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Brain abscess

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Synonyms and keywords: Intracranial abscess, cerebral abscess, CNS abscess

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal bone, epidural abscess) or remote (lung, heart, kidney etc.) infectious sources within the brain tissue. The infection may also be introduced through a skull fracture following a head trauma or surgical procedures. Although underlying pathology (tumor, blood, etc.) can sometimes be a nidus for infection, the majority of cases occur in a previously healthy brain. Brain abscess is usually associated with congenital heart disease in young children. It may occur at any age but is most frequent in the third decade of life. Due to advanced treatments of the ear, sinus, and orofacial infections, brain abscess occurrences are now rare, only present in about 1,500 to 2,500 infections each year in the United States. If left untreated, a brain abscess can be fatal. Common complications include abscess rupture, hydrocephalus, and brain herniation. With treatment, the mortality rate decreases to about 10% of the population.

Historical Perspective

Prior to the 1800s, brain abscesses were almost uniformly fatal, and were rarely diagnosed preceding an autopsy. French surgeon S.F. Morand was the first to complete a successful drainage of a brain abscess during the 16th century. It was not until the late 19th century that methodical developments of surgery were available to treat these abscesses.

Pathophysiology

Brain abscesses are usually polymicrobial in nature. Infected brain cells, white blood cells, live and dead bacteria, and fungi collect in an area of the brain. Although underlying pathology (tumor, bloodetc.) can sometimes be a nidus for infection. Bacterial abscesses rarely arise de novo within the brain. The most common organism recovered from cultures is the bacterium Streptococcus. A wide variety of other bacteria may cause brain abscess; these include Proteus, Pseudomonas, Pneumococcus, Meningococcus, and Haemophilus.

Causes

The majority of cases of brain abscess are due to infections with either bacteria or fungi. Common causes of brain abscess include Cryptococcus neoformans, Staphylococcus aureus, Toxoplasma gondii, and Viridans streptococci. The germs that cause a brain abscess usually reach the brain through the blood. Germs may also travel from a nearby infected area (such as an ear infection), can enter the body during an injury (from a gun or knife wound), or result from surgery.

Differentiating brain abscess from other Conditions

Brain abscess must be differentiated from metastatic tumors, necrotic tumors, and lymphomas. The true diagnosis for a brain abscess is sometimes not determined until biopsy.

Epidemiology and Demographics

There has been a remarkable shift in the epidemiology of brain abscesses over the past several years. Traditionally, and still the case in underdeveloped countries, most brain abscesses are due to under-treated otitis and sinusitis. More recently, especially in the U.S., more cases are being seen in immunocompromised patients. The prevalence of brain abscess accounts for approximately 1 in 10,000 hospital admissions.

Risk Factors

Common risk factors in the development of brain abscesses are immunodeficiency, chronic diseases, and congenital heart diseases. In adults, drugs that suppress the immune system and a weakened immune system are prevalent risk factors. In children, sinusitis and otitis are seen with greatest frequency.

Natural History, Complications, and Prognosis

Common complications include abscess rupture, hydrocephalus, and brain herniation. With treatment, the mortality rate decreases to about 10% of the population. Early detection and treatment is preferential. After surgery, some patients can experience long-term neurological problems. While the mortality rate was 40% in 1960, it has dropped down to 15% within the past decade alone. About 70% of patients with brain abscesses have a good outcome, rarely with minimal neurological sequelae.

Diagnosis

History and Symptoms

A complete history will help determine the correct therapy and helps in determining the prognosis. Specific areas of focus when obtaining a history from the patient include a history of a clinical triad of fever, headaches, and focal neurological deficits and immunosuppression. The symptoms and findings depend largely on the specific location of the abscess in the brain. Most symptoms are caused by a combination of increased intracranial pressure from space-occupying lesions (headache, vomiting, confusion, coma) or infection (fever, fatigue etc.)

Physical Examination

Patients with brain abscess generally appear healthy. Most findings are neuromuscular in nature. Significant findings on physical examination include significant derangements in vital signs, including high-grade fever and dysarthria. Aphasia ataxia are two common neuromuscular examinations.

Laboratory Findings

Most laboratory tests are not diagnostic for brain abscess. In 25% of findings, the cerebrospinal fluid CSF is normal or shows unspecific changes. An increase of the erythrocyte sedimentation rate (ESR) has also been associated with brain abscess. Some patients have been seen to herniate after CSF procedure. It is difficult to isolate the pathogens from the CSF.

CT

The diagnosis of brain abscess is established by a computed tomography (CT) (with contrast) examination. The CT scan can detect edema, hydrocephalus, midline shifts, or ventricular ruptures.

MRI

Magnetic resonance imaging (MRI) is the diagnostic procedure of choice to diagnose a brain abscess. MRI scans appear more sensitive than CT for detecting cerebral edema and early changes correlated to a brain abscess because they can stage the abscess and gauge the response to therapy with more accuracy.

Electrocardiogram

An electrocardiogram (EEG) can also be used to diagnose a brain abscess by providing detailed information in regards to localization of the abscess. In most cases, the result is abnormal in patients as the brain abscess lateralizes to the side of the lesion.

Treatment

Medical Therapy

The treatment of brain abscess includes prompt administration of antimicrobial therapy and occasionally drainage to reduce the mass effect. Neurosurgery should always be consulted upon diagnosis. The decision of whether to surgically drain, aspirate, or simply administer antimicrobial therapy depends on the number of abscesses, their size, and their location.

Surgery

If the size of the brain abscess exceed 2.5 cm in diameter, surgery is the mainstay treatment. Otherwise, the decision to drain the tumor surgically vs. aspiration is again based on the number of abscesses in respect to their size and location.

Prevention

Primary preventive strategies for brain abscess include antibiotics, treatment for sinusitis, and highly active antiretroviral therapy for patients with HIV. Secondary prevention for brain abscess include continued treatment of predisposing causes in appropriate patients.

References

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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

During the 16th century, French surgeon S.F. Morand was the first to complete a successful drainage of a brain abscess. Hippocrates was one of the first authors to explore the findings that ear infections, an event associated with brain abscesses, could progress to delirium and death. It was not until the late 19th century that methodical developments of surgery were available to treat these abscesses.[1]

Historical Perspective

Important landmarks in the history of brain abscess include the following:[1][2][3]

  • 1752: The first successful drainage by S.F. Morand.
  • 1893: Publication of William Macewan’s Monograph of Pyogenic Infective Diseases of the Brain and Spinal Cord, the most comprehensive study of pyogenic brain diseases and surgical prevention of its time.
  • 1924: The first marsupialization method was introduced by King.
  • 1928: Dr. Percy Sargent introduced the procedure of enucleation on an encapsulated brain abscess.
  • 1971: Dr. Heineman and colleagues introduced successful medical management of brain abscesses.

References

  1. ↑ 1.0 1.1 Brain Abscess. MedMerits (2011). http://www.medmerits.com/index.php/article/brain_abscess Accessed on October 7, 2015
  2. ↑ Canale DJ (1996). “William Macewen and the treatment of brain abscesses: revisited after one hundred years”. J Neurosurg. 84 (1): 133–42. doi:10.3171/jns.1996.84.1.0133. PMID 8613822.
  3. ↑ Bavelloni A, Piazzi M, Raffini M, Faenza I, Blalock WL (2015). “Prohibitin 2: At a communications crossroads”. IUBMB Life. 67 (4): 239–54. doi:10.1002/iub.1366. PMID 25904163.

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

Brain abscesses are usually polymicrobial in nature. Swelling and irritation (inflammation) develop in response to this infection. Infected brain cells, white blood cells, live and dead bacteria, and fungi collect in an area of the brain. Tissue forms around this area and creates a mass. While this immune response can protect the brain by isolating the infection, it can also do more harm than good. Infected material can block the blood vessels of the brain. Although underlying pathology (tumor, blood etc.) can sometimes be a nidus for infection, the majority of cases occur in a previously healthy brain.

Pathophysiology

Pathogenesis

The location of the primary lesion may be suggested by the location of the abscess. It depends on the source of infection, as does the specific microbial flora. Roughly 25% of brain abscess result from hematogenous seeding from extra-cranial infection. Penetrating trauma accounts for nearly 10% of cases. About 20 to 30% of cases are iodiopathic, and no obvious focus can be identified. Common locations include:[1][2][3]

  • Infections of the middle ear result in lesions in the middle cranial fossal.
    • Approximately 47% of cases arise from a contiguous infection, most commonly in the middle ear, the paranasal sinuses and teeth.
  • Posterior cranial fossae
  • Congenital heart disease with right-to-left shunts often result in abscesses in the distribution of the middle cerebral artery.
  • Infection of the Frontal and Ethmoid sinuses usually results in collection in the subdural sinuses.

The most common organism recovered from cultures is the bacterium Streptococcus. A wide variety of other bacteria may cause brain abscess. These include:[4]

  • Organisms that are most frequently-associated with brain abscess in patients with AIDS are Mycobacterium tuberculosis, Toxoplasma gondii and Cryptococcus neoformans, though in infection with the latter organism, symptoms of meningitis generally predominate.
  • Bacterial abscesses rarely (if ever) arise de novo within the brain. There is almost always a primary lesion elsewhere in the body that must be sought assiduously, because failure to treat the primary lesion will result in relapse. In cases of trauma, for example in compound skull fractures where fragments of bone are pushed into the substance of the brain, the cause of the abscess is obvious. Similarly, bullets and other foreign bodies may become sources of infection if left in place.[4]

Gross Pathology

Experimental models have identified four stages for abscess formation. These include:

  • Early cerebritis (days 1 – 3): focal inflammation and edema
  • Late cerebritis (days 4 – 9): development of a necrotic center
  • Early capsular (days 10 – 14): formation of a well-vascularized, ring-enhancing capsule with peripheral gliosis and/or fibrosis
  • Late capsular: (after 2 weeks): formation of a well-formed fibrous capsule

References

  1. ↑ Macewan W (1893). Pyogenic Infective Diseases of the Brain and Spinal Cord. Glasgow: James Maclehose and Sons.
  2. ↑ Ingraham FD, Matson DD (1954). Neurosurgery of Infancy andChildhood. Springfield, Ill: Charles C Thomas. p. 377.
  3. ↑ Raimondi AJ, Matsumoto S, Miller RA (1965). “Brain abscess in children with congenital heart disease”. J Neurosurg. 23: 588&ndash, 95.
  4. ↑ 4.0 4.1 “Brain abscess – Wikipedia, the free encyclopedia”.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2]

Overview

The majority of cases of brain abscess are due to infections with either bacteria or fungi. Common causes of brain abscess include Cryptococcus neoformans, Staphylococcus aureus, Toxoplasma gondii, and Viridans streptococci.

Causes

Brain abscesses commonly occur when bacteria or fungi infect part of the brain. The source of the infection, however, is often not found. The germs that cause a brain abscess usually reach the brain through the blood. Germs may also travel from a nearby infected area (such as an ear infection), can enter the body during an injury (from a gun or knife wound), or result from surgery. Though not as often, a heart infection can also be a cause of brain abscesses.[1][2]

Common Causes

Causes by Organ System

Cardiovascular Atrial septal defect, bacterial endocarditis, cyanotic congenital heart disease, Ebstein’s anomaly of the tricuspid valve, endocarditis, infective endocarditis, prosthetic heart valve, pulmonary arteriovenous malformation, ventricular septal defect
Chemical/Poisoning No underlying causes
Dental Dental braces, dental extraction, dental sepsis, tooth infection
Dermatologic Hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome
Drug Side Effect Chronic steroid use, intravenous drug use
Ear Nose Throat Cholesteatoma, ear infection, hereditary hemorrhagic telangiectasia, mastoiditis, Osler-Weber-Rendu syndrome, sinusitis, suppurative otitis media
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic Amebic dysentery, cystic fibrosis, intra-abdominal infection
Genetic Cystic fibrosis, hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome
Hematologic No underlying causes
Iatrogenic Esophageal dilatation, neurosurgery, organ transplant, ventriculoperitoneal shunt
Infectious Disease Actinobacillus actinomycetemcomitans, actinomyces, actinomycosis, aggregatibacter actinomycetemcomitans, amebic dysentery, amoebiasis, anaerobic bacteria, aspergillosis, aspergillus, bacterial endocarditis, bacterial meningitis, bacteroides, candida albicans, Chagas disease, cladosporium trichoides, clostridium, coccidioides immitis, congenital listeriosis, corynebacterium, cryptococcus neoformans, curvularia, cysticercosis, empyema, endocarditis, entamoeba histolytica, enterobacter, enterobacteriaceae, enterococcus, erysipelothrix rhusiopathiae, escherichia coli, fungi, fusobacterium, group B streptococcal infection, haemophilus aphrophilus, haemophilus, HIV, infective endocarditis, intra-abdominal infection, klebsiella pneumoniae, klebsiella, Lemierre’s syndrome, listeria, listeriosis, lung abscess, mastoiditis, mucorales, mucormycosis, mycobacterium tuberculosis, mycoplasma hominis, nocardia, nocardiosis, opportunistic infections, orbital cellulitis, paragonimus, parasites, peptococcus, peptostreptococcus, prevotella, propionibacterium, proteus, pseudomonas, pyomyositis, rhodococcus equi, salmonella, scedosporium apiospermum, schistosoma japonicum, sinusitis, staphylococcus aureus, staphylococcus epidermidis, streptococcus milleri, streptococcus pneumoniae, streptococcus, suppurative otitis media, tooth infection, toxoplasma, upper respiratory tract infections, urinary tract infection, viridans streptococci, wound infections
Musculoskeletal/Orthopedic No underlying causes
Neurologic Bacterial meningitis, brain surgery, brain tumor, cholesterol granuloma, foreign body aspiration, hereditary hemorrhagic telangiectasia , neurological disorders related to AIDS, neurosurgery, Osler-Weber-Rendu syndrome, skull fracture, traumatic brain injury
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic Brain tumor, cholesterol granuloma, hematogenous spread, neoplasms
Ophthalmologic Orbital cellulitis
Overdose/Toxicity Chronic steroid use, drug abuse, intravenous drug abuse
Psychiatric No underlying causes
Pulmonary Bronchiectasis, cystic fibrosis, empyema, foreign body aspiration, lung abscess, mycobacterium tuberculosis, upper respiratory tract infections
Renal/Electrolyte Urinary tract infection
Rheumatology/Immunology/Allergy Immunodeficiency
Sexual No underlying causes
Trauma Head trauma, penetrating head trauma, puncture wound to brain, skull fracture, traumatic brain injury
Urologic Urinary tract infection
Miscellaneous Alcoholism, near drowning, ventriculoperitoneal shunt

Causes

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References

  1. ↑ Tunkel AR. Brain abscess. In: Bennett JE, Dolin R, Blaser MJ, eds.Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases
  2. ↑ Tunkel AR, Scheld WM. Brain abscess. In: Winn HR, ed.Youman’s Neurological Surgery
  3. ↑ Saghrouni F, Ben Youssef Y, Gheith S, Bouabid Z, Ben Abdeljelil J, Khammari I; et al. (2011). “Twenty-nine cases of invasive aspergillosis in neutropenic patients”. Med Mal Infect. 41 (12): 657–62. doi:10.1016/j.medmal.2011.09.011. PMID 22036518.
  4. ↑ 4.0 4.1 Wu PC, Tu MS, Lin PH, Chen YS, Tsai HC (2014). “Prevotella brain abscesses and stroke following dental extraction in a young patient: a case report and review of the literature”. Intern Med. 53 (16): 1881–7. PMID 25130130.
  5. ↑ Clifton TC, Kalamchi S (2012). “A case of odontogenic brain abscess arising from covert dental sepsis”. Ann R Coll Surg Engl. 94 (1): e41–3. doi:10.1308/003588412X13171221499667. PMC 3954226. PMID 22524927.
  6. ↑ 6.0 6.1 Sveinsson OA, Asgeirsson H, Olafsson IH (2013). “[Brain abscess – overview]”. Laeknabladid. 99 (1): 25–31. PMID 23341403.
  7. ↑ 7.0 7.1 7.2 Patel K, Clifford DB (2014). “Bacterial brain abscess”. Neurohospitalist. 4 (4): 196–204. doi:10.1177/1941874414540684. PMC 4212419. PMID 25360205.
  8. ↑ Cano P, Horseman MA, Surani S (2010). “Rhinocerebral mucormycosis complicated by bacterial brain abscess”. Am J Med Sci. 340 (6): 507–10. doi:10.1097/MAJ.0b013e3181f0aad1. PMID 20861715.
  9. ↑ Mays R, Gordon R, Wilson JM, LaPolla WJ, Sra KK, Madkan V; et al. (2012). “Persistent erythematous plaque after minor trauma in an immunocompromised woman”. Dermatol Online J. 18 (4): 2. PMID 22559017.

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Differentiating Brain abscess from other Diseases

Differentiating Brain abscess from other Diseases


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

Brain abscess must be differentiated from metastatic tumors, necrotic tumors, and lymphomas.[1][2]

Differential Diagnosis

Brain abscess must be differentiated from:

Metastatic Tumor

  • The big differential is that the abscess is often located in watershed regions, and tumors often enhance diffusely with contrast.

Necrotic Tumor

  • Diagnosis of brain abscesses and necrotic tumors is often impossible without conventional MR imaging.[1]
    • Several studies demonstrate the utility of Diffusion-weighted imaging (DWI) to differentiate between necrotic or cystic lesions and brain abscesses.[3]
    • DWI has a sensitivity and specificity of over 90% for distinguishing abscess (low ADC) from necrotic tumors (high ADC).

Lymphoma

  • Some studies suggest that indium scans can help differentiate abscess from CA, and thallium SPECT scans can distinguish CNS toxoplasmosis from lymphoma.[2]

Despite these differences, the true diagnosis is sometimes not made until biopsy.

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[4][5] ✔ Cancer cells[6] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia, gradual progression of symptoms
Delirium tremens ✔ Clinical diagnosis ✔ ✔ ✔ ✔ ✔ ✔ Alcohol intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[7] ✔ Xanthochromia[8] CT scan without contrast[9][10] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ✔ Normal CT scan without contrast ✔ ✔ ✔ ✔ ✔ TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[11][12] ✔ ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[13]

✔ ✔ ✔ ✔ ✔ ✔ Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ✔ Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis ✔ Clinical assesment ✔ ✔ ✔ ✔ ✔ History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ✔ ✔ ✔ History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess ✔ ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

✔ ✔ ✔ ✔ ✔ ✔ ✔ History of drug abuse, endocarditis, ↓ immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity ✔ ✔ Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance ↓ or ↑ Depends on the cause ✔ ✔ Confusion, seizures
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG ✔ ✔ ✔ ✔ Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ✔ Clinical assesment and MRI ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or ↑ Serum blood glucose

HbA1c

✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness, low serum, glucose

Differentiating brain abscess in immunocompromised host

Brain abscess is common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. It should be differentiated from the following diseases:

Disease Differentiating signs and symptoms Differentiating tests
CNS lymphoma[14]
Disseminated tuberculosis[15]
Aspergillosis[16]
Cryptococcosis
Chagas disease[17]
CMV infection[18]
HSV infection[19]
Varicella Zoster infection[20]
Brain abscess[21][22]
Progressive multifocal leukoencephalopathy[23]
  • Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms
Differentiating brain abscess from other brain cystic lesions
Disease Prominent clinical features Lab findings Radiological findings
Neurocysticercosis
Brain abscess
  • Lumbar puncture is contraindicated but when done, it was variable between patients.
  • Culture from the CT-guided aspirated lesion helps in identifying the causative agent.
Brain tumors
  • CT may be used in localizing the tumor and getting a rough estimate on the dimensions.
  • MRI: Gadolinium-enhanced MRI is the preferred imaging modality for assessing the extension of the tumor and its exact location.[26]
Brain tuberculoma
  • Presentations are usually due to the pressure effect, not the T.B. bacilli.
  • Presenting symptoms and signs in order of occurrence:[27]
  1. Episodes of focal seizures
  2. Signs of increased intracranial pressure
  3. Focal neurologic deficits.
  • CT: Contrast-enhanced CT scan shows a ring enhancing lesion surrounded by an area of hypodensity (cerebritis) and the resulting mass effect.
  • MRI: Better than CT scan in assessing the site and size of the tuberculoma. Gadolinium-enhanced MRI shows a ring enhancing lesion between 1-5 cm in size (In NCC, the wall is thicker, calcifications are eccentric and the diameter is less than 2 cm)
Neurosarcoidosis
  • 70% of the patients present with the neurological symptoms rather than the presentation of systemic disease. Common presentations are:[28]
  1. Cranial nerve neuropathies: Facial palsy is the most common presentation.
  2. Meningeal involvement: diffuse meningeal inflammation can cause diffuse basilar polyneuropathy in 40% of the patients. with neurosarcoidosis.
  3. Inflammatory spinal cord disease: Inflammatory span usually more than 3 spinal cord segments which helps to differentiate it from Multiple Sclerosis.
  4. Peripheral neuropathy: Asymmetric polyneuropathy or mononeuritis multiplex. It may also manifest as Guillain-Barré syndrome (GBS) like presentation.
  5. HPO axis involvement: may present as diabetes insipidus. More than 50% of the cases have no radiological signs.
MRI brain showing brain abscess – Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4933“
MRI brain showing Glioblastoma multiforme – Case courtesy of A.Prof Frank Gaillard, <a href=”https://radiopaedia.org/“>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/28272“>rID: 28272</a>
MRI brain showing tuberculoma – Case courtesy of Dr G Balachandran, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/5489“
MRI brain showing Neurosarcoidosis – Case courtesy of A.Prof Frank Gaillard, https://radiopaedia.org/ From the case https://radiopaedia.org/cases/4364S

References

  1. ↑ 1.0 1.1 Desprechins B, Stadnik T, Koerts G, Shabana W, Breucq C, Osteaux M (1999). “Use of diffusion-weighted MR imaging in differential diagnosis between intracerebral necrotic tumors and cerebral abscesses”. AJNR Am J Neuroradiol. 20 (7): 1252–7. PMID 10472982.
  2. ↑ 2.0 2.1 Ruiz A, Ganz WI, Post MJ, Camp A, Landy H, Mallin W; et al. (1994). “Use of thallium-201 brain SPECT to differentiate cerebral lymphoma from toxoplasma encephalitis in AIDS patients”. AJNR Am J Neuroradiol. 15 (10): 1885–94. PMID 7863938.
  3. ↑ Bavelloni A, Piazzi M, Raffini M, Faenza I, Blalock WL (2015). “Prohibitin 2: At a communications crossroads”. IUBMB Life. 67 (4): 239–54. doi:10.1002/iub.1366. PMID 25904163.
  4. ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  5. ↑ Invalid <ref> tag; no text was provided for refs named pmid3883130
  6. ↑ Weston CL, Glantz MJ, Connor JR (2011). “Detection of cancer cells in the cerebrospinal fluid: current methods and future directions”. Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  7. ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  8. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). “Cerebrospinal fluid in cerebral hemorrhage and infarction”. Stroke. 6 (6): 638–41. PMID 1198628.
  9. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). “Imaging in acute stroke”. West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  10. ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). “ACR Appropriateness Criteria® on cerebrovascular disease”. J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  11. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). “Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients”. J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  12. ↑ Berger JR, Dean D (2014). “Neurosyphilis”. Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  13. ↑ Ho EL, Marra CM (2012). “Treponemal tests for neurosyphilis–less accurate than what we thought?”. Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  14. ↑ Gerstner ER, Batchelor TT (2010). “Primary central nervous system lymphoma”. Arch. Neurol. 67 (3): 291–7. doi:10.1001/archneurol.2010.3. PMID 20212226.
  15. ↑ von Reyn CF, Kimambo S, Mtei L, Arbeit RD, Maro I, Bakari M, Matee M, Lahey T, Adams LV, Black W, Mackenzie T, Lyimo J, Tvaroha S, Waddell R, Kreiswirth B, Horsburgh CR, Pallangyo K (2011). “Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality”. Int. J. Tuberc. Lung Dis. 15 (8): 1087–92. doi:10.5588/ijtld.10.0517. PMID 21740673.
  16. ↑ Latgé JP (1999). “Aspergillus fumigatus and aspergillosis”. Clin. Microbiol. Rev. 12 (2): 310–50. PMC 88920. PMID 10194462.
  17. ↑ Rassi A, Rassi A, Marin-Neto JA (2010). “Chagas disease”. Lancet. 375 (9723): 1388–402. doi:10.1016/S0140-6736(10)60061-X. PMID 20399979.
  18. ↑ Emery VC (2001). “Investigation of CMV disease in immunocompromised patients”. J. Clin. Pathol. 54 (2): 84–8. PMC 1731357. PMID 11215290.
  19. ↑ Bustamante CI, Wade JC (1991). “Herpes simplex virus infection in the immunocompromised cancer patient”. J. Clin. Oncol. 9 (10): 1903–15. doi:10.1200/JCO.1991.9.10.1903. PMID 1919640.
  20. ↑ Hambleton S (2005). “Chickenpox”. Curr. Opin. Infect. Dis. 18 (3): 235–40. PMID 15864101.
  21. ↑ Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR (2013). “Brain abscess: Current management”. J Neurosci Rural Pract. 4 (Suppl 1): S67–81. doi:10.4103/0976-3147.116472. PMC 3808066. PMID 24174804.
  22. ↑ Patel K, Clifford DB (2014). “Bacterial brain abscess”. Neurohospitalist. 4 (4): 196–204. doi:10.1177/1941874414540684. PMC 4212419. PMID 25360205.
  23. ↑ Tan CS, Koralnik IJ (2010). “Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis”. Lancet Neurol. 9 (4): 425–37. doi:10.1016/S1474-4422(10)70040-5. PMC 2880524. PMID 20298966.
  24. ↑ Brouwer MC, Tunkel AR, McKhann GM, van de Beek D (2014). “Brain abscess”. N. Engl. J. Med. 371 (5): 447–56. doi:10.1056/NEJMra1301635. PMID 25075836.
  25. ↑ “Brain Abscess — NEJM”.
  26. ↑ 26.0 26.1 “Primary Brain Tumors in Adults – American Family Physician”.
  27. ↑ “The Journal of Association of Chest Physicians – Tuberculoma of the brain – A diagnostic dilemma: Magnetic resonance spectroscopy a new ray of hope : Download PDF”.
  28. ↑ 28.0 28.1 “Neurosarcoidosis”.
Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

There has been a remarkable shift in the epidemiology of brain abscess over the past several years. Due to advanced treatments of the ear, sinus, and orofacial infections within the last half century, brain abscess occurrences are now rare, only present in about 1,500 to 2,500 infections each year in the United States.[1]

Epidemiology and Demographics

Prevalence

  • The prevalence of brain abscess accounts for approximately 1 in 10,000 hospital admissions.[2]
  • After penetrating trauma or neurosurgical procedures, the prevalence ranges from 2-14%.[1]

Age

  • Brain abscess can arise due to paranasal infections in patients ages 10 to 30.
  • It is uncommon in children, yet has a peak incidence seen in ages 4 to 7.[3]

Gender

  • Brain abscess occurrence is more common in males than in females.[3]

Developed Countries

  • More cases are being seen in immunocompromised patients, especially in the United States.
  • There has been an advancement of treatment, making brain abscess occurrence more rare.[1]

Underdeveloped Countries

References

  1. ↑ 1.0 1.1 1.2 Honda H, Warren DK (2009). “Central nervous system infections: meningitis and brain abscess”. Infect. Dis. Clin. North Am. 23 (3): 609–23. doi:10.1016/j.idc.2009.04.009. PMID 19665086.
  2. ↑ Brain Abscess. MedMerits (2011). http://www.medmerits.com/index.php/article/brain_abscess Accessed on October 7, 2015
  3. ↑ 3.0 3.1 3.2 Sinusitis. Cleveland Clinic (2000-2015). http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/allergy/rhino-sinusitis/ Accessed on October 19th, 2015

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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

Common risk factors in the development of brain abscess are immunodeficiency, chronic diseases, and congenital heart diseases.

Risk Factors

Common risk factors in the development of brain abscesses in adults include: [1][2]

Common risk factors in the development of brain abscess in children include:[3]

References

  1. ↑ Nath A. Brain abscess and parameningeal infections. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 438.
  2. ↑ Brouwer MC, Tunkel AR, McKhann GM, van de Beek D (2014). “Brain abscess”. N Engl J Med. 371 (5): 447–56. doi:10.1056/NEJMra1301635. PMID 25075836.
  3. ↑ Brain Abscess. MedMerits (2011). http://www.medmerits.com/index.php/article/brain_abscess Accessed on October 7, 2015

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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Overview

If left untreated, a brain abscess can be fatal. Common complications include abscess rupture, hydrocephalus, and brain herniation. With treatment, the mortality rate decreases to about 10% of the population.

Natural History

If left untreated, a brain abscess is almost always fatal. If there is an abscess rupture into the ventricular system, ventriculitis can result.[1] Early detection and treatment is preferential. After surgery, some patients can experience long-term neurological problems.[2]

Complications

Common complications include:[1]

Prognosis

With treatment, the mortality rate is about 10% to 30%. While the mortality rate was 40% in 1960, it has dropped down to 15% within the past decade alone. About 70% of patients with brain abscesses have a good outcome, rarely with minimal neurological sequelae.[1]

References

  1. ↑ 1.0 1.1 1.2 Brouwer MC, Tunkel AR, McKhann GM, van de Beek D (2014). “Brain abscess”. N Engl J Med. 371 (5): 447–56. doi:10.1056/NEJMra1301635. PMID 25075836.
  2. ↑ Nath A. Brain abscess and parameningeal infections. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 438.

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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | CT | MRI | Other Imaging Findings | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case #1


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