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Dr. Amanj Burhan specialist Neurosurgeon

BRAIN ABSCESS. Dr. Amanj Burhan specialist Neurosurgeon. INCIDENCE: ETIOLOGY MICROBIOLOGY PATHOGENESIS CLINICAL PRESENTATION DIAGNOSIS MANAGEMENT OUTCOME. INCIDENCE. Is 1-2% of SOL in brain (USA) Is 8% (INDIA) Decreased incidence (because of antibiotic and improved life)

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Dr. Amanj Burhan specialist Neurosurgeon

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  1. BRAIN ABSCESS Dr. Amanj Burhan specialist Neurosurgeon Brain Abscess

  2. INCIDENCE: • ETIOLOGY • MICROBIOLOGY • PATHOGENESIS • CLINICAL PRESENTATION • DIAGNOSIS • MANAGEMENT • OUTCOME Brain Abscess

  3. 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 . Brain Abscess

  4. 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) Brain Abscess

  5. 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 Brain Abscess

  6. 3. Penetrating trauma : 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 ? Brain Abscess

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

  8. 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 Brain Abscess

  9. 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% Brain Abscess

  10. 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 Brain Abscess

  11. 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 ) Brain Abscess

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  17. 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 Brain Abscess

  18. 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 Brain Abscess

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

  20. 4. radiological characteristic of brain abscess • Brain CTS with contrast • ring enhancement • Multi loculation • Multiplicity • Finding of gas Brain Abscess

  21. MRI : • T1 : • necrotic center ( hypointence) • Capsule ( hyperintence) • Edema ( hypointence) • T2 : • necrotic center ( hyperintence) • Capsule ( hypointence) • Edema ( hyperintence Brain Abscess

  22. 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) Brain Abscess

  23. Advantage of antibiotic therapy • Small size • Deep seated • Multiple Brain Abscess

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

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  26. 3.Excision of brain abscess • Advantages • Traumatic abscess ( contain foreign body and bone fragment ) • Fungal abscess • Gas containing abscess • Disadvantages Brain Abscess

  27. 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 Brain Abscess

  28. 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) Brain Abscess

  29. 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) Brain Abscess

  30. Thank you Brain Abscess

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