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BRAIN ABSCESS

BRAIN ABSCESS. M.RASOOLINEJAD, MD DEPATMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE. BRAIN ABSCESS. Focal & Suppurative Process in Brain Parenchyma. Anatomical Relationships of the Meninges. Bone Dura Mater Arachnoid Pia Mater Brain.

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BRAIN ABSCESS

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  1. BRAIN ABSCESS M.RASOOLINEJAD, MD DEPATMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE

  2. BRAIN ABSCESS Focal & Suppurative Process in Brain Parenchyma

  3. Anatomical Relationships of the Meninges • Bone • Dura Mater • Arachnoid • Pia Mater • Brain • Epidural Abscess • Subdural Empyema • Meningitis

  4. EPIDEMIOLOGY • Uncommon intracranial infections • Incidence 1:100,000/year • Predisposing conditions: Paranasal Sinusitis • Otitis Media • Dental infections • Immunocompromised pts Uncommon org • (T.gondii, Aspergillus spp, Nocardia spp, …)

  5. ETHIOLOGY • Abrain abscess may develop: • Direct spread from a contagious cranial of infections • ( Paranasal sinusitis, Otitis media, Mastoiditis,…..) • 2. Following head trauma or Neurological procedure • 3. Hematogenous spread from remote site of inf • 4. No obivious primary source of inf ( 20-30% ) • (Cryptogenic brain abscess )

  6. ETHIOLOGY • Most common organisms are : • Paranasal sinusitis:Microaerophilic & • Anaerobic strep • Haemophilus spp • Bacteroides spp • Fusobacterium spp • Dental infections: Streptococci spp • Prevetella • Prophyromanas

  7. ETHIOLOGY Most common organisms are : Otitis media & Mastoiditis: Streptococci Bacteroides spp P. aeroginosa Enterobacteriaceae Hematogenous: S. Viridance S. Aureous Neurosergical procedure & open head trauma: (S. aureous, Enterobactericeae, P. aeroginosa)

  8. SOURSE OF BRAIN ABSCESS • Frontal lobe:Frontal & Ethmoidal & Sphenoidal sinuses • Dental infections • Temporal lobe: Middle ear, Mastoid, Maxillary sinuses • Cerebellum & Brain Stem: Middle ear & Mastoid • Posterior Frontal or Parietal lobes: • Middle Cerebral Artery • Gray- White matter • Often multiple

  9. PATHGENESIS • Bacterial invasion of brain • (Parenchyma ) • Preexisting or concomitant : • Ischemia & • Necrosis & • Hypoxia of brain tissue

  10. PATHGENESIS 4 Stages Brain Abscess formation: Stage 1 • Early cerebritis ( days 1 to 3 ) • Prevascular infiltration of inflammatory cells • Central core of coagulative necrosis • Marked edema surrounds the lesions

  11. Early Cerebritis

  12. Early cerebritis

  13. PATHGENESIS 4 Stages Brain Abscess formation: Stage 2 • Late cerebritis ( days 4 to 9 ) • Pus formation ( necrotic center ) • Macrophages & Fibroblastrs • Thin capsule ( Fibroblast & Reticular fibers ) • Marked edema around the lesions

  14. Late Cerebritis

  15. PATHGENESIS 4 Stages Brain Abscess formation: Stage 3 • Early Capsule formation ( days 10 to13 ) • Capsule formation • Ring-enhancing capsule ( Imaging )

  16. Early Capsule formation

  17. PATHGENESIS 4 Stages Brain Abscess formation: Stage 4 • Late Capsule formation ( > 14 days ) • Well formed necrotic center • Dense peripheral collagenous capsule • No cerebral edema • Marked gliosis & reactive astrocytes • Gliosis  Seizures

  18. CLINICAL PRESENTATIONS Brain abscess presents as an Expanding Intracranial mass • Headache > 75% • Constant, Dull, • Aching sensation • Hemicranial or General • Progressive  Refractory • Fever: 50% & Low grade • Seizure: New onset • Focal or Generalized

  19. CLINICAL PRESENTATIONS • Increased Intracranial Pressure: • Papilledema • Nausea • Vomiting • Drowsiness • Confusion • Meningismus: • When it has ruptured into Ventricle or subarachnoid space

  20. CLINICAL PRESENTATIONS • Focal neurologic deficit > 60% • Frontal lobe Hemiparesis • Mental status, Drowsiness • Temporal lobe  Dysphasia Upper homonymous quadrantanopia Ipsilateral headache

  21. CLINICAL PRESENTATIONS • Focal neurologic deficit > 60% • Cerebellar  Nystagmus, Ataxia • Dysmetria, vomiting • Brain stem  Facial weakness, • Fever, Hemiparesis, Dysphagia, • Vomiting, Headache, Fever

  22. DIAGNOSIS NEUROIMAGING STUDIES • Brain CT- Scan • MRI ( Early cerebritis, Posterior Fossa) • Steriotactic Needle aspiration • Lumbar puncture  Risk of Herniation • CSF  Non Specific • Peripheral leucocytosis: 50% • Elevated ESR: 60%

  23. Left parietal abscess

  24. Marked edema

  25. Ring Enhancement

  26. Multiple abscess in a 6 years old boy

  27. Presumed source of polymicrobial abscess

  28. Cerebellar Abscess

  29. Mixed Abscess Location

  30. T. Gondii Encephalitis

  31. T. Gondii Encephalitis

  32. T. Gondii Encephalitis

  33. TREATMENT SURGICOMEDICAL • Aspiration Or Open Drainage • Empirical Combination • Antimicrobial Therapy • Duration: 6 to 8 wks IV • Prophylactic Anticonvulsant Therapy • Glucocorticoids( Severe Edema & ICP ) • Serial CT-Scan or MRI

  34. ANTIMICROBIAL THERAPY • Otitis media & Mastoiditis: • Metronodazole & 3rd Cephalosporin • Sinusitis: • Metronidazole & 3rd Cephalosporine • Dental Sepsis: • Penicillin & Metronidazole

  35. ANTIMICROBIAL THERAPY • Penetrating trauma &Neurosurgury: • Vancomycin & 3rd Cephalosporin • Bacterial endocarditis: • Vancomycin & Gentamycin • Nafcilline (Oxacillin) & Ampicillin • & Gentamycin • Unknown: • Vancomycin & Metronidazole & 3rd Cephalosporin

  36. PROGNOSIS • Successfully treatment  • Good prognosis • Seizures are a • common complication 70%

  37. THE END

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