate for patients who have small
lesions (< 2-3 cm in diameter), are clinically stable, have no
signs of increased intracranial pressure, have been
diagnosed within 2 weeks after the initial presentation,
abscesses in an inaccessible location, or patients who are
2,18
critically ill .
Broad spectrum antibiotics are used in medical
treatment or combined with surgical interventions. The
most commonly used antibiotics include penicillin,
ceftriaxone/cefotaxime, metronidazole, or carbapenem.
Antibiotic therapies are normally continued for 4 to 8 weeks
2,7,12
.
Surgical interventions are invasive, but it has several
advantages. It is able to remove the pathogens and
necrotic tissues, and reduce the mass effect and
intracranial pressure. In addition, pus sample can be
obtained and send for bacteriological analysis during the
18
surgical procedure .
The advantages of aspiration are, it is minimal invasive,
can be performed under local anesthetic, and has less
potential morbidity. Sterotactic aspiration provides a more
19
precise and rapid access to the abscess . It is more useful
in deep-seated abscess or abscess located in eloquent
20
areas . Very often, aspiration may require repeated
9
aspirations to clear the abscess .
Craniotomy and excision of abscess is more invasive.
Craniotomy and excision of abscess is recommended for
patients with multiple abscess, larger lesions with
significant mass effect, or recurrent pus collection after
19
several aspiration . Patients after craniotomies and
excision of abscesses often do not require second
9
surgeries .
Corticosteroids are often prescribed for reducing
cerebral edema. Fifteen percent to twenty eight percent of
patients with brain abscesses present with seizures. It is
the also the most common post-operative complication.
Anti-epileptic agents are frequently used as seizure
2,4
prophylaxis .
Nursing Implication
Frequent neurological assessment such as level of
consciousness, motor and sensory function, and cranial
nerve function should be performed to monitor for any signs
of complications such as increased intracranial pressure or
14
cerebral herniation .
Due to patients with brain abscess requiring long term
intravenous antibiotic therapy, long term central venous
catheters are recommended to avoid risks of infections
21
such as phlebitis .
References
1) Bouwer, M.C., Coutinho, J.M., & van de Beek, D. (2014). Clinical
characteristics and outcome of brain abscess: Systematic review and
met-analysis. American Academy of Neurology, 82, 806-813.
2) Johnson, T.J., & King, C. (2013). An 11-year-old girl with right-sided
weakness secondary to cerebral abscess: A case report. Pediatric
Emergency Care, 29, 360-363.
3) Nicolosi, A., Hauser, W.A., Musicco, M., & Kurland, L.T. (1991).
Incidence and prognosis of brain abscess in a defined population:
Olmsted county, Minnesota, 1935-1981. Neuroepidemiology, 10, 122131.
4) Zhang, C., Hu, L., Wu, X., Hu, G., Ding, X., & Lu, Y. (2014). A
retrospective study on the aetiology, management, and outcome of
brain abscess in an 11-year, single-center study from China. BMC
Infectious Diseases, 14, 311, 1-7.
5) Ç avuşoglu, H., Kaya, R.A., Türkmenoglu, O.N., Ç olak, I., & Aydin, Y.
(2008). Brain abscess: Analysis of results in a series of 51 patients
with a combined surgical and medical approach during an 11-year
period. Neurological Focus, 24, E9, 1-7.
6) Antunes, A.A., de Santana Santos, T., de Carvalho, R.W.F., Avelar,
R.L., Pereira, C.U., & Pereira, J.C. (2011). Brain abscess of
odontogenic origin. The Journal of Craniofacial Surgery, 22, 23632365.
7) Felsenstein, S., Williams, B., Shingadia, D., Coxon, L., Riordan, A.,
Demetriades, A.K., ... Bryant, P.A. (2013). Clinical and microbiologic
features guiding treatment recommendations for brain abscesses in
children. The Pediatric Infectious Disease Journal, 32, 129-135.
8) Oyama, H., Kito, A., Maki, H., Hattori, K., Noda, T., & Wada, K. (2012).
Inflammatory index and treatment of brain abscess. Nagoya Journal of
Medical Science, 74, 313-324.
9) Sarmast, A.H., Showkat, H.I., Kirmani, A.R., Bhat, A.R., Patloo, A.M.,
Ahmad, S.R., & Khan, O.M. (2012). Aspiration versus excision: A
single center experience of forty-seven patients with brain abscess
over 10 years. Neurologia medico-chirurgica, 52, 724-730.
10) Goodkin, H.P., Harper, M.B., & Pomeroy, S.L. (2004). Intracerebral
abscess in children: Historical trends at Children’s Hospital Boston.
Pediatric, 113, 1765-1770.
11) Choudhury, N., Khan, A.B., Tzvetanov, I., Garcia-Roca, R.,
Oberholzer, J., & Benedetti, E. (2014). Multiple aspergillus brain
abscess after liver transplantation. Transplantation, 97, e72-e73.
12) Helweg-Larsen, J., Astradsson, A., Richall, H., Erdal, J., Laursen, A.,
& Brennum, J. (2012). Pyogenic brain abscess, a 15 year survey.
BMC Infectious Diseases, 12, 1-10.
13) Frazier, J.L., Ahn, E.S., & Jallo, G.I. (2008). Management of brain
abscesses in children. Neurological Focus, 24, E8, 1-10.
14) Twomey, C.R. (1992). Brain abscess: An update. Journal of
Neuroscience Nursing, 24, 34-39.
15) Chen, M.H., Kao, H.W., & Cheng, C.A. (2013). Complete resolution of
a solitary pontine abscess in a patient with dental caries. American
Journal of Emergency Medicine, 31, 892.e3-892.e4.
16) Erdoğan, E., & Cansever, T. (2008). Pyogenic brain abscess.
Neurosurgical Focus, 24, E2, 1-10.
17) Couloigner, V., Sterkers, O., Redondo, A., & Rey, A. (1998). Brain
abscess of ear, nose, and throat origin: Comparison between otogenic
and sinogenic etiology. Skull Base Surgery, 4, 163-168.
18) Hakan, T. (2008). Management of bactyerial brain abscess.
Neurosurgical Focus, 24, E4, 1-7.
19) Moorthy, R.K., & Rajshekhar, V. (2008). Management of brain
abscess: An overview. Neurosurgical Focus, 24, E3, 1-6.
20) Kocherry, X.G., Hegde, T., Sastry, K.V.R., & Mohanty, A. (2008).
Efficacy of sterotatic aspiration in deep-seated and eloquent-region
intracranial pyogenic abscess. Neurosurgical Focus, 24, E13, 1-5.
21) Baumann, C.K. (1997). Multiple bilateral cerebral abscesses with
hemorrhage. Journal of Neurosciences Nursing, 29, 1-11.
© 2014
Disclaimer: The author of this article neither represents nor guarantees that the
practices described herein, if followed, ensure safe and effective patient care. The
author further assumes no responsibility or liability in connection with any
information or recommendations contained in this article. The recommendations and
instructions in this article are based on the knowledge and practice in neuroscience
as of the date of publication. These recommendation and instructions are subject to
change based on the availability of new scientific information.