Dr. Amanj Burhan specialist Neurosurgeon BRAIN ABSCESS Dr. Amanj Burhan specialist Neurosurgeon 4/15/2017 Brain Abscess

CLINICAL PRESENTATION DIAGNOSIS MANAGEMENT OUTCOME INCIDENCE: ETIOLOGY MICROBIOLOGY PATHOGENESIS CLINICAL PRESENTATION DIAGNOSIS MANAGEMENT OUTCOME 4/15/2017 Brain Abscess

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 . 4/15/2017 Brain Abscess

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) 4/15/2017 Brain Abscess

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 4/15/2017 Brain Abscess

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 ? 4/15/2017 Brain Abscess

Brain abscess from penetrating trauma is preventable or not? B. Basal skull fracture with CSF leak and meningitis cause post traumatic abscess Brain abscess from penetrating trauma is preventable or not? 4/15/2017 Brain Abscess

5. Immune compromised person 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 4/15/2017 Brain Abscess

Otogenic and dental infection caused by anaerobic organism 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% 4/15/2017 Brain Abscess

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 4/15/2017 Brain Abscess

3.stage three (early encapsulation)(day10—13) 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 ) 4/15/2017 Brain Abscess

4/15/2017 Brain Abscess

4/15/2017 Brain Abscess

4/15/2017 Brain Abscess

4/15/2017 Brain Abscess

4/15/2017 Brain Abscess

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 : Edema Cerebral tissue destruction 4/15/2017 Brain Abscess

2. Change in conscious level ( 60 %) 3. FND ( 60 %) 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 4/15/2017 Brain Abscess

Laboratory findings WBC : normal or mild increase ESR : increase in 90% CSF : not specific Opening pressure Protein Glucose Culture 4/15/2017 Brain Abscess

4. radiological characteristic of brain abscess Brain CTS with contrast ring enhancement Multi loculation Multiplicity Finding of gas 4/15/2017 Brain Abscess

MRI : T1 : T2 : necrotic center ( hypointence) Capsule ( hyperintence) Edema ( hypointence) T2 : necrotic center ( hyperintence) Capsule ( hypointence) Edema ( hyperintence 4/15/2017 Brain Abscess

Management 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) 4/15/2017 Brain Abscess

Advantage of antibiotic therapy Small size Deep seated Multiple 4/15/2017 Brain Abscess

Remove of purulent material 2. Aspiration : Advantages : Confirm diagnosis Remove of purulent material Provide environment for antibiotics to work Provide immediate relief of IICP Stereotactic guided aspiration 4/15/2017 Brain Abscess

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3.Excision of brain abscess Advantages Traumatic abscess ( contain foreign body and bone fragment ) Fungal abscess Gas containing abscess Disadvantages 4/15/2017 Brain Abscess

CT weekly during antibiotic therapy And then monthly CT 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 4/15/2017 Brain Abscess

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) 4/15/2017 Brain Abscess

Long term morbidity : ( seizure , FND, Cognitive dysfunction) Recurrence: ( 5-10%) causes ( inadequate antibiotic therapy, incorrect choice of AB, presence of foreign body , failure to eradicate source of the abscess) 4/15/2017 Brain Abscess

Thank you 4/15/2017 Brain Abscess