Brain abscess and

Empyema

Dr. Sugandha Shrestha

Brain abscess
Brain abscess is a focal, suppurative infection
within the brain parenchyma.

An abscess forms when an area of cerebral

inflammation becomes necrotic and
encapsulated by glial cells and fibroblasts.

Edema around the abscess may increase

intracranial pressure.
Etiology
Originate from infection of contiguous
structures e.g otitis media, sinusitis,
mastoiditis, dental infections, subdural
empyema.

Secondary to hematogenous spread from a

remote site e.g cyanotic congenital heart
disease, IV drug abuse, bacterial endocarditis.

The infection may also be introduced through

a skull fracture following a head trauma or
surgical procedures.
Bacterial cause
Staphylococci -------------- Cranial trauma
Neurosurgery
Endocarditis

Enterobacteriaceae -------Chronic ear

infections

Toxoplasma gondii ------- HIV-infected

Pathophysiology
brain abscesses have led to a four-stage:
Early cerebritis stage : Direct inoculation of
bacteria into brain parenchyma results in focal
inflammation and edema. And develops in the
first 1 to 3 days after inoculation .
late cerebritis : Typically, there is neutrophil
accumulation, edema, and some tissue
necrosis. Astrocytes and microglia are
activated early on, and this activation persists
afterward. The area of cerebritis expands and
a necrotic center develops on days 4 to 9 .
Macrophages and lymphocytes predominate in
the infiltrate .

Early capsule stage : The third stage is
characterized by the development of a capsule
that is vascularized and ring enhancing on CT
scan, days 10 to 14.

Late capsule stage: In the fourth stage, the

host immune response causes the capsule to
wall off, and there is destruction of some
surrounding healthy brain tissue in an attempt
to sequester the infection.
Clinical manifestation
The clinical presentation depends upon on :
location
nature of primary infection
level of ICP.

1.Acc/to location
Frontal lobe abscess: hemiparesis

Temporal lobe abscess: disturbance of

language (dysphagia)
Cerebellar abscess: ataxia
Symptoms
2.The classic clinical traid:
Severe headache

High grade fever

Focal neurologic deficit.

3.Symptoms of increased intracranial pressure:
Headache nausea
vomiting lethargy
Seizures personality changes
papilledema
Diagnosis
contrast-enhanced MRI or, if unavailable,
contrast-enhanced CT is done.

A fully developed abscess appears as an

edematous mass with ring enhancement,
which may be difficult to distinguish from a
tumor or occasionally infarction.

CT-guided aspiration, culture, surgical excision,

or a combination may be necessary.
 Culture results help direct antibiotic
therapy.

Lumbar puncture is not done because it

may precipitate transtentorial herniation
and CSF findings are nonspecific.
Differential diagnosis
Bacterial meningitis
Brain cancer (primary or metastatic)
Cryptococcosis
Cysticercosis
Epidural Abscess
Mycotic aneurysm
Septic cerebral emboli causing infarction
Septic Dural sinus thrombosis
Treatment
Before the abscess has become encapsulated
and localized, antimicrobial therapy,
accompanied by measures to control
increasing intracranial pressure, is essential.

Once an abscess has formed, surgical excision

or drainage combined with prolonged
antibiotics (usually 4-8 wk) remains the
treatment of choice.
 If streptococci : high dose of penicillin G or 3rd
generation cephalosporin e.g ceftriaxone or
cefotaxime.
Metronidazole to cover penicillin resistant
anaerobes i.e gram ve bacilli.
If S.aureus : vancomycin and metronidazole
If Pseudomonas aeruginosa: Cefepime or
ceftazidime
T gondii infection is treated with
pyrimethamine and sulfadiazine.
Complications
Reoccurring brain abscesses
Brain damage :
Mild brain damage: headache and memory
problems.
Moderate brain damage: changes in mood, problems
with tasks that require high-level thinking, ataxia.
Severe brain damage: weakness in certain parts of
the body, coma or persistent vegetative state.
Epilepsy
Meningitis
Prognosis
Death occurs in 10-20%.
Early treatment and the patient's overall
health have an effect on prognosis.
Other factors include: antibiotic resistance or
the abscess location.

An abscess deep within the brain is more

difficult to treat than others.
Subdural Empyema
Subdural empyema
Subdural empyema is an intracranial focal
collection of purulent material located
between the dura mater and the arachnoid
mater.
About 95% of subdural empyemas are located
within the cranium.
Mostly involve the frontal lobe.
Subdural empyema is a life-threatening
infection.
Etiology
Aerobic and anaerobic streptococci,
staphylococci, enterobacteriacae and anaerobic
bacteria are most common causative organism.

Staphylococci and gram negative bacilli are

common causative organism for head trauma
and neurosurgical procedure.

Recent history (< 2 wk) of sinusitis, otitis media,

mastoiditis, meningitis, cranial surgery or
trauma, sinus surgery, or pulmonary infection.
Clinical manifestations
Fever
Headache - Initially focal and later generalized
Confusion, drowsiness, stupor, or coma
Hemiparesis or hemiplegia
Seizure - Focal or generalized
Nausea or vomiting
Blurred vision
Speech difficulty (dysphasia)
History of intracerebral abscess (recent or in
the past)
Diagnosis
CBC blood count : >white blood cells and ESR
may be elevated, consistent with infection.
Blood is often cultured for bacteria.
MRI and/or CT with contrast can help to
identify the fluid-filled mass lesion in the
subdural space and associated swelling.
Ultimately, open surgical sampling of the
purulent material can allow the causative
bacteria to be cultured and identified.
LP: to r/o meningitis.
Differential diagnosis
Acute Subdural Hematoma
Benign Skull Tumors
Cavernous Sinus Syndromes
Cerebral Aneurysms
Intracranial Hemorrhage
Meningitis
Benign Positional Vertigo
Treatment
Antibiotic treatment:
adequate for small subdural empyema (ie, <
1.5 cm diameter).
patients with major contraindications to
surgery or significant mortality risks.
surgical treatment:
surgical drainage and debridement is usually
the best treatment option.
provides the opportunity to sample the
infected material to isolate and identify the
bacteria.
The end