II. Epidemiology
- Peak Incidence in children: Ages 4 to 7 years old
III. Pathophysiology
- Frontal, temporal, and Parietal Lobes are most commonly affected
IV. Causes: Source
- Unknown primary source of abscess in 20-40% of cases
- Direct Spread
- Subdural Abscess (Subdural Empyema) is spread of Sinusitis or Mastoiditis in 60-90% of cases
- Mastoiditis (due to Chronic Otitis Media)
- Frontal Sinusitis or Ethmoid Sinusitis
- Most common in children who have highly vascular sinuses
- Dental Infection
- Retained Foreign Body such as bullet fragments (abscess development may be years later)
- Neurosurgery (abscess development may be >1 year later)
- Epidural Abscess (rare)
- Subdural Abscess (Subdural Empyema) is spread of Sinusitis or Mastoiditis in 60-90% of cases
- Hematogenous spread
- Lung Abscess or empyema in host with chronic lung disease (e.g. Cystic Fibrosis, Bronchiectasis)
- Esophageal procedures (e.g. esophageal dilation, Varices management)
- Cyanotic Congenital Heart Disease
- Bacterial Endocarditis
- Pulmonary AV Malformation with right to left shunt
- Skin Infections
- Intraabdominal and pelvic infections
- Dental Infection
V. Causes: Organisms
- Strepotococcus esp. viridans (60-70%), as well as Pneumococcus
- Staphylococcus, esp. Staphylococcus Aureus (10-14%)
- Other source site-specific organisms (in addition to Staphylococcus and Streptococcus species)
- Actinomyces (lung)
- Bacteroides (sinus, dental, ear) in up to 20-40% of cases
- Clostridium (penetrating Head Trauma)
- Enterobacteriaciae, Gram Negative Rods (ear) in up to 25-33% of cases
- Enterobacter (urine, penetrating Head Trauma, neurosurgery)
- Fusobacterium (sinus, dental, lung)
- HaemophilusInfluenzae (sinus, dental)
- Pseudomonas (ear, urine, neurosurgery)
-
Immunocompromised patients
- See Brain Lesion in HIV
- Aspergillus
- Coccidioides
- Cryptococcus
- Listeria
- Nocardia
- Toxoplasma gondii
- Other fungus (e.g. Candida)
-
Immigrants
- Cysticercosis (most common)
- Entamoeba histolytica
- Schistosoma
VI. Symptoms
- Often initially subacute (results in delayed diagnosis typically >1 week)
- However, Subdural Empyema may rapidly progress
- Headache (69%), typically unilateral in the region of abscess
- Neck Stiffness (15%), associated with posterior abscess (e.g. occiput)
- Vomiting (suggests Increased Intracranial Pressure)
VII. Signs
- Fever (45%)
- Focal neurologic deficit (50%)
- Often a delayed finding (>1 week after Headache onset)
- Oculomotor findings (CN 3 or CN 6) suggests Increased Intracranial Pressure
- Seizure (25%)
- Altered Level of Consciousness (associated with significant brain edema and with worse prognosis)
IX. Differential Diagnosis
X. Diagnostics
-
Lumbar Puncture
- Contraindicated in focal symptoms/signs, CNS mass, Increased Intracranial Pressure (risk of Herniation)
- Obtain CNS imaging prior to Lumbar Puncture
XI. Labs
-
Serology
- Blood anti-Toxoplasma IgG
- CSF anti-cysticercal Antibody
- CT-guided or neurosurgery obtained fluid
- Gram Stain
- Acid-fast stain and modified acid fast (Mycobacteria, Nocardia)
- Fungal stains
- Aeorbic and Anaerobic Bacterial cultures
- Mycobacterial culture
- Fungal Culture
XII. Management
- See Toxoplasmosis
-
Bacterial cause (initial empiric therapy, including for Subdural Empyema)
- Overall Antibiotic course of 4-6 weeks is typical
- Cefotaxime 2 g IV q4 hours OR Ceftriaxone 2 g IV every 12 hours (or Pen G 3-4 MU q4h) AND
- Metronidazole 7.5 mg/kg every 6 hours
- Add Vancomycin for suspected Staphylococcus Aureus
- Nocardia initial empiric therapy
- Post-Trauma or Post-Surgical
- Vancomycin 15-20 mg/kg every 8-12 hours (or Linzeolid 600 mg q12h) AND
- Cefepime 2 g IV every 8 hours (or Meropenem 2 g IV every 8 hours)
XIII. References
- (2016) Sanford Guide, accessed 4/9/2016
- Southwick in Calderwood (2016) UpToDate, accessed 4/9/2016
- Brouwer (2014) N Engl J Med 371:447 [PubMed]
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Related Studies
Definition (MSH) | A circumscribed collection of purulent exudate in the brain, due to bacterial and other infections. The majority are caused by spread of infected material from a focus of suppuration elsewhere in the body, notably the PARANASAL SINUSES, middle ear (see EAR, MIDDLE); HEART (see also ENDOCARDITIS, BACTERIAL), and LUNG. Penetrating CRANIOCEREBRAL TRAUMA and NEUROSURGICAL PROCEDURES may also be associated with this condition. Clinical manifestations include HEADACHE; SEIZURES; focal neurologic deficits; and alterations of consciousness. (Adams et al., Principles of Neurology, 6th ed, pp712-6) |
Concepts | Disease or Syndrome (T047) |
MSH | D001922 |
SnomedCT | 441806004, 60404007, 192738001 |
English | Brain Abscesses, Abscess, Brain, BRAIN ABSCESS, brain abscess, brain abscess (diagnosis), Brain abscess NOS, Abscess of brain (disorder), Abscess of brain, Brain Abscess [Disease/Finding], brain abscesses, cerebral abscess, abscess brain, abscess cerebral, Brain Abscess, Brain abscess, Brain--Abscess, brain; abscess, abscess; brain |
Italian | Ascesso cerebrale, Ascesso cerebrale NAS, Ascesso del cervello |
Dutch | hersenabces NAO, abces; hersenen, hersenen; abces, hersenabces, Abces, hersen-, Hersenabces |
French | Abcès cérébral SAI, Abcès du cerveau, Abcès cérébral, Abcès cérébraux |
German | Gehirnabszess NNB, Gehirnabszess, Hirnabszeß |
Portuguese | Abcesso cerebral NE, Abscesso Encefálico, Abscesso Cerebral, Abcesso do cérebro |
Spanish | Absceso cerebral NEOM, Absceso Encefálico, absceso de cerebro (trastorno), absceso de cerebro, Absceso Cerebral, Absceso cerebral |
Japanese | 脳膿瘍NOS, ノウノウヨウNOS, ノウノウヨウ, 脳膿瘍, 膿瘍-脳 |
Swedish | Hjärnabscess |
Czech | mozek - absces, Absces mozku, Absces mozku NOS |
Finnish | Aivopaise |
Russian | MOZGA GOLOVNOGO ABSTSESS, ABSTSESS GOLOVNOGO MOZGA, АБСЦЕСС ГОЛОВНОГО МОЗГА, МОЗГА ГОЛОВНОГО АБСЦЕСС |
Croatian | MOŽDANI APSCES |
Polish | Ropień mózgu |
Hungarian | agytályog k.m.n., agytályog |
Norwegian | Hjerneabscess |
Ontology: Intracranial abscess (C0021874)
Concepts | Disease or Syndrome (T047) |
ICD9 | 324.0 |
SnomedCT | 192746000, 192738001, 27614006 |
English | Intracranial abscess NOS, intracranial abscess (diagnosis), intracranial abscess, Intracranial abscess NOS (disorder), Intracranial abscess, Intracranial abscess (disorder), abscess; intracranial, intracranial; abscess, Intracranial abscess, NOS, Intracranial Abscess |
Dutch | intracraniaal abces, abces; intracraniaal, intracraniaal; abces |
French | Abcès intracrânien |
German | intrakranieller Abszess |
Italian | Ascesso intracranico |
Portuguese | Abcesso intracraniano |
Spanish | Absceso intracraneal, absceso intracraneal, SAI (trastorno), absceso intracraneal, SAI, absceso intracraneal (trastorno), absceso intracraneal |
Japanese | 頭蓋内膿瘍, トウガイナイノウヨウ |
Czech | Intrakraniální absces |
Hungarian | Intracranialis abscessus |
Ontology: Intracranial and intraspinal abscesses (C0154660)
Concepts | Disease or Syndrome (T047) |
ICD9 | 324.9, 324 |
SnomedCT | 192751006, 155050004, 192737006 |
English | Intracranial and intraspinal abscess, Intracranial / spinal abscess, Intracranial / spinal absc.NOS, Intracranial or intraspinal abscess NOS, Abscess central nervous system NOS, CNS abscess NOS, Cns abscess NOS, Central nervous system abscesses, Intracranial or intraspinal abscess NOS (disorder), Central nervous system abscess, Intracranial and intraspinal abscesses, CNS abscess, Intracranial and intraspinal abscesses (disorder), Intracranial and intraspinal abscess of unspecified site, Central nervous system abscess NOS |
Italian | Ascessi del sistema nervoso centrale, Ascesso del sistema nervoso centrale, Ascesso intracranico ed intrarachideo, Ascesso intracranico ed intrarachideo di sede non specificata, Ascesso del sistema nervoso centrale NAS, Ascesso NAS del sistema nervoso centrale |
Dutch | centraal zenuwstelselabces NAO, abces centraal zenuwstelsel NAO, intracraniaal en intraspinaal abces op niet-gespecificeerde plaats, intracraniaal en intraspinaal abces, centraal zenuwstelsel abcessen, centraal zenuwstelselabces |
French | Abcès intracrânien et intrarachidien, Abcès du système nerveux central SAI, Abcès intracrânien et intrarachidien de site non précisé, Abcès du système nerveux central, Nombre d'abcès du système nerveux central |
German | intrakranialer und intraspinaler Abszess unspezifischer Stelle, intrakranialer und intraspinaler Abszess, Abszess des Zentralnervensystems NNB, Abszess des ZNS NNB, Abszess im Zentralnervensystem, Abszesse des Zentralnervensystems |
Portuguese | Abcesso NE do SNC, Abcesso intracraniano e intraspinhal, Abcesso do SNC NE, Abcesso intracraniano e intraspinhal de localização NE, Abcessos do sistema nervoso central, Abcesso do SNC |
Spanish | Absceso intracraneal e intraespinal, Absceso del SNC NEOM, Absceso del sistema nervioso central NEOM, Absceso intracraneal e intraespinal de localización no especificada, absceso intracraneal o intrarraquídeo, SAI, absceso intracraneal o intrarraquídeo, SAI (trastorno), absceso intracraneal e intrarraquídeo, SAI (trastorno), absceso intracraneal e intrarraquídeo, SAI, abscesos intracraneal e intramedular (trastorno), abscesos intracraneal e intramedular, Abscesos del sistema nervioso central, Absceso en sistema nervioso central |
Japanese | 中枢神経系膿瘍, 中枢神経系膿瘍NOS, チュウスウシンケイケイノウヨウNOS, チュウスウシンケイケイシュヨウ, チュウスウシンケイケイノウヨウ |
Czech | Absces CNS, NOS, Absces centrálního nervového systému NOS, Intrakraniální a intraspinální absces blíže neurčené části CNS, Abscesy centrálního nervového systému, Absces centrálního nervového systému, Intrakraniální a intraspinální absces |
Hungarian | Központi idegrendszer abscessusok, Intracranialis és intraspinalis abscessus, Nem meghatározott elhelyezkedésű intracranialis és intraspinalis abscessus, KIR abscessus k.m.n., központi idegrendszeri tályog, Központi idegrendszeri tályog k.m.n. |
Ontology: Cerebral abscess (C1510428)
Definition (NCI) | A bacterial, fungal, or parasitic abscess that develops in the cerebral hemispheres. Causes include skull trauma, middle ear infection, congenital heart disease, and frontal and ethmoid sinus infection. |
Concepts | Disease or Syndrome (T047) |
MSH | D001922 |
SnomedCT | 192739009, 60404007 |
English | Abscess, Cerebral, Abscesses, Cerebral, Cerebral Abscesses, Parenchymal intracran absc, Cerebral intracranial abscess, Abscess;cerebral, Cerebral abscess, Brain Abscess, Cerebral intracranial abscess (disorder), Parenchymal intracranial abscess, Cerebral abscess (disorder), cerebral; abscess, abscess; cerebral, Cerebral Abscess, Abscess, cerebral, cerebral abscess |
French | Abcès intracérébral, Abcès intracérébraux |
German | Zerebraler Abszeß, Abszeß, zerebraler |
Spanish | absceso parenquimatoso intracraneal, absceso de cerebro, absceso cerebral intracraneal, absceso cerebral intracraneal (trastorno), absceso cerebral (trastorno), absceso cerebral |
Italian | Ascesso cerebrale |
Norwegian | Cerebral abscess |
Dutch | abces; cerebraal, cerebraal; abces |