Differential diagnosis of brain abscess

•Epidural and subdural empyema

•Septic dural sinus thrombosis
•Mycotic cerebral aneurysms
•Septic cerebral emboli with associated infarction
•Acute focal necrotizing encephalitis (most commonly due to
herpes simplex virus)
•Metastatic or primary brain tumors
•Pyogenic meningitis
 Dental infection

Frontal or ethmoid
sinuses
Brain Direct
abscess spread
otitis media and
mastoiditis

Post neurosurgery

Bullet wounds
 Chronic pulmonary
infections
Skin infections

Pelvic infection

Brain Hematogenous Intraabdominal

abscess spread infection

Esophageal dilation and

endoscopic sclerosis of
esophageal varices

Bacterial
Cyanotic endocarditis
congenital
heart diseases
 Microbiologic pathogens in brain abscesses, according to major primary
source of infection
Source of infection
Paranasal sinuses
Odontogenic sources
Otogenic sources
Lungs
Urinary tract
Penetrating head trauma
Neurosurgical procedure
Endocarditis
Congenital cardiac malformations
(especially right-to-left shunts)
Pathogens
Streptococcus (especially Streptococcus
milleri), haemophilus, bacteroides,
fusobacterium
Streptococcus, bacteroides, prevotella,
fusobacterium, haemophilus
Enterobacteriaceae, streptococcus,
pseudomonas, bacteroides
Streptococcus, fusobacterium,
actinomyces
Pseudomonas, enterobacter
Staphylococcus aureus, enterobacter,
clostridium
Staphylococcus, streptococcus,
pseudomonas, enterobacter
Viridans streptococcus, S. aureus
Streptococcus
 Viridans streptococci

Streptococcus milleri

Streptococcus pneumoniae

Gram-positive
cocci Staphylococcus aureus

Aerobic
Gram-negative Escherichia coli,
rods

Pseudomonas spp,

Klebsiella pneumoniae,

Proteus spp
 The most frequent anaerobes cultured from a brain
abscess
•anaerobic streptococci.
• Bacteroides spp (including B. fragilis).
•Prevotella melaninogenica.
• Propionibacterium.
•Fusobacterium.
• Eubacterium.
• Veillonella.
•Actinomyces
 Immunocompromised hosts
•Toxoplasma gondii
•Listeria
•Nocardia asteroides
•Aspergillums'
•Cryptococcus neoformans.
•Coccidioides immitis.
• Mucormycosis
 CT-Scan
Early cerebritis appears as an irregular area of low
density that does not enhance following contrast
injection.
the lesion enlarges with thick and diffuse ring
enhancement following contrast injection

thin ring which may not be uniform in thickness

 MRI
•more sensitive for early cerebritis
•more sensitive for detecting satellite lesions
•More accurately
•estimates the extent of central necrosis
•ring enhancement,
•cerebral edema
•Better visualizes the brainstem
 LP
a lumbar puncture (LP) is contraindicated
Decompression of the cerebrospinal fluid (CSF)
pressure associated with brain stem herniation
in 1.5 to 30 percent of cases
 Culture and biopsy
•Gram's stain
• aerobic
• anaerobic
• mycobacterial
•fungal culture
 Antibiotics
•Penicillin G covers most mouth flora including both aerobic and anaerobic
streptococci.
•Metronidazole readily penetrates brain abscesses, Given the excellent
intralesional concentrations and the high probability of anaerobes.
•Ceftriaxone covers most aerobic and microaerophilic streptococci also covers
many Enterobacteriaceae
•Ceftazidime should be used when brain abscess complicates a neurosurgical
procedure or in cases where the abscess culture grows P. aeruginosa.
•Vancomycin should be included when brain abscess follows penetrating head
trauma or craniotomy or when S. aureus bacteremia is documented
 Aspiration
•preferred for speech areas and regions of the
sensory or motor cortex and in comatose
patients.

•Not preferred for:

•Early cerebritis without evidence of cerebral
necrosis.
•Abscesses located in vital regions of the brain or
those inaccessible to aspiration
 Surgery
•indications for excision after initial aspiration
and drainage:

•Traumatic brain abscesses (to remove bone chips

and foreign material)
•Encapsulated fungal brain abscesses
•Multiloculated abscesses