BRAIN AND SPINAL ABSCESSES

A brain abscess is a free or encapsulated collection of infectious material of brain parenchyma, between the dura
and the arachnoid linings (subdural abscess) or between the dura and the skull (epidural abscess). Spinal
abscesses typically occur in the epidural region.
Pathophysiology and Etiology
Intracranial subdural abscesses, usually due to a streptococcus organism, are caused by purulent drainage
between the dura and arachnoid. It can result from pus from the meninges, middle ear or mastoid, sinuses,
septicemia, or skull fracture. It occurs most frequently in children and young adults.
Intracranial epidural abscesses, typically involving an infection of the cranium, commonly occur due to chronic
mastoiditis or sinusitis, head trauma, or craniotomy. Abscesses may be related to a subdural empyema
(collection of purulent drainage originating from nasal sinuses, meninges, middle ear, or skull osteomyelitis),
meningitis, or intraparenchymal abscess.
Spinal epidural abscesses occur in the spinal canal external to the dura. Epidural penetration may seed through
the blood and occur from infected adjacent tissue (eg, infected pressure ulcer), from another infected site (eg,
skin), or contamination from spinal surgery or spinal instrumentation (eg, lumbar puncture). S. aureus is a
frequent causative agent and the midthoracic vertebrae are most commonly affected.
Intermedullary abscesses are more common in the pediatric population, and are associated with lumbosacral
dermal sinuses. Approximately 20% to 30% are “cryptic” abscesses with no apparent source of infectious
seeding.
In the initial inoculation period, organisms invade the brain parenchyma resulting in local inflammation and
edema. The resulting cerebritis develops into a necrotic lesion and then becomes encapsulated.
Fungal brain abscesses are commonly seen in HIV-positive patients and other populations that are
immunosuppressed. Diffuse microabscesses may occur with infections caused by Candida species.
M. tuberculosis may cause abscesses of pus containing acid-fast bacilli (AFB) surrounded by a dense capsule.
These abscesses are also found in patients who are HIV-positive or have other immunosuppressive diseases.
Clinical Manifestations
Headache is poorly localized with a dull ache.
Increased ICP may result in nausea, vomiting, decreased LOC.
Fever is found in less than 50% of cases.
Neurologic findings such as hemisensory and paresis deficits, aphasia, ataxia may be present.
Seizures are frequently present.
Dental abscess, sinusitis, and otitis media may be present.
Signs and symptoms of a cerebral subdural empyema include severe headache, fever, nuchal rigidity, and
Kernig's sign.
Patients with intracranial epidural abscess commonly present with fever, lethargy, and severe headache.
Spinal epidural abscesses may be evidenced by severe back pain, fever, headache, lower extremity weakness
or paralysis, nuchal rigidity, Kernig's sign, and local tenderness.
Diagnostic Evaluation
CT scan, MRI with contrast locate the sites of abscess, and follow evolution and resolution of the suppurative
process.
In the inflammatory stage of cerebritis, imaging reveals a high signal intensity centrally (inflammation) and
peripherally (edema). When an abscess develops, the capsule becomes isointense.
There may be decreased ring enhancement with patients who are immunosuppressed, which may be due to a
lack of inflammatory response.
Microabscesses may not be detected by the CT scan or MRI.
MRI with gadolinium enhancement should be considered to detect spinal epidural abscesses.
Blood cultures are obtained to identify the organism, positive Gram's stain, leukocytosis, and elevated
erythrocyte sedimentation rate (ESR).
Cultures are obtained from the suspected source of infection, using stereotaxic needle aspiration or brain
surgery, to identify the organism and sensitivity to antimicrobials.
A metastatic brain abscess may be differentiated from a metastatic tumor by CT scan or MRI. Abscesses have
hypodense centers with a smooth surrounding capsule, whereas tumors may have irregular borders and diffuse
enhancement.
EEG detects seizure disorders.
Findings in cerebral subdural empyema include increased WBC and increased pressure of the CSF.
In intracranial epidural abscesses, CT or MRI scans are useful; MRIs are usually more sensitive. Findings from
the CSF may not be definitive. To avoid transtentorial herniation, lumbar puncture is not indicated until large
cranial masses are ruled out.
Diagnostic findings in spinal epidural abscesses may include increased WBC and ESR. The CSF may be cloudy.
Myelography is typically abnormal.
Management
With cerebral subdural empyema or intracranial epidural abscesses, management consists of trephining (drilling
through skull to evacuate purulent material), systemic antibiotics, and treatment of cerebral edema.
Spinal epidural abscesses may be managed with a laminectomy and surgical drainage, with antibiotics before
and after the procedure. The abscess site is thoroughly irrigated with antibiotic solution and aerobic and
anaerobic cultures are taken.
Closed stereotaxic needle biopsy, under CT guidance, may be used for drainage evacuation instead of
craniotomy.
Radical surgical débridement, especially with fungal infections, may be indicated with antimicrobial therapy.
Initiation of empiric antimicrobial therapy is based on Gram's stain and the suspected site of origin.Because brain
abscesses are frequently caused by multiple organisms, antimicrobial therapy is directed toward the most
common etiologic agents: streptococci, anaerobic bacteria (eg, Bacteroides species).
S. aureus may be suspected if surgical procedures have been performed.
Gram-negative bacteria (eg, Clostridium species) should be suspected if a cranial wound has been contaminated
with soil.
A 6- to 8-week course of parenteral antibiotics is typical, followed by a 2- to 3-month course of oral antimicrobial
therapy.
Penicillin G, metronidazole, and third-generation cephalosporins are common therapeutic agents.
Antifungal therapy, such as amphotericin B, is initiated for candidiasis and other fungal infections.
Antituberculosis pharmacotherapy, such as rifampin, isoniazid, and pyrazinamide, should be used to treat
abscesses containing AFB.
Adjunctive therapy includes corticosteroids and osmotic diuretics to reduce cerebral edema, and anticonvulsants
to manage seizures.
Complications
The brain abscess can rupture into the ventricular space, causing a sudden increase in the severity of the
patient's headache. This complication is often fatal.
Papilledema may occur in less than 25% of cases, indicating intracranial hypertension.
Lumbar puncture may be dangerous due to the possibility of brain stem herniation. Lumbar puncture is also
contraindicated if there is a spinal epidural abscess because pus may be transferred into the subarachnoid
space. Cervical puncture should be considered in such patients.
Permanent neurologic deficits, such as seizure disorders, visual defects, hemiparesis, and cranial nerve palsies,
may be present.
There is greater mortality if the patient has symptoms of short duration, has severe mental status changes, and
has rapid progression of neurologic impairment.
Delayed treatment of a spinal epidural abscess may result in transaction syndrome, in which flaccid paraplegia
with sensory loss occurs at the level of the abscess.
In chronic otitis media, intracranial and intratemporal complications frequently result from progressive bony
erosion, which may expose the dura, labyrinth, and facial nerves.
Nursing Assessment
Obtain history of previous infection, immunosuppression, headache, and related symptoms.
Perform neurologic assessment, including cranial nerve evaluation, motor, and cognitive status.
Nursing Diagnoses
Acute Pain related to cerebral mass
Disturbed Thought Processes related to disease process
Risk for Injury related to neurologic deficits
Anxiety related to surgery, prognosis, and relapse
Nursing Interventions
Relieving Pain
Administer pain medications as ordered.
Provide comfort measures, such as quiet environment, positioning with head slightly elevated, and assistance
with hygiene needs.
Provide passive relaxation techniques, such as soft music and backrubs.
Promoting Thought Processes
Frequently monitor vital signs, LOC, orientation, and seizure activity.
Report changes, which can signal increased ICP, to health care provider.
Administer medications as ordered, noting response and adverse reactions.
Prepare patient for repeated diagnostic tests to evaluate response to therapy and surgery.
Minimizing Neurologic Deficits
Maintain a safe environment with side rails up, call light within reach, and frequent observation.
Evaluate other cranial nerve function, and report changes.
Refer to occupational therapy, speech therapist, or other rehabilitation specialist to provide adjunct to nursing
rehabilitation.
Reducing Anxiety
Prepare patient and family for surgery when indicated. Encourage discussion with surgeon to understand risks,
benefits of the procedure.
Explain postoperative progression and nursing care.
Community and Home Care Considerations
Patient follow-up is essential for sinusitis, otitis media, respiratory infections, and other infectious processes that
may result in a brain abscess.
Continue with rehabilitation to regain or compensate for neurologic deficits.
Continue with pharmacologic regimen in community setting.
Observe for recurrence of brain and spinal abscesses.
Patient Education and Health Maintenance
Maintain wellness with vaccinations, immunizations, and overall health.
Reinforce need for dental procedure prophylaxis to avoid dental abscesses.
Instruct in need for immediate assessment of head wounds.
Evaluation: Expected Outcomes
Verbalizes reduced pain
Oriented to person, place, and time; follows simple commands
No injury related to neurologic deficits
Reduced anxiety regarding disease process and procedures