s1ar019 Brain Abscess - Neurologic Disorders - Merck Manuals Proessional Elton Abrain abscess is an intracerebral collection of pus. Symptoms may include headache, lethargy, fever, and focal neurologic deficits. Diagnosis is by contrast-enhanced MRI or CT. Treatment is with antibiotics and usually CT-guided stereotactic aspiration or surgical drainage. (Gee also introduction to Brain infections) ‘An abscess forms when an area of cerebral inflammation becomes necrotic and encapsulated by glial cells and fibroblasts. Edema around the abscess may increase intracranial pressure, as may the abscess itself. Etiology Abrain abscess can result from * Direct extension of cranial infections (eg, osteomyelitis, mastoiditis, sinusitis, subdural empyema) © Penetrating head wounds (including neurosurgical procedures) ‘© Hematogenous spread (eg, in bacterial endocarditis, congenital heart disease with right-to-left shunt, or IV drug abuse) © Unknown causes ‘The bacteria involved are usually anaerobic and sometimes mixed, often including anaerobes, such as Bactero anaerobic and microaerophilic streptococci. Staphylococci are common after cranial trauma, neurosurgery, or endocarditis. Enterobacteriaceae may be isolated in chronic ear infections. Fungi (eg, Aspergillus) and protozoa (eg, Toxoplasma gondii, particularly in HIV-infected patients) can cause abscesses, sand Symptoms and Signs Symptoms result from increased intracranial pressure and mass effect. Classically, headache, nausea, vomiting, lethargy, seizures, personality changes, papilledema, and focal neurologic deficits develop over days to weeks; however, In some patients, these manifestations are subtle or absent unti late in the clinical course. Fever, chills, and leukocytosis may develop before the infection is encapsulated, but they may be absent at presentation or subside over time. Diagnosis © Contrast-enhanced MRI or, if unavailable, contrast-enhanced CT When symptoms suggest an abscess, contrast-enhanced MRI with diffusion-welghted images or, if MRI is unavailable, contrast-enhanced CT is done. A fully developed abscess appears as an edematous mass with ring enhancement, which may be difficult to distinguish from a brain tumor or occasionally infarction; CT-guided aspiration, culture, surgical excision, or a combination may be necessary. Culturing pus aspirated from the abscess can make targeted antibiotic therapy of the abscess possible, However, antibiotics should not be withheld until culture results are available. Cerebellar Absc 4! \ htps:www.merckmanuals.comiprotessionalinurclogic-disordrsloain-infections/brair-abscess# 1s1ar019 Brain Abscess - Neurologic Disorders - Merck Manuals Professional Elton Lumbar puncture is not done because It may precipitate transtentorial hernlation and because CSF findings are nonspecific (see table Cerebrospinal Fluid Abnormalities in Various Disorders). Treatment = Antibic lly cefotaxime or ceftriaxone, plus metronidazole for Bacteroides sp or vancomycin for Staphylococcus aureus based on suspicion, then as guided by culture and susceptibility testing) ‘© Usually CT-guided stereotactic aspiration or surgical drainage ‘Sometimes corticosteroids, antiseizure drugs, or both All patients receive antibiotics for a minimum of 4 to 8 wk. Initial empiric antibiotics include cefotaxime 2 g 1V q 4h o ceftriaxone 2 g IV q 12 h; both are effective against streptococci, Enterobacteriaceae, and most anaerobes but not against ides frogilis. If cliniclans his also required. If. @ to nafcilin (2 gq 4h} ssponse to antibiotics Is b Drainage ( eotactic or open) p py and is necessary for most ss that are solitary and surgically accessible, particularly those > 2 cm in diameter. If abscesses are <2 cm in diameter, antibiotics alone may bet ‘abscesses must then be monitored with serial MRI oF CT; if ab enlarge after being treated with surgical drainage is indicated, Patients with increased intracranial pre (dexamethasone 10 mg IV once, then 4 m Antiseizure drugs are sometimes re spect Bacteroides sp, metronidazole 15 mg/kg (loading dose) followed by 7.5 mgrkg lV q 6 Is suspected, vancomycin 1 gq 12h Is used (with cefotaxime or ceftriaxone) until sensitivity monitored by serial MRI or CT. lure may benefit from a short course of high-dose corticosteroids IVq6h for 3 or 4 days). to prevent seizures, Key Points * Brain abscess can result from direct extension (eg, of mastoiditis, osteomyelitis, sinusitis, or subdural empyema), penetrating wounds (including neurosurgery), or hematogenous spread. ‘© Headache, nausea, vomiting, lethargy, selzures, pers ality changes, papilledema, and focal neurologic deficits develop over days to weeks; fever may be absent at presentation. + Docontrast ;nhanced MRI or, If MRI is unavailable, contrast-enhanced CT. ‘Treat all brain abscess with antibiotics (usually initially with ceftriaxone or cefotaxime plus metronidazole If clinicians suspect Bacteroides sp or with vancomycin if they suspect S. aureus), typically followed by CT-gulded stereotactic aspiration or surgical drainage. + Ifabscesses are <2 cm in diameter, they may be treated with antibiotics alone but must then be monitored. closely with MRI or CT; if abscesses enlarge after being treated with antibiotics, surgical drainage is hitps:www.merckmanuals.comiprotessionalineuologic-disorérsioain-infections/brair-abscess# 20s1ar019 Brain Abscess - Neurologic Disorders - Merck Manuals Proessional Elton Drugs Mentioned In This Article Drug Name Select Trade dexamethasone ‘OZURDEX metronidazole FLAGYL ceftriaxone ROCEPHIN cefotaxime CLAFORAN vancomycin VANCOCIN nafeillin NALLPEN IN PLASTIC CONTAINER Tost evewrrevsion Janary 2019 by Jona EGre © merck (© 2018 Merck Sharp & Dohme Corp, a subsidiary of Merck & Co, Inc. Kenilworth, Nj, USA) htps:www.merckmanuals.comiprotessionalineurclogic-disorérsloaininfections/brar-abscess# a9