2. Department of Neurosurgery
cpc
Department of Neurosurgery
RMC n Allied Hospitals
Dr Osama Ahmad Dr Soban Sarwar Gondal
Registrar Senior Registrar
Prof. Dr Nadeem Akhter
Head of Department

3. Demographic Details
Name : Rizwan Saeed Father name : Mohd Saeed Age/Sex : 34 years/ M R/O : Rawalpindi Occupation : Employee in oil and gas company D.O.A : M.O.A : Emergency

4. Presenting Complaints
Altered Sensorium days.
Headache week.
Fever week.
(R) Ear discharge months.

5. History Of Presenting Illness
Headache continuous, generalized, moderate to severe in intensity , partially relieved by analgesics, associated with nausea and vomiting . No associated fits .
Fever off and on , low grade (unrecorded) with no associated features.
Drowsy and disoriented for the last 3 days.

6. History Of Presenting Illness
Previous h/o of intermittent (R) ear discharge for the last 1 year with recent intermittent exacerbation for the last 3 months , purulent, yellowish in color , foul smelling with associated impaired hearing on that side.
He consulted multiple local doctors regarding the ear discharge and took off and on treatment

7. Systemic Review CNS : Drowsiness GIT : NAD Chest : NAD
Genitourinary : NAD
CVS : NAD
Locomotor : NAD
Endocrine : NAD

8. Past History Medicine : Surgical
Off and on treatment for ear discharge from local doctor (No record available).
Took analgesics for headache.
No pre-morbidity.
Surgical
No past surgical history.

9. History Personal Socioeconomic Non smoker. Non addict
Employee at oil and gas company.
Married with two daughters.
Socioeconomic
Middle class family.

10. General Physical Examination
Young patient with altered sensorium lying in his bed.
Pallor º
Jaundiceº
Dyspneaº
Clubbingº
Cyanosis º
Vitals
Pulse : 94/min
B.P : 110/70
R.R : 20/min
Temp : 100 ˚F

11. Central nervous system
GCS: 12/15.
Higher Mental functions :
Patient was drowsy and disoriented .
Apathic
Cranial Nerves:
Fundoscopy: Grade 2 papilledema bilaterally
Cranial nerves: Grossly normal.

12. Central nervous system
Motor system
Bulk normal B/L
Tone normal B/L
Power: moving all four limbs.
Reflexes
Superficial … Intact
Deep … Intact
Plantars … Downgoing B/L

13. Central nervous system
Lobes :
Could not be assessed because of decrease level of consciousness.
Cerebellar signs:
Sensory system:
Could not be assessed because of decrease level of consciousness.

14. Systemic Respiratory : B/L air entry equal
GIT : Soft, Nontender B.S+ve
CVS : S1+S2+0

15. Investigations Blood Tests Imaging CBC (TLC-12000/uL) CRP (3.2 mg/L)
ESR (28 mm/hr).
Imaging
CT scan Brain ( plain )
CT scan Brain with contrast.
MRI Brain with contrast.

20. Treatment Medical Inf N/S 1000ml iv BD Triple regimen started.
Inj ceftriaxone 2g iv BD
Inj Vancomycin 1g iv TDS
Inj metronidazole 500mg TDS
Inj decacdron 4mg iv TDS
Inj epival 500mg iv BD
Inf mannitol 150ml iv TDS
Inj Toradol 30mg iv TDS
Inj Zantac 50mg iv TDS

21. CT Scan Brain with contrast ( after 1 week)

22. Surgery Aspiration thru burr hole (28-6-16) 15 ml pus aspirated
Pus sent for culture and sensitivity.

23. Check Ct scan ( 1st POD)

24. Postoperative period Patient conscious oriented Taking orally
Pus for C/S showed proteus mirabilis.
Discharged on 4th POD with iv antibiotics ( 4 weeks ).
Advised:
Wound care
Daily dressing
OPD follow up after 10 days.

25. Follow up Presented on 11th POD Conscious , oriented Wound … healthy.
Stitches removed
IV antibiotics ( 4 weeks )
ENT consultation

26. ENT
Advised:
Admission
Plan of Mastoidectomy.

27. Surgery
Modified radical mastoidectomy by ENT department ( )

28. Follow up
Patient remain well for 1 week again started having the same symptoms .
Presented in emergency with decreased level of consciousness.
After initial management CT scan was performed which showed re-accumulation of abscess.

30. Surgery
Total excision along with capsule ( )

31. Per Op

36. Per Op

37. PostOp Scan ( 1st POD)

38. Specimen : Wall Biopsy of Brain Abscess Diagnosis
Histopathology
Specimen : Wall Biopsy of Brain Abscess
Diagnosis
Abscess wall Showing xanthogranulomatous inflammation
Negative for Granulomatous inflammation
Negative for malignancy

39. Follow Up Discharged on 5th POD with iv antibiotics.
Advised OPD follow up after 1 week.

40. `

41. Cerebral Abscess
TOPIC DISCUSSION

42. INCIDENCE 1-2% of SOL in brain (USA) 8% (Subcontinent)
Decreased incidence (because of antibiotic and improved life)
Increased incidence in immune compromised patient .

43. ETIOLOGY From PNS ,middle ear and mastoid
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)

44. 2. Heamatogenous
Dissemination of microorganism from remote site of infection
Multiple and deeply located
Mostly located in the frontal and parietal lobe
Primary foci include (skin pustule ,pulmonary infection , diverticulitis)
Most common type of CHD is TOF 50%
Brain abscess in CHD are generally solitary

45. Can occur within days or years
3. Penetrating trauma :
Can occur within days or years
Contaminated bone fragments and debris provide a nidus for infection
Lodged bullet may be source of infection
Basal skull fracture with CSF leak and meningitis cause post traumatic abscess

46. 4.Previous craniotomy
Because of :
A. Introduce of micro-organisms at time of surgery
B. Or spread of intracranialy through the wound
C. Bone flap infection
5. Immune compromised person

47. 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.
In immune deficiency caused by fungus
In AIDS by toxoplasma gondi
Incidence of –ve culture is 25-30%

48. PATHOGENESIS AND HISTOPATHOLOGY OF BRAIN ABSCESS

54. Clinical presentation :
Occur in majorities in the first 2 decades of life
Males more affected ( cause is unknown )
Largely dependent on immune status
Infants : increase in head circumference , bulging fontanel , separation of cranial sutures , vomiting , irritability , seizures
Signs of Raised ICP and Focal Neurological Deficit
Edema
Cerebral tissue destruction

55. 2. Change in conscious level ( 60 %) 3. FND ( 60 %)
Symptoms :
1. Headache ( 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

56. Laboratory findings WBC : normal or mild increase
ESR : increase in 90%
CSF : not specific
Opening pressure
Protein
Glucose
Culture

57. Investigations Radiological characteristic of brain abscess
Brain CT with contrast
Ring enhancement
Sigle Locus/Multi loculation
Multiplicity
Finding of gas

60. MRI T1 : necrotic center ( hypointense) Capsule ( hyperintense)
Edema ( hypointense)
T2 :
necrotic center ( hyperintense)
Capsule ( hypointense)
Edema ( hyperintense)

63. Management Antibiotic therapy :
Antibiotic is mandatory and should given
Antibiotics depends on C/S
Treatment depend on the etiology
Sinusitis : ( penicillin + metronidazole )
Otitis : ( penicillin + metronidazole + 3rd generation cephalosporin)
Metastatic abscess :(metronidazole + 3rd generation cephalosporin)
Post traumatic abscess ( vancomycin)
Advantage of antibiotic therapy
Small size
Deep seated
Multiple

64. Treatment Options 2. Aspiration : Advantages : Confirm diagnosis
Remove of purulent material
Provide environment for antibiotics to work
Provide immediate relief of IICP
Stereotactic guided aspiration

65. Treatment Options 3.Excision of brain abscess Advantages
Traumatic abscess ( contain foreign body and bone fragment )
Fungal abscess
Gas containing abscess
Disadvantages

67. 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

68. 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

69. 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)

70. Thank You