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Transcript
Focal CNS Infections Anatomic Relationships of the Meninges • Bone – Epidural Abscess • Dura Mater – Subdural Empyema • Arachnoid – Meningitis • Pia Mater • Brain Anatomic relationships of the Brain • Frontal Lobe – Frontal and Ethmoidal Sinuses • Sella Turcica – Sphenoidal sinuses • Temporal Lobe – Middle Ear, Mastoid, Maxillary Sinuses • Cerebellum, Brain Stem – Middle Ear, Mastoid Brain Abscess • 50% - Local Source – otitis media, sinusitis, dental infection • 25% Hematogenous spread – – – – adults - lung abscess, bronchiectasis and empyema children - cyanotic congenital heart disease (4-7%) pulmonary AVM - Osler-Weber-Rendu syndrome (5%) rarely bacterial endocarditis • 10% trauma / surgery Subdural Empyema • Located in the potential space between the dura and the arachnoid. • May spread rapidly due to lack of anatomical boundaries. • Less mass effect than brain abscess • Surgical Emergency • Usually from a local source of infection – >50% stem from a paranasal sinusitis (fronto-ethmoidal) – trauma or surgery – progression of an epidural abscess, ostermyelitis Etiologies of SDE • • • • • • • paranasal sinusitis - 67-75% otitis-14% post neurosurgical - 4% trauma -3% meningitis (mainly peds) - 2% congenital heart disease - 2% other 7% Intracranial Epidural Abscess • Localized between dura and bone • sharply defined - mainly be dural adherence to bone at suture lines • focal osteomyelitis • associated with subdural empyema Spinal Epidural Abscess -source • Hematogenous spread – Skin infections – Parenteral infections (IVDA) – Bacterial endocarditis – UTI – Respiratory infection – Dental abscess Spinal Epidural Abscess -source • direct – decubitus ulcer – psoas abscess – trauma – pharyngeal infection – mediastinitis – pyelonephritis Spinal Epidural Abscess -source • Following spinal procedures – open procedure • for example disectomy – closed procedure • LP • Epidural catheter • No source in 50% of patients in some series Spinal Epidural Abscess - location • Cervical – 15% • Thoracic - 50% • Lumbar - 35% • Posterior to the Cord - 82% Parasitic Infections - Cysticercosis • Most common parasitic infection in CNS – Caused by larval stage of Taenia solium- pork tapeworm – Incubation period from months to decades • 83% of cases show symptoms within 7 years of exposure Parasitic Infections - Cysticercosis • Common routes of infection – Food (usually vegetables) or water containing eggs from human feces – Fecal - Oral autoinfection (poor sanitation habits) – Autoinfection from reverse peristalsis - (theory possibly offered by patients who autoinfected themselves) Parasitic Infections - Cysticercosis • cystercercus cellulosae - (3-20 mm) – regular round thin walled cyst, – produces only mild inflammation – larva in cyst • cystercercus racemosus - (4-12 cm) – active growing – grape like clusters – intense inflammation – no larva in cyst Parasitic Infections - Cysticercosis • Location: – meningeal 27-56% – parenchymal 30-63% – ventricular 12-18% (may cause hydrocephalus) – mixed - 23% • Clinical – symptoms of increased intracranial pressure Parasitic Infections - Cysticercosis • serology – antibody titers significant if 1:64 in the serum and 1:8 in the CSF • CT scan – ring enhancing / calcified lesions, multiple Fungal Infections • Cryptococcosis - most common fungal infection in CNS diagnosed in live patients – Cryptococcoma (mucinous pseudocyst) - occurs almost entirely in the HIV population – 3-10mm, most commonly in the basal ganglia • Candidiasis - most common fungal infection in CNS diagnosed in dead patients – rare in healthy individuals • Aspergillosis • Coccidiomycosis - normally causes meningitis