Infeksi SSP

Abses Serebri
PENDAHULUAN
Topik yang aktual, berhubungan dgn
morbiditas dan perkembangan obat
(antibiotika)
Negara berkembang mempunyai insidensi
lebih tinggi dibanding negara maju

Insidensi
3-4 / 1 juta penduduk
USA : 1,1 / 100.000 penduduk/tahun
Case fatality ratio 37%
Male : female = 2:1
Faktor Resiko
Cyanotic congenital heart disease
Infeksi Otorhinolaryngologic seperti ; sinusitis, mastoiditis, and chronic otitis media
Meningitis (khususnya pada neonatus)
Penetrating head trauma
Surgical manipulation of the brain (ventriculoperitoneal shunts, tumor removal)
Esophageal manipulation (sclerotherapy or dilation)
Cystic fibrosis
Infeksi gigi (Dental infections)
Infeksi paru (Lung infections)
Infeksi lain (osteomyelitis, orbital, cellulitis, urinary tract infections)
Pasen dengan riwayat mengunjungi daerah endemik neurocysticercosis (Latin
America, parts of Africa, Asia, dan Indian subcontinent)
Congenital atau acquired immunocompromised patients (HIV/AIDS)
Etiologi yang tidak jelas terjadi pada 30% pasen

Etiologi
Bakteri merupakan penyebab tersering
Streptococcus spp. , Staphylococcus spp. Sering ditemukan pada
kultur
Pada Neonatus dapat terjadi abses esp. Gram-negative meningitis
(Proteus, Citrobacter, and Enterobacter).
Single organism ditemukan pada ~70% pasen
Anaerobic organisms (Bacteroides, Peptostreptococcus,
Fusobacterium, Propionibacterium, Actinomyces, Veillonella, and
Prevotella)
30% specimens steril
Infeksi parasit sering disebabkan Taenia solium (neurocysticercosis)
Fungi dan protozoa seing ditemukan pada pasen
immunocompromised

Patofisiologi
HEMATOGENOUS SPREAD
Dewasa: lung abscess (the
most common). bronchiectasis
and empyema
Anak: congenital cyanotic
heart disease (CCHD) (4-7%).
Esp. tetralogy of Fallot.
pulmonary arteriovenous
fistulas: ~ 50% dikenal sebagai
sindroma Osler-Weber Rendu
(AKA hereditary hemorrhagic
telangectasia)
bacterial endocarditis
dental abscess
GI infections
CONTIGUOUS SPREAD
1. Dari sinusitis purulen:
penyebaran lokal
osteomyelitis or by phlebitis
of emissary veins.
middle-ear and mastoid air
sinus infections ~ temporal
lobe and cerebellar abscess.
nasal sinusitis ~ frontal lobe
abscess
sphenoid sinusitis
2. odontogenic
Brain Abscess - signs & symptoms

Brain Abscess - history
The location of the brain abscess or abscesses will often influence the
history of presentation and physical exam.
Fever, headache and vomiting each occur ~6070% of cases.
Classic triad of fever, headache, and focal neurologic findings occurs in
<30% of cases.
Headache is the most common complaint.
Average duration of symptoms prior to diagnosis is 4 weeks.
Vomiting and mental-status changes can often be the presenting chief
complaints.
Neonates will often have a history of meningitis before developing a brain
abscess.
Questions should focus on acute or chronic otolaryngologic infections such
as sinusitis, chronic otitis media, and mastoiditis, as well as a history of
cholesteatomas.
Cyanotic congenital heart disease should be determined, as well as
partially repaired cyanotic congenital heart disease.


Brain Abscess - physical exam
Neonates may present with a full fontanel,
increasing head circumference, seizures, or
vomiting.
Older children may have signs of a focal
neurologic deficit, hemiparesis, or even
papilledema.
Meningeal symptoms occur in ~30% of patients.
Ataxia may be found with cerebellar lesions.

Histological Staging
Stage 1
early cerebrjtjs: (days 1-3) early infection & inlIammation,
poorly demarcated from surrounding brain, toxic changes in
neurons, perivascular infiltrafes

Stage 2
late cerebritis: (days 4-9) reticular matrix (collagen precursor) &
developing necrofic center
Stage 3
early capsule: (days 10-13) neovascularity, ne-erotic center, reticular
networK surrounds (less well developed along side facing ventricles)

Stage 4
(> day 14) collagen capsule, ne-erotic center, gliosis around capsule
EVALUATION

BLOODWORK
Leukositosis atau normal : meningkat pada
6070% kasus (biasanya > 10,000)
Blood cultures: biasanya negative
Eritrosit: normal
C-reactive protein (CRP): Sensitivity is -90%,
specificity is 77%

Lumbal punksi
Tidak spesifik untuk abses serebri
Tekanan meningkat
Pleiositosis polinuklearis 25 - 300
Jumlah protein meningkat dari normal
Kadar CL & glukosa normal
Bila kronis jumlah sel menurun lebih sering
ditemukan limfosit dari pada PMN
CT Scan :
tanpa kontras area hipodens = liquor
Kontras terlihat cincin/ring enhancement
(densitas meningkat)
Sering dikelilingi edema hebat (densitas
menurun)
Lokasi temporal & oksipital white matter
EEG : gelombang lambat 3x/sec
MRI
Brain Abscess - differencial diagnosis

Infectious:
Meningitis
Encephalitis
Subdural empyema
Epidural abscess
Vascular:
Venous sinus thrombosis
Migraine
Cerebral infarct
Cerebral hemorrhage
Miscellaneous:
Primary or secondary tumor
Pseudotumor cerebri
Hydrocephalus

Brain Abscess - TREATMENT

Broad-spectrum antibiotics should be started at the time of diagnosis, until identification of
the micro-organism is determined. At that time, the antibiotics can be tailored to the
offending micro-organism.
Most brain abscesses are removed surgically. A few may require CT-guided aspiration.
MRI or CT guided stereostatic aspiration is encouraged.
When multiple abscesses are found on CT scan, 1 lesion should be aspirated to identify the
micro-organism.
Some patients are managed successfully with antibiotics alone.
Antiparasitic medications are controversial in the treatment of neurocysticercosis.
Antifungals should be considered for immunocompromised patients.
The use of steroids is controversial.
If a patient is manifesting signs and symptoms of increased intracranial pressure (Cushing
triad: Bradycardia, hypertension, and abnormal respirations) or if the patient is comatose and
is unable to protect his or her airway, the patient should be intubated, hyperventilated, and
given mannitol.
Patients with unknown predisposing factors should be evaluated by cardiology, dental, and
otorhinolaryngology. Immunology should be considered in children with significant medical
histories of chronic infections.

MEDICAL TREATMENT
In general, surgical drainage or excision is employed in the treatment. Purely medical
treatment of ~ abscess (cerebritis stage)',

Medical therapy alone is more successful if:
1. treatment begun in cerebritis stage (before complete encapsulation), even though many of
these lesions subsequently go on to become encapsulated
2.small lesions: diameter of abscesses successfully treated with antibiotics alone were 0.8-2.5 em
0.7 mean). Those that failed were 2-6 em (4.2 mean). 3 cm is suggested as a cutoff , above
this surgery should be included
3. duration of symptoms s 2 wks (correlates with cerebritis stage)
4.patients show definite clinical improvement within the first week
Medical management alone considered if:
1. poor surgical candidate (NB: with local
anesthesia, stereotactic biopsy can be done in
almost any patient with normal blood clotting)
2.multiple abscesses, especially ifsmall
3.abscess in critical location: e.g. dominant
hemisphere or brain stem"
4.concomitant meningitis/ependymitis
5.hydrocephalus requiring shunt that could become
infected in surgery

SURGICAL TREATMENT
Indications for initial ~treatment include:
1. significant mass effect exerted by lesion on CT
2. difficulty in diagnosis (especially in adults)
3. proximity to ventricle: indicates likelihood of intraventricular rupture which
is associated with poor outcome
4. evidence of significantly increased intracranial pressure
5. poor neurologic condition (patients responds only to pain, or does not even
response
to pain)
6. traumatic abscess associated with foreign material
7. fungal abscess
8.multiloculated abscess
9. CT scans cannot be obtained every 1-2 weeks
Brain Abscess - FOLLOW UP

A delay in diagnosis or performing a lumbar puncture
for suspected meningitis increases mortality and
morbidity.
With the advent of CT and MRI scans, the mortality
rate has dropped from ~30% to <14%.
Multiple abscesses, coma on presentation, <2 years of
age, performance of a lumbar puncture, and rupture of
abscess into the ventricle carry a higher mortality rate.
3040% of patients have some morbidity. This ranges
from seizures, hemiparesis, focal neurologic deficits, or
hydrocephalus to cognitive/behavior problems.