1. 1 Journal Reading 報告者： MR 陳航正 指導醫師： MA 吳孟書 2008/12/30

2. 2 Topic 1

3. 3 Post-traumatic brain abscess: experience of 36 patients –British Journal of Neurosurgery (1995) 9, –R. PATIR, S. SOOD & R. BHATIA –Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences

4. 4 Clinical materials and methods Retrospective analysis of 36 consecutive patients with post-traumatic brain abscess from 1971 to 1989 9.3% of total 384 patients with brain abscess

5. 5 Clinical materials and methods An abscess was considered a sequel of the injury if there was –With hx of head injury with los of consciousness –An obvious clinical compounding –A fracture of the skull

6. 6 Definition Externally compound injury –Scalp laceration overlying a fracture with or without CSF leak leakage, brain herniation through the wound or presence of an intracranial foreign body Internally compound injury –Bled from the ear, nose or mouth –CSF otorrhea, or rhinorrhea –Intracranial air on radiograph or CT –Absence of external compounding

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9. 9 Results

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15. 15 Discussion In 10 patients it was indisputably a closed head injury –Possible that small lacerations or punctured wounds may have been overlooked Organisms cultured from the abscess were similar from closed and compound injuries-> S. aureus most common Interval between injury and presentation with an bscess was 113 days

16. 16 Discussion Externally compound injury developed earlier than those with closed injuries –Maybe realted to presence of necrotic brain and external detris promote abscess formation The interval between injury and presentation with an abscess was 113 days –Absence of virulent anaerobic bacteria nad liberal use of anti following injury

17. 17 Topic 2

18. 18 Management of brain abscesses in children –Neurosurg Focus 24 (6):E8, 2008 –JAMES L. FRAZIER, M.D., EDWARD S. AHN, M.D., AND GEORGE I. JALLO, M.D. –Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland

19. 19 Predisposing Factors The cause of the abscess is unknown in 15– 30% of cases Common predispos-ing factors include hematogenous dissemination, contigu-ous infection, and penetrating head injuries Infants and toddlers are more susceptible as complications of bacterial meningitis or bacteremia Complication of neurosurgical procedures in 8– 10%

20. 20 Predisposing Factors Developing countries: leading cause is chronic suppurative otitis media The prevalence of brain abscesses in children with cyanotic congenital heart disease is 6– 51% Patients diagnosed with a brain abscess, 30– 34% haveunderlying heart defects Pronounced right-to-left shunting secondary to cardiac defects increases the risk of brain abscesses via paradoxical emboli

21. 21 Predisposing Factors Hematogenic metastatic brain abscesses: Endocarditis, bacteremia, chronic pulmonary infections, bronchiectasis,immunodeficiency, osteomyelitis contiguous spread of infection into brain: Otitis media, sinusitis, mastoiditis, dental infections, and meningitis Penetrating head injuries -> retained debris and/or bone fragments can serve as a nidus of infection

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23. 23 Clinical Presentation and Diagnosis Clinical signs and symptoms contingent on the location and size of the lesion, presence of surrounding edema, virulence of the infectious microorganisms, and signs of infection Some authors have reported fever, headache, seizures, and emesis as the predominant symptoms in children with brain abscesses

24. 24 Clinical Presentation and Diagnosis Elevated WBC, ESR, CRP could be found A mass effect associated with brain abscesses is a strong contraindication for lumbar puncture Blood cultures are infrequently positive for bacteria, but should be obtained in all cases

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26. 26 Imaging Diagnosis of Brain Abscesses The abscess typically has a hypodense center with ring enhancement on contrast-enhanced CT sensitivity of CT between 95 and 99% specificity of CT is decreased because of difficult differentiating from tumors, cysticercosis, tuberculomas, or some vascular lesions

27. 27 Imaging Diagnosis of Brain Abscesses The advantages of MRI over CT: better differentiation of edema from liquefactive necrosis, greater sensitivity for early satellite lesions, and more sensitivity in early cerebritis Hypointense on T1-weighted and Hyperintense on T2-weighted Images

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29. 29 Microbiological Characteristics Culture via aspiration orcraniotomy can play a significant role in the diagnosis Pathogens vary depend on different underlying source of infection Gram-positive cocci such as Staphylococci, Streptococci, and Peptostreptococci spp. Are the most common Gram-negative bacilli, including Klebsiella, Escherichia coli, Salmonella Bacteroides, Haemophilus, and Proteus spp.

30. 30 Medical Management Systemic treatment with antibiotic agents plays a critical role, minimum 6 to 8 week course of intravenous antibiotics In patients who are treated by nonsurgical means only, broad-spectrum antibiotics would be needed steroids is considered when there is mass effect secondary to significant cerebral edema leading to neurological deficits and/or impending herniation

31. 31 Surgical Management Stereotactic Aspiration –Diagnostic and theraputic –Typically abscess >2.5cm required surgery Craniotomy –Image-guided stereotactic craniotomy considered in fungal or multiloculated abscesses, or failed multiple aspiration –Intraventricular rupture, peri-ventricular enhancement suggest debridement Neuroendoscopy

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34. 34 Management of Recurrent Brain Abscesses Abscess recurrence has been found to be more common after aspiration than surgical extirpation Incidence after stereotactic aspiration ranges from 3–25% compared with 0–6% after excision Medical management alone of large abscesses is usually inadequate and tends to lead to recurrence

35. 35 Role of Imaging During Treatment Interval CT or MR images should be obtained in evaluate the efficacy of treatment Complete resolution of the abscess and associated abnormal contrast enhancement may take up to 12–16 weeks Small area of residual contrast enhancement may last 6 months The size of the abscess decreases in 1–4 weeks with antibiotic therapy alone or in combination with stereotactic aspiration

36. 36 Prognosis Current motality rate: 4-12% range Poor prognosis –multiple deep-seated abscesses –ventricular rupture –congenital heart disease –hydrocephalus, –poor neurological status –associated meningitis –neonates and infants

37. 37 Thanks for your attention