 Challenging clinical problem with substantial

case fatality rate

 Causes: bacteria, mycobacteria, fungi,
parasites (protozoa and helminths)
 0,4 – 0,9 / 100.000 population
◦ in immunosuppresed ones
 Underlying disease
(HIV)
Disruption of brain
Unknown
barrier (operation,
mechanisms trauma, mastoiditis,
Brain sinusitis, dental infection)

absces
Systemic source of
s
Hematogenous
(1/3 cases) infection (endocarditis
or bacteremia)

Contiguous
Spread Immuno-suppresive drugs
(1/2 cases)
 Depending on predisposing conditions

Organ HIV
transplant infection
Nocardial brain T.Gondii
abscess abscess

90% Fungal
abscess M.Tuberculosis
(aspergillus, infection
candida)
Neurosurgical or Contiguous Hematogenous
head trauma spread spread
• Skin- • Parameningeal • Cardiac,
colonizing foci infection pulmonary,
bacteria (S. • Streptococcus distant foci
aureus & S. sp. • Staphylococcus
epidermidis) • Staphylococcal sp
• Gram (-) bacilli • Polymicrobial • Streptococcus
(anaerobes & sp.
Gram (-) • Polymicrobial
bacilli) (paranasal
sinus & dental
infection)
1st stage: cerebritis  perivascular
inflammatory surrounding necrotic center
 edema in the surrounding white
matter

Necrotic center max  capsule formed

(fibroblasts & neovascularization)

Capsule thickens (reactive collagen)

Inflammation & edema extend beyond

capsule
 Headache
 Fever + altered consciousness  frequently
absent
 Neurologic sign depend on the site, can be subtle
for days to weeks
 Behavioral changes  frontal or right temporal
 Cr nerve palsy, gait disorder  brainstem or
cerebellum
 Headache or altered mental status due to
hydrocephalus
 Up to 25% seizures
 Underlying diseases or infection may present
symptoms
 Brain tumors
 Stroke
 Bacterial meningitis
 Epidural abscess
 Subdural empyema
 In HIV patients, DD/ include primary CNS
lymphoma
 Cranial CT scan with contrast  rapid tools
 MRI  differentiate from primary, cystic, or
necrotic tumors
 Blood and CSF cultures  identify causative
pathogen
 CSF cultures:
◦ Suspicion of meningitis
◦ Suspicion of abscess rupture into ventricular system
◦ No contraindications (brain shift, coagulation disorder)
 Culture of underlying foci of infection
CT Imaging:
 Hypodense center
 Isodense ring
 Surrounding
hypodense zone
(edema)
 Hypointense necrotic +
pus
 Ring-shape
enhancement wall
 Hypointense
surrouding zone
(edema)
 Hypointense (apparent-
Hyperintense(DWI) diffusion-coefficient imaging)
 Identify causative pathogen
 Reducing size of the abscess
 Stereotactic neurosurgical techniques:
◦ At least 1 cm φ
◦ Regardless location
◦ Abscess drainage
◦ Avoid eloquent area (speech, movement, sensation,
vision)
 Aspirating purulent center  diagnosis +
decompression
◦ Contraindicated of organism type + clinical
condition
 If no central cavity showed in imaging:
◦ Stereotactic biopsy OR
◦ Administering empirical antimicrobial treatment
 HIV + probable toxoplasmosis 
presumptive th/
◦ IgG antitoxoplasma (+)
◦ Withhold surgery  risk
 If stereotactic navigation not available
intraoperative ultrasonography through a
burr hole or craniotomy
◦ Direct abscess drainage
◦ Not recommended for small & deep abscess
 Diagnostic aspiration  maximal drainage
 Continous drainage  catheter into abscess
cavity
◦ reoperation rate
◦ Not routinely recommended
◦ Postoperative administration antimicrobial directly
to cavity  still few data and not routinely
recommended
Total resection : now limited
 Superficial abscess and not in eloquent tissue:
 Susp fungal or TB or branching bacteria
(actinomyces or nocardia)

If causative pathogen identified aspiration

depends on:
 Size, location
 Clinical condition
 Decompression after procedure
 Antimicrobial th/ alone  prone to failure
◦ Limited data
 Abscess more than φ2,5 cm  neurosurgery
◦ This size not definitive indication
 Multiple small abscesses:
◦ Largest one aspirated for diagnostic
◦ Other abscesses aspirated depend on size,
surrounding edema, symptoms, respons to
antimicrobial th/
 Abscess + brain shift:
◦ indication of surgery regardless of the size
 Abutted abscess but not yet ruptured to
ventricular system:
◦ drainage to prevent abscess ruptur & causing
ventriculitis
 Microbiologic evaluation of CSF, blood, or
aspirate (Gram staining, aerob, anaerob)
 Immunocompromised + history of pulmonary
TB or opportunistic infection  cultures of
mycobacteria, nocardia species, fungi, PCR
assay for T.gondii
 If culture (-) for suspicion of bacterial
abscess: PCR-based 16S ribosomal DNA for
definitive etiologic
 Delayed  poor outcome
 Should be started if suspected brain abscess
 Could be postponed after aspiration if:
◦ Not severe
◦ Clinically stable
◦ Surgery can be performed within few hours
◦ CAUTION: abscess may progress rapidly &
unexpectedly
 Based on organisms that most likely causing
◦ Based on mechanism of infection
◦ Predisposing condition
◦ Patterns on antimicrobial susceptibility
◦ Ability of antimicrobial agent to penetrate abscess
 After organ transplant:
◦ Bacterial: 3rd cephalosporin (ceftriaxon or cefotaxime)
+ metronidazole
◦ Nocardia: TMP-SMX/sulfadiazine
◦ Fungal (esp aspergillus): voriconazole
 HIV patients:
◦ Toxoplasmosis th/ (pyrimethamine+sulfadiazine)
added if IgG antitoxoplasma (+)
◦ TB th/ (INH, rifampicine, pyrazinamide, ethambutol)
added if HIV & immigrants from or have traveled from
endemic TB, or have risk factor for TB
 For neurosurgery and head trauma (+skull
fractures) :
◦ Vancomycin + 3rd or 4th cephalosporine (cefepime)
+ metronidazole
 Spread for parameningeal focus + no history
of neurosurgery:
◦ Ceftriaxone/cefotaxime + metronidazole
◦ Vancomycin added if suspicion of staphylococcus
 If cephalosporin or metronidazole
contraindicated: meropenem
 For hematogenous spread:
◦ 3rd cephalosporin + metronidazole (for anaerobes)
+ vancomycin (added for potential staphylococcal
infection)
 If pathogen identifed  modify the
antimicrobial therapy
 If single pathogen identified  repeat
cultures, continue broad spectrum
antimicrobial
 After neurosurgery or head trauma 
multidrug-resistant gram-negative bacilli
 Duration: 6-8 weeks
 Prolonged metronidazole  neuropathy
◦ Improved if metronidazole stopped
 Working Party of the British Society for
Antimicrobial Chemotherapy :
◦ Bacterial brain abscess: 1-2weeks iv th/, then
change to oral (metronidazole, ciprofloxacin, and
amoxicillin)
◦ Still not standard therapy
 Neurologic condition
 Abscess size
 Performed imaging :
◦ Immediately if there is clinical deterioration
◦ After 1-2 weeks if there is no improvement
◦ Biweekly basis for up to 3 months until clinical
recovery is evident
 Further neurosurgery if:
◦ Clinical deterioration + abscess size despite th/
 consciousness  immediate brain imaging
 hydrocephalus or herniation
 Abscess rupture to ventricular system 
ventriculitis  hydrocephalus  mortality >>
 If ruptured: external ventricular catheter
◦ Drainage, CSF sampling, monitor ICP, direct route
for antibiotics
 Abscess in posterior fossa  hydrocephalus
 Seizure or status epilepticus  decreased
consciousness
 Prophylactic epileptic drugs not
recommended
 Abscess growth or surrounding edema 
focal neurologic deficits
 Glucocorticoid th/  limited
◦ Reducing passage of antimicrobial th/
 Improved over the past 50 years
◦ Imaging techniques
◦ Antimicrobial regimens
◦ Minimally invasive neurosurgery procedures
 Mortality
 Good outcome: no or minimal neurologic
sequelae
THANK YOU
 Cefotaxime : 2gr / 4-6 hours
 Ceftriaxone: 2 gr/12 hours
 Metronidazole: 500 mg / 6-8 hours
 Meropenem : 2 gr / 8 hours
 Vancomycin: 15 mg / kgBW / 8-12 hours
 Penicillin G: 2-4 million units / 4 hours OR
continous infusion 12-24 million units daily
 Ampicillin: 2 gr / 4 hours
 INH: 300 mg / 24 hours oral
 Rifampin 600 mg / 24 hours oral
 Pyrazinamide: 15-30 mg / kg / 24 hours
 Ethambutol: 15 mg/kg / 24 hours oral
 TMP-SMX: 10-20mg TMP + 50-100mg
SMX/kg per day, administered 2-4 divided
doses
 Sulfadiazine: 1-1,5 g / 6 hours (oral)
 Ceftazidime: 2 gr / 8 hours
 Cefepime: 2 gr / 8 hours
 Nafcillin: 2 gr / 4 hours
 Oxacillin: 2 gr / 4 hours
 Voriconazole: 4 mg / kg / 12 hours after
loading dose 6 mg / kg / 12 hours for 2
doses
 Amphotericin B deoxycholate: 0,6-1 mg / kg
/ 24 hours, doses up to 1,5 mg / kg for
aspergillosis or mycomycosis
 Amphotericin B lipid complex: 5 mg / kg /24
hours
 Liposomal amphotericin B: 5-7,5 mg / kg/ 24
hours
 Pyrimethamine: 25-75 mg / 24 hours oral
 Sulfadiazine: 1-1,5 g / 6 hours
 Aminoglycoside: gentamicin 1,7mg / kg / 8
hours
 Addition 25 mg flucitosine / kg / 6 hours for
candida & cryptococcus