1. Dr. Amanj Burhan specialist Neurosurgeon 8/25/20191Brain Abscess

2. INCIDENCE: ETIOLOGY MICROBIOLOGY PATHOGENESIS CLINICAL PRESENTATION DIAGNOSIS MANAGEMENT OUTCOME 8/25/20192Brain Abscess

3. INCIDENCE Is 1-2% of SOL in brain (USA) Is 8% (INDIA) Decreased incidence (because of antibiotic and improved life) Lastly increased incidence because of opportunistic infection in immune compromised patient. 8/25/20193Brain Abscess

4. ETIOLOGY 1.Infection : From PNS,middle ear and mastoid Characterized by solitary and located superficially Infection spread by either direct or through veins(thrombophlibitis of diploic vein) PNS (frontal and temporal lobe ) Middle ear (temporal lobe) mastoid (temporal lobe and cerebellum) 8/25/20194Brain Abscess

5. 2. Heamatogenous hematogenous dissemination microorganism from remote site of infection The abscess are multiple and deeply located Mostly located in the frontal and parietal lobe? Primary foci include (skin pustule,pulmonary infection, diverticulitis …etc. In Cyanotic cong. Heart dis. Brain abscess is leading cause of mortality and morbidity Most common type of CHD. Is TOF 50% Brain abscess in CHD are generally solitary 8/25/20195Brain Abscess

6. 3. Penetrating trauma : A. Penetrating trauma are seen occur soon or after years from trauma. Contaminated bone fragments and debris provide anidus for infection Bullet cause brain abscess or not ? 8/25/20196Brain Abscess

7. B. Basal skull fracture with CSF leak and meningitis cause post traumatic abscess Brain abscess from penetrating trauma is preventable or not? 8/25/2019Brain Abscess7

8. 4.Previous craniotomy Because of : A. Introduce of M.O.at time of surgery B. Spread of M.O. intracranialy through the wound C. Bone flap infection 5. Immune compromised person 8/25/20198Brain Abscess

9. MICROBIOLOGY Otogenic and dental infection caused by anaerobic organism Sinusitis caused by staph aureus, aerobic streptococci CHD caused by strep. SPP. In immune deficiency caused by fungus In AIDS by toxoplasma gondi Incidence of –ve culture is 25-30% 8/25/20199Brain Abscess

10. PATHOGENESIS AND HISTOPATHOLOGY OF BRAIN ABSCESS Preceding antibody formation there is an area of necrosis which is seeded by bacteria Brain abscess formation are 4 stages 1.stage I:early cerebritis (day 1 to day 3) characterized by necrotic tissue,local inflammatory response, marked edema This stage there is no demarcation between the lesion and surrounding brain 8/25/201910Brain Abscess

11. 2.stage two (late cerebritis)(day 4-10): characterized by : pus, maximum edema 3.stage three (early encapsulation)(day10—13) Capsule limits spread of infection Capsule develops slowly in medial wall of abscess? 4.Stage four: late capsule stage ( day 14 and on ) 8/25/201911Brain Abscess

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17. Clinical presentation : Occur in majorities in the first 2 decades of life Males more affected ( cause is unknown ) adults depend on immune status Infants : increase in head circumference, bulging fontanel, separation of cranial sutures, vomiting, irritability, seizures Signs of IICP and FND : 1. Edema 2.Cerebral tissue destruction 8/25/201917Brain Abscess

18. Symptoms : 1. Head ache ( 90 %) 2. Change in conscious level ( 60 %) 3. FND ( 60 %)  Parietal lobe : hemiparesis  Temporal lobe : dysphasia  Cerebellar : ataxia and nystagmus 4.Fever (more than 50 %) 5. Nausea and vomiting ( 50 %) 6. Seizure ( 50 %) 7.Papilledema and meningismus 8/25/2019Brain Abscess18

19. Laboratory findings 1.WBC : normal or mild increase 2.ESR : increase in 90% 3.CSF : not specific 1.Opening pressure 2.Protein 3.Glucose 4.Culture 8/25/2019Brain Abscess19

20. 4. radiological characteristic of brain abscess 1.Brain CTS with contrast ring enhancement Multi loculation Multiplicity Finding of gas 8/25/2019Brain Abscess20

21. MRI : T1 : necrotic center ( hypointence) Capsule ( hyperintence) Edema ( hypointence) T2 : necrotic center ( hyperintence) Capsule ( hypointence) Edema ( hyperintence 8/25/2019Brain Abscess21

22. Management 1.Antibiotic therapy : Antibiotic is mandatory and should given Antibiotics depends on C/S Imperial treatment depend on the etiology – Sinusitis : ( penicillin + metronidazole ) – Otitis : ( penicillin + metronidazole + 3rd generation cephalosporin) – Metastatic abscess :(metronidazole + 3rd generation cephalosporin) – Post traumatic abscess ( vancomycin) 8/25/2019Brain Abscess22

23. Advantage of antibiotic therapy Small size Deep seated Multiple 8/25/2019Brain Abscess23

24. 2. Aspiration : Advantages : 1.Confirm diagnosis 2.Remove of purulent material 3.Provide environment for antibiotics to work 4.Provide immediate relief of IICP Stereotactic guided aspiration 8/25/2019Brain Abscess24

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26. 3.Excision of brain abscess Advantages 1.Traumatic abscess ( contain foreign body and bone fragment ) 2.Fungal abscess 3.Gas containing abscess Disadvantages 8/25/2019Brain Abscess26

27. Follow up CT weekly during antibiotic therapy And then monthly CT 2-3 week decrease size of abscess 3-4 months complete resolution of abscess 6-9 months no residual contrast enhancement 8/25/2019Brain Abscess27

28. Outcome of abscess : Mortality influenced by ( herniation, rupture of abscess to the ventricle, clinical course of the patient, type of abscess, neurological state of patient at time of diagnosis) 8/25/2019Brain Abscess28

29. 1.Long term morbidity : ( seizure, FND, Cognitive dysfunction) 2.Recurrence: ( 5-10%) causes ( inadequate antibiotic therapy, incorrect choice of AB, presence of foreign body, failure to eradicate source of the abscess) 8/25/2019Brain Abscess29

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