Brain Abscess

Khoi D. Than, MD, Anthony C. Wang, MD, Jean-Christophe A. Leveque, MD, & Stephen E.
Sullivan, MD

Brain abscesses are an uncommon entity, with approximately 2000 cases reported in the United
States each year. There is a higher incidence in developing countries, and men are affected
slightly more often than women. Classically, these abscesses arise locally from otorhinolaryngeal
infections or hematogenously from distant infections, though opportunistic infections have
become an important consideration upon initial presentation as well. The pathogenic organisms
most commonly implicated are of the Streptococcus family; Klebsiella, Staphylococcus aureus,
and anaerobes are also frequent. In immunocompromised patients, it is important to include
Toxoplasma, Listeria, and Nocardia as possible etiologic agents, as well as fungal pathogens.

A patient with a brain abscess can present with nonspecific symptoms. Headache, nausea,
vomiting, and altered mental status can occur due to increased intracranial pressure, while
unilateral headache, seizures, and many focal neurological deficits occur due to the presence of a
mass lesion. Fever and nuchal rigidity are also seen in many cases. Additional findings in the
newborn patient may include cranial enlargement, meningeal signs, irritability, and failure to
thrive.

Risk factors for brain abscess include sinus, ear, or dental infections. These sources usually lead
to formation of frontal or temporal lobe abscesses through direct spread. Hematogenous spread
from intra-abdominal, pelvic, pulmonary, or cardiac seeding occurs most commonly via the
middle cerebral artery, leading to microembolic infarcts at the gray-white junction. Risk factors
for these types of abscesses include infectious lung processes or congenital cyanotic heart
disease. In these conditions, the lungs have a decreased filtering capability, and the associated
relative hypoxia promotes abscess formation. Head traumablunt, penetrating, or surgicalcan
introduce a nidus for infection with delayed abscess formation. Parasitic infections such as
cysticercosis should be considered more likely in recent foreign travelers.

The differential diagnosis for brain abscess includes subdural empyema, septic emboli, dural
sinus thrombosis, mycotic aneurysm, meningitis, focal necrotizing encephalitis (HSV), and
tumor, as all of these conditions can present with headaches and altered mental status. In the
initial evaluation of brain abscess, blood work that can be drawn includes a white blood cell
count, cultures, erythrocyte sedimentation rate, and C-reactive protein; however, normal test
results do not rule out the diagnosis. The key to diagnosing brain abscess is correlating the
clinical scenario with an imaging study, such as contrast-enhanced CT or MRI. The classic
finding on CT or MRI is a circular lesion with a strongly contrast-enhancing surround rim. CT
images are typically the first obtained on admission, although MRI is the imaging modality of
choice, as it can provide greater anatomic detail. MRI evaluation for brain abscess should always
include diffusion-weighted images, which can differentiate between ring-enhancing lesions of
infectious and neoplastic origin, as abscesses are typically hyperintense on diffusion-weighted
images, while neoplastic lesions are hypointense.
One general warning is to avoid immediate lumbar puncture, because CSF results are often
nondiagnostic and this procedure is associated with a worsened outcome in patients with brain
abscesses. Less than one quarter of patients have positive CSF cultures, and with a large enough
abscess, there is a real risk for transtentorial or brainstem herniation. CSF sampling should be
considered only if parasitic pathogens are suspected. A definitive diagnosis is made by biopsy
sampling of the abscess through surgical means.

The treatment of brain abscesses involves both surgical and medical therapy. Treatment should
also be aimed at correcting the primary source of infection (ie, draining a pulmonary empyema
or repairing a correctable heart defect). Initial surgical treatment usually consists of needle
aspiration of the abscess. A total excision can be performed if the abscess is in its chronic,
encapsulated form. It is advisable to perform surgery before starting antibiotics in order to
confirm the diagnosis as well as to identify the organisms and their antibiotic sensitivities.
Antibiotic therapy typically consists of 6 to 8 weeks of intravenous treatment followed by 4 to 8
weeks of oral treatment. Patients should receive routine follow-up imaging and should also be
started on an antiepileptic medication. Glucocorticoids should be considered to counteract
symptomatic intracranial hypertension, although their role is less important than in the treatment
of brain tumors.

In certain situations, medical therapy can suffice without the need for surgery. These situation
include an abscess in its early stages (ie, symptoms for less than 2 weeks), a small (< 2 cm)
abscess, or a definite clinical improvement after 1 week of antibiotics only. Medical treatment
without surgery should also be considered in poor surgical candidates, patients with multiple
abscesses and/or concomitant meningitis, patients with abscesses in eloquent locations, or
patients with hydrocephalus and ventricular shunts.

Patients with brain abscess have a reported mortality risk of 0% to 30% depending on etiology
and presentation. An overall 50% morbidity risk of permanent neurological deficits is conferred,
which depends heavily on the severity of presenting symptoms.
Subdural Empyema

A subdural empyema is a collection of pus that forms in the subdural space. It is less common
than brain abscess, but like abscesses, it is more commonly found in males. Subdural empyema
is an emergent condition because, unlike the brain parenchyma, the subdural space does not pose
much of a barrier to prevent the spread of infection. Additionally, antibiotics have poor
penetration into the subdural space.

The most common cause of subdural empyema (70%) is paranasal sinusitis, especially in cases
involving the frontal sinus. Chronic otitis media accounts for another 15% of cases. As such, the
organisms typically cultured from a subdural empyema include Streptococcus (aerobic and
anaerobic) and Staphylococcus. Symptoms present in the majority of patients with subdural
empyema include fever, headache, nuchal rigidity, hemiparesis, and altered mental status. Other
common symptoms include seizures and sinus tenderness.

CT or MRI imaging will typically diagnose a subdural empyema. Three fourths of empyemas are
located over the convexity, while 15% are parafalcine (ie, adjacent to the falx cerebri). Just as
with brain abscesses, lumbar puncture should be avoided due to the risk of herniation.

Almost all cases of subdural empyema will require surgical drainage, preferably emergently. The
two surgical options are burr-hole drainage and craniotomy. Although burr-hole drainage is less
invasive, it is also less effective; thus, craniotomy is the preferred surgical option. Antibiotics are
used for a course of 4 to 6 weeks, and patients are put on therapeutic or prophylactic antiseizure
medication. Medical treatment alone can be effective if the empyema is small, there is minimal
neurologic involvement, and antibiotics have an early efficaciousness.

Subdural empyema carries a 15% mortality rate. Half of patients have residual neurological
deficits at the time of hospital discharge. Factors known to be associated with poor prognosis
include age over 60 years, obtunded or comatose state at presentation, and empyema formation
secondary to surgery or trauma.