Brain abscess: Difference between revisions

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==Treatment==
==Treatment==
[[Brain abscess medical therapy|Medical therapy]] | [[Brain abscess surgery|Surgical options]] | [[Brain abscess primary prevention|Primary prevention]]  | [[Brain abscess secondary prevention|Secondary prevention]] | [[Brain abscess cost-effectiveness of therapy|Financial costs]] | [[Brain abscess future or investigational therapies|Future therapies]]
[[Brain abscess medical therapy|Medical therapy]] | [[Brain abscess surgery|Surgical options]] | [[Brain abscess primary prevention|Primary prevention]]  | [[Brain abscess secondary prevention|Secondary prevention]] | [[Brain abscess cost-effectiveness of therapy|Financial costs]] | [[Brain abscess future or investigational therapies|Future therapies]]
== Treatment ==
Treatment is generally a team approach and most reliably depends on obtaining tissue via a stereotactic needle Bx. Although randomized, controlled trials have not been done, the consensus is that abscesses > 3cm should be drained (if accessible).
The treatment includes lowering the increased intracranial pressure and starting intravenous [[antibiotic]]s (and meanwhile identifying the causative organism mainly by blood culture studies).
Surgical drainage of the abscess remains part of the standard management of bacterial brain abscesses.  The location and treatment of the primary lesion also crucial, as is the removal of any foreign material (bone, dirt, bullets, and so forth).
There are a few exceptions to this rule: [[Haemophilus influenzae]] [[meningitis]] is often associated with subdural effusions that are mistaken for subdural empyemas. These effusions resolve with antibiotics and require no surgical treatment. [[Tuberculosis]] can produce brain abscesses that look identical to bacterial abscesses on [[CT]] imaging and surgical drainage or aspiration is often necessary to make the diagnosis, but once the diagnosis is made no further surgical intervention is necessary.
*Antibiotics: Brain abscesses are usually polymicrobial, with the most common bugs being microaerophilic [[streptococci]] (viridans) and anaerobic bacteria (bacteroides, anaerobic strep and [[fusobacterium]]).
:* [[S. aureus]], and enterobacteriacae are also seen.
:* Bugs associated with [[trauma]] include [[S. aureus]] and [[clostridium]] sp.
:* Empiric Rx usually starts with high-dose PCN (10 – 20 million units / d), [[metronidazole]], +/- a 3rd gen [[cephalosporin]].
::* Even if the abscess is associated with a dental procedure and other organisms are considered ([[actinomyces]] sp.) they generally respond to the above Rx.
::* If extending from an [[otitis]], empiric Rx should also cover [[pseudomonas]] and enterobacteriacaea.
::* If hematogenously spread, coverage depends on the original bug.
*The penetration of abx into an abscess does not necessarily equate with their penetration into the [[CSF]] (the blood-brain barrier is not the same as the blood-CSF barrier).
:* Drugs like [[vancomycin]], which have poor [[CSF]] levels (<10% of serum) have been shown to have good abscess levels (90% of serum).
* Most patients are treated parenterally for at least 8w.
:* Some authors also recommend an additional 2 – 3 month course of oral abx to clear up any ‘residual’ infection and to prevent relapses.
:* One study actually suggests that, when combined with surgical excision, 3w may be adequate.
:* Other studies have reported good outcomes with abx alone in patients with small lesions (<2cm), in well vascularized areas (cortex), who were poor surgical candidates.
* There have not been any studies reporting benefit from intra-thecal or intra-abscess abx.
* There seems to be consensus on obtaining q 2 – 4w f/u [[CT]]/[[MRI]] scans to document resolution.
=== Surgery ===
Surgery has evolved dramatically over the last few decades. 
:Once requiring open craniotomy and drainage / excision, most procedures are currently minimally invasive, closed, and performed under local anesthesia with conscious sedation and [[CT]] guidance.
:* [[CT]] guidance is accurate to within 4 – 5mm.
:* Stereotactic drainage can also be used if necessary, and is accurate to within 1 – 2mm.
:* Open craniotomy with complete excision is usually reserved for patients with multiloculated abscesses or in cases due to more resistant pathogens (e.g. fungi and [[nocardia]]).
==== Adjuvants ====
:* Although steroids have not been studies in well-designed trials, many authors use them in patients with elevated ICP.
:* Some animal studies suggest interference with granulation tissue formation and bacterial clearance.
:* [[Anticonvulsant]]s are recommended prophylactically for the 1st 3m, though the data supporting this is lacking.
== Prognosis ==  
== Prognosis ==  
Once an almost always fatal disease before the [[CT]] era. If the abscess is treated before the person goes into a [[coma]] then the death rate has been estimated from 5% to 20%.  
Once an almost always fatal disease before the [[CT]] era. If the abscess is treated before the person goes into a [[coma]] then the death rate has been estimated from 5% to 20%.  

Revision as of 20:16, 23 January 2012

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Once an almost always fatal disease before the CT era. If the abscess is treated before the person goes into a coma then the death rate has been estimated from 5% to 20%.

Early treatment and the patients overall health has an effect on prognosis. Other factors include: antibiotic resistance or the abscess location. An abscess deep within the brain is more difficult to treat than others.

In general

  • Mortality is currently quoted to range from 0 – 24%.
  • Poor prognostic indicators include:
  • Intraventricular rupture:
  • 80% mortality rate, often treated with open drainage and debridement f/b ventriculostomy catheter for drainage and intrathecal abx
  • Mental status and neurologic function at time of Dx:
  • The most common sequellae is seizures, which develop in 35 – 70% of patients.

References

Additional Resources

Mathisen, G.E., Johnson, J.P., Brain abscess, Clin Infectious Disease 1997; 25: 763-781.

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