Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Brain Abscess

  • Author: Itzhak Brook, MD, MSc; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Oct 05, 2015
 

Background

Intracranial abscesses are uncommon, serious, life-threatening infections. They include brain abscess and subdural or extradural empyema and are classified according to the anatomical location or the etiologic agent. The term brain abscess is used in this article to represent all types of intracranial abscesses.[1]

Intracranial abscesses can originate from infection of contiguous structures (eg, otitis media, dental infection, mastoiditis, sinusitis) secondary to hematogenous spread from a remote site (especially in patients with cyanotic congenital heart disease), after skull trauma or surgery, and, rarely, following meningitis. In at least 15% of cases, no source can be identified.[2]

In recent years, the complex array of etiologic agents that cause brain abscess has become better understood.

Next

Pathophysiology

Brain abscess is caused by intracranial inflammation with subsequent abscess formation. The most frequent intracranial locations (in descending order of frequency) are frontal-temporal, frontal-parietal, partial, cerebellar, and occipital lobes.[3] In at least 15% of cases, the source of the infection is unknown (cryptogenic).[4]

Infection may enter the intracranial compartment directly or indirectly via 3 routes.

Contiguous suppurative focus (45-50% of cases)

Direct extension usually causes a single brain abscess and may occur from necrotic areas of osteomyelitis in the posterior wall of the frontal sinus, the sphenoid and ethmoid sinuses, mandibular dental infections, as well as from subacute and chronic otitis media and mastoiditis.[5] This direct route of intracranial extension is more commonly associated with subacute and chronic otitic infection and mastoiditis than with sinusitis.[6]

Subacute and chronic otitis media and mastoiditis generally spread to the inferior temporal lobe and cerebellum. Frontal or ethmoid sinus spread to the frontal lobes. Odontogenic infections can spread to the intracranial space via direct extension or a hematogenous route. Mandibular odontogenic infections also generally spread to the frontal lobe.

The frequency of brain abscesses resulting from ear infections has declined in developed countries. However, abscesses complicating sinusitis has not decreased in frequency.[7] Contiguous spread could extend to various sites in the central nervous system, causing cavernous sinus thrombosis; retrograde meningitis; and epidural, subdural, and brain abscess.

The valveless venous network that interconnects the intracranial venous system and the vasculature of the sinus mucosa provides an alternative route of intracranial bacterial entry. Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins of the skull, the dural venous sinuses, the subdural veins, and, finally, the cerebral veins. By this mode, the subdural space may be selectively infected without contamination of the intermediary structure; a subdural empyema can exist without evidence of extradural infection or osteomyelitis.

Intracranial extension of the infection by the venous route is common in paranasal sinus disease, especially in acute exacerbation of chronic inflammation. Chronic otitis media and mastoiditis generally spread to the inferior temporal lobe and cerebellum, causing frontal or ethmoid sinus infection and dental infection of the frontal lobe.[8]

Trauma (10% of cases)

Trauma that causes an open skull fracture allows organisms to seed directly in the brain. Brain abscess can also occur as a complication of intracranial surgery, and foreign body, such as pencil tip, lawn dart, bullets, and shrapnel. Occasionally brain abscess can develop after trauma to the face.

Hematogenous spread from a distant focus (25% of cases)

These abscesses are more commonly multiple and multiloculated and are frequently found in the distribution of the middle cerebral artery. The most common effected lobes (in descending frequency) are the fontal, temporal, parietal, cerebellar, and occipital.[9]

Hematogenous spread is associated with cyanotic heart disease (mostly in children), pulmonary arteriovenous malformations, endocarditis, chronic lung infections (eg, abscess, empyema, bronchiectasis), skin infections, abdominal and pelvic infections, neutropenia, transplantation,[10] esophageal dilatation, injection drug use,[11] and HIV infection.

Previous
Next

Epidemiology

Frequency

United States

Before the emergence of the AIDS pandemic, brain abscesses were estimated to account for 1 per 10,000 hospital admissions, or 1500-2500 cases annually.[2] The prevalence of brain abscess in patients with AIDS is higher, so the overall rate has thus increased.[12] The frequency of fungal brain abscess has increased because of the frequent administration of broad-spectrum antimicrobials, immunosuppressive agents, and corticosteroids.

International

Brain abscesses are rare in developed countries but are a significant problem in developing countries. The predisposing factors vary in different parts of the world.

Mortality/Morbidity

With the introduction of antimicrobics and the increasing availability of imaging studies, such as CT scanning and MRI, the mortality rate has decreased to less than 5-15%. Rupture of a brain abscess, however, is associated with a high mortality rate (up to 80%).

The frequency of neurological sequelae in persons who survive the infection varies from 20-79% and is predicated on how quickly the diagnosis is reached and antibiotics administered.[13]

Sex

Brain abscesses are more common in males than in females.

Age

Brain abscesses occur more frequently in the first 4 decades of life. Because the main predisposing cause of subdural empyema in young children is bacterial meningitis, a decrease in meningitis due to the Haemophilus influenzae vaccine has reduced the prevalence in young children.

Previous
 
 
Contributor Information and Disclosures
Author

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey D Band, MD, FACP, FIDSA Professor of Medicine, Oakland University William Beaumont School of Medicine; Health System Chair, Healthcare Epidemiology and International Medicine, Beaumont Health System; Former Chief of Infectious Diseases, Beaumont Hospital; Clinical Professor of Medicine, Wayne State University School of Medicine

Disclosure: Nothing to disclose.

References
  1. Muzumdar D, Jhawar S, Goel A. Brain abscess: an overview. Int J Surg. 2011. 9(2):136-44. [Medline].

  2. Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis. 1997 Oct. 25(4):763-79. [Medline].

  3. Nielsen H, Gyldensted C, Harmsen A. Cerebral abscess. Aetiology and pathogenesis, symptoms, diagnosis and treatment. A review of 200 cases from 1935-1976. Acta Neurol Scand. 1982 Jun. 65(6):609-22. [Medline].

  4. Helweg-Larsen J, Astradsson A, Richhall H, Erdal J, Laursen A, Brennum J. Pyogenic brain abscess, a 15 year survey. BMC Infect Dis. 2012. 12:332. [Medline].

  5. Brook I, Friedman EM. Intracranial complications of sinusitis in children. A sequela of periapical abscess. Ann Otol Rhinol Laryngol. 1982 Jan-Feb. 91(1 Pt 1):41-3. [Medline].

  6. Glickstein JS, Chandra RK, Thompson JW. Intracranial complications of pediatric sinusitis. Otolaryngol Head Neck Surg. 2006 May. 134(5):733-6. [Medline].

  7. Brook I. Microbiology and antimicrobial treatment of orbital and intracranial complications of sinusitis in children and their management. Int J Pediatr Otorhinolaryngol. 2009 Sep. 73(9):1183-6. [Medline].

  8. Migirov L, Duvdevani S, Kronenberg J. Otogenic intracranial complications: a review of 28 cases. Acta Otolaryngol. 2005. 125:819-22. [Medline].

  9. Carpenter J, Stapleton S, Holliman R. Retrospective analysis of 49 cases of brain abscess and review of the literature. Eur J Clin Microbiol Infect Dis. 2007 Jan. 26:1-11. [Medline].

  10. Singh N, Husain S. Infections of the central nervous system in transplant recipients. Transpl Infect Dis. 2000 Sep. 2:101-11. [Medline].

  11. Tunkel AR, Pradhan SK. Central nervous system infections in injection drug users. Infect Dis Clin North Am. 2002 Sep. 16(3):589-605. [Medline].

  12. Bensalem MK, Berger JR. HIV and the central nervous system. Compr Ther. 2002 Spring. 28(1):23-33. [Medline].

  13. Tseng JH, Tseng MY. Brain abscess in 142 patients: factors influencing outcome and mortality. Surg Neurol. 2006 Jun. 65(6):557-62; discussion 562. [Medline].

  14. Brook I. Brain abscess in children: microbiology and management. J Child Neurol. 1995 Jul. 10(4):283-8. [Medline].

  15. Brook I. Microbiology of intracranial abscesses and their associated sinusitis. Arch Otolaryngol Head Neck Surg. 2005 Nov. 131(11):1017-9. [Medline].

  16. Finegold SM. Anaerobic Bacteria in Human Disease. New York, NY: Academic Press; 1977.

  17. Schwartz S, Thiel E. Update on the treatment of cerebral aspergillosis. Ann Hematol. 2004. 83 Suppl 1:S42-4. [Medline].

  18. Naesens R, Ronsyn M, Druwe P, et al. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol. 2009 Sep. 58(Pt 9):1247-51. [Medline].

  19. Le Moal G, Landron C, Grollier G, et al. Characteristics of brain abscess with isolation of anaerobic bacteria. Scand J Infect Dis. 2003. 35(5):318-21. [Medline].

  20. Tsou TP, Lee PI, Lu CY, et al. Microbiology and epidemiology of brain abscess and subdural empyema in a medical center: a 10-year experience. J Microbiol Immunol Infect. 2009 Oct. 42(5):405-12. [Medline].

  21. Kranick SM, Vinnard C, Kolson DL. Propionibacterium acnes brain abscess appearing 10 years after neurosurgery. Arch Neurol. 2009 Jun. 66(6):793-5. [Medline].

  22. Goodkin HP, Harper MB, Pomeroy SL. Intracerebral abscess in children: historical trends at Children's Hospital Boston. Pediatrics. 2004 Jun. 113(6):1765-70. [Medline].

  23. Swartz MN, Karchmer AE. Balow's infections of the central nervous system. Anaerobic Bacteria: Role in Disease. Springfield: CC Thomas; 1974. 309-25.

  24. Sanchez-Portocarrero J, Perez-Cecilia E, Corral O, et al. The central nervous system and infection by Candida species. Diagn Microbiol Infect Dis. 2000 Jul. 37(3):169-79. [Medline].

  25. Erdogan E, Beyzadeoglu M, Arpaci F, Celasun B. Cerebellar aspergillosis: case report and literature review. Neurosurgery. 2002 Apr. 50(4):874-6; discussion 876-7. [Medline].

  26. Al Masalma M, Lonjon M, Richet H, Dufour H, Roche PH, Drancourt M, et al. Metagenomic analysis of brain abscesses identifies specific bacterial associations. Clin Infect Dis. 2012 Jan. 54(2):202-10. [Medline].

  27. Bernardini GL. Diagnosis and management of brain abscess and subdural empyema. Curr Neurol Neurosci Rep. 2004 Nov. 4(6):448-56. [Medline].

  28. Muzumdar D, Jhawar S, Goel A. Brain abscess: an overview. Int J Surg. 2011. 9(2):136-44. [Medline].

  29. Brook I. The importance of lactic acid levels in body fluids in the detection of bacterial infections. Rev Infect Dis. 1981 May-Jun. 3(3):470-8. [Medline].

  30. Nguyen JB, Black BR, Leimkuehler MM, et al. Intracranial pyogenic abscess: imaging diagnosis utilizing recent advances in computed tomography and magnetic resonance imaging. Crit Rev Comput Tomogr. 2004. 45(3):181-224. [Medline].

  31. Sener RN. Diffusion MRI findings in neonatal brain abscess. J Neuroradiol. 2004 Jan. 31(1):69-71. [Medline].

  32. Leuthardt EC, Wippold FJ 2nd, Oswood MC, et al. Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses. Surg Neurol. 2002 Dec. 58(6):395-402. [Medline].

  33. Lai PH, Chang HC, Chuang TC, Chung HW, Li JY, Weng MJ, et al. Susceptibility-Weighted Imaging in Patients with Pyogenic Brain Abscesses at 1.5T: Characteristics of the Abscess Capsule. AJNR Am J Neuroradiol. 2012 Jan 26. [Medline].

  34. Rath TJ, Hughes M, Arabi M, Shah GV. Imaging of cerebritis, encephalitis, and brain abscess. Neuroimaging Clin N Am. 2012 Nov. 22(4):585-607. [Medline].

  35. Yogev R, Bar-Meir M. Management of brain abscesses in children. Pediatr Infect Dis J. 2004 Feb. 23(2):157-9. [Medline].

  36. Kocherry XG, Hegde T, Sastry KV, Mohanty A. Efficacy of stereotactic aspiration in deep-seated and eloquent-region intracranial pyogenic abscesses. Neurosurg Focus. 2008. 24(6):E13. [Medline].

  37. Honda H, Warren DK. Central nervous system infections: meningitis and brain abscess. Infect Dis Clin North Am. 2009 Sep. 23(3):609-23. [Medline].

  38. Infection in Neurosurgery Working Party of the British Society for Antimicrobial Chemotherapy. The rational use of antibiotics in the treatment of brain abscess. Br J Neurosurg. 2000 Dec. 14(6):525-30. [Medline].

  39. Livraghi S, Melancia JP, Antunes JL. The management of brain abscesses. Adv Tech Stand Neurosurg. 2003. 28:285-313. [Medline].

  40. Lonsdale DO, Udy AA, Roberts JA, Lipman J. Antibacterial therapeutic drug monitoring in cerebrospinal fluid: difficulty in achieving adequate drug concentrations. J Neurosurg. 2013 Feb. 118(2):297-301. [Medline].

  41. Ratnaike TE, Das S, Gregson BA, Mendelow AD. A review of brain abscess surgical treatment--78 years: aspiration versus excision. World Neurosurg. 2011 Nov. 76(5):431-6. [Medline].

  42. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1. 52(3):e18-55. [Medline].

  43. Diamond Y, Carr JP, Gwee A, Freyne B. Brain Abscess Due to Staphylococcus lugdunenis: A CoNSiderable Pathogen. J Pediatr. 2015 Oct. 167 (4):939-939.e1. [Medline].

 
Previous
Next
 
CT scan of a brain abscess.
MRI of a brain abscess.
Brain abscess.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.