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Updated: Dec 12 2021

Brain Abscess

  • Snapshot
    • A 59-year-old man presents to the emergency department with a headache. He has never had headaches in the past and reports his headache worsens with cough. He describes his headaches as severe and located on the right-side of his head. His headaches are unresponsive to over the counter analgesics. Medical history is remarkable for recent manipulation of his ventriculoperitoneal shunt due to malfunction. Physical examination is notable for 4-/5 power in the left-sided upper extremity. An MRI brain with contrast demonstrates a ring enhancing lesion in the right primary motor cortex. Neurosurgery has been consulted for removal of the mass in order to time empiric antibiotic administration.
  • Introduction
    • Definition
      • focal purulent collection in the brain parenchyma
  • Epidemiology
    • Risk factors
      • infection of contiguous structures
        • otitis media
        • dental infection
        • mastoiditis
        • sinusitis
      • skull trauma or surgery (e.g., ventriculoperitoneal shunt)
      • endocarditis leading to hematogenous spread
      • immunocompromised state
  • Etiology
    • Pathogens include (note that infections are often polymicrobial)
      • Streptococcus (most common)
      • Staphylococcus aureus and epidermidis
      • gram-negative enteric organisms
  • Pathophysiology
    • Immune-mediated response to the microbial pathogen
  • Presentation
    • Symptoms
      • headache (main chief complaint)
    • Physical exam
      • fever (not a reliable clinical indicator)
      • focal neurological deficit (e.g., extremity weakness)
      • seizures
  • Imaging
    • MRI brain with contrast
      • indication
        • imaging study of choice in patients which there is a strong suspicion for brain abscess
          • CT head with contrast can also be used
      • findings
        • round-like encapsulated mass with central necrosis and surrounding edema
      • comment
        • differential diagnosis for a ring-enhancing lesion is MAGIC DR
          • Metastasis
          • Abscess
          • Glioblastoma
          • Infarct and inflammatory (e.g., neurocysticercosis and tuberculoma)
          • Contusion
          • Demyelinating disease
          • Radiation necrosis or resolving hematoma
  • Studies
    • Making the diagnosis
      • can be suggestive based on neuroimaging but confirmed with surgical removal and histopathology
  • Differential
    • Neurocysticercosis
      • differentiating factors
        • significantly elevated opening pressure
        • encapsulated yeast forms on India ink when testing the cerebral spinal fluid
    • Glioblastoma
      • differentiating factors
        • biopsy results demonstrate cellular polymorphism and microvascular proliferation with a central area of necrosis
  • Treatment
    • Medical
      • empiric antibiotics
        • indication
          • a component of the mainstay of treatment for brain abscess
        • medications
          • ceftriaxone or cefotaxime with metronidazole
            • vancomycin can be considered if the patient is at risk of developing Staphylococci infection (e.g., recent brain surgery)
    • Operative
      • neurosurgical removal
        • indication
          • a component of the mainstay of treatment for brain abscess
        • approach
          • stereotactic neurosurgical aspiration
          • surgical excision (less commonly used)
  • Complications
    • Seizures
    • Brain herniation
    • Ventriculitis secondary to abscess rupture and seeping in ventricles
    • Meningitis
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