Text Book Medical Analysis

Definition
Brain abscess is a bacterial infection within the brain.

Description
The brain is usually well insulated from infection by bacteria, protected by the skull, the meninges (tissue layers surrounding the brain), the immune system, and the highly regulated barrier between the bloodstream and the brain. Under certain circumstances, however, bacteria can invade the brain and cause a localized infection called an abscess. Brain abscess is relatively rare, accounting for 1 in 10,000 hospital admissions. Single abscess occurs in 75% of cases, and the remainder of cases involve multiple abscesses. If not treated, brain abscess is almost always fatal.

Causes and symptoms
One-half of all brain abscesses are caused by the spread of bacteria from a nearby infection. Sources of bacteria include:

middle ear infections (otitis media) or infections in the bony spaces in front of the middle ear (mastoiditis)

sinus infections

an abscessed tooth.

other sources of bacteria include:

lung infections

abdominal infection

infection of the heart's lining (endocarditis)

penetrating head wounds

Brain abscess can be caused by a variety of organisms, many of them related to ear and sinus infections. Many times brain abscess cases are caused by two or more bacteria. In 30-60% of cases, the bacteria combination includes streptococci, microorganisms that can live without oxygen (anaerobes), and enterobacteria. A small number of cases are caused by yeast, fungi, and single-cell organisms (protozoa).

The symptoms of brain abscess often develop slowly, usually within a period of about two weeks. The most common symptoms are:

headache

neurologic symptoms related to the specific part of the brain that is infected

altered mental status

seizures

Fever and stiff neck occur in less than one-third of cases. Additional symptoms may include vomiting, eye tremor (nystagmus), poor balance, and uncoordinated movements.

Diagnosis
Diagnosis of brain abscess is performed by using a computed tomography scan (CT) or a magnetic resonance imaging (MRI) scan to determine the site of infection. Tissue removal (biopsy) is usually performed as well. A biopsy is performed to determine the type of bacterium involved. Biopsies can also be used to rule out tumor or other noninfectious localized lesions, which may look the same on the scans.

Other tests are performed to determine the source of the infection. These tests include blood cultures, x rays of the chest, and a physical exam of the ears, sinuses, and teeth. A test for human immunodeficiency virus (HIV) is usually also performed.

Treatment
Treatment for brain abscess begins with intravenous antibiotics, chosen to match the infecting bacterium if known, or to cover a wide spectrum of possibilities if not. Treatment usually continues for six to eight weeks.

Aspiration surgery is almost always done to drain the abscess. In this procedure, a needle is guided to the infected site by CT scan, and fluid is removed (aspirated) from the abscess. Aspiration may be repeated several times until the bacteria are completely killed or removed. Surgical removal of infected or dead tissue may be needed in some cases. For patients with many sites of infection, aspiration or surgical removal is not done because of the increased difficulty and risk of the procedure. For these patients, antibiotic therapy alone is used. Steroid treatment is controversial, but may be indicated in some cases.

Prognosis
Even with prompt treatment, brain abscess is fatal in about 20% of cases. About half of those who survive have some residual neurological problems, including seizures in many patients.
There are several reasons why patients with brain abscess can have a poor prognosis. The illness may not be diagnosed correctly or an accurate diagnosis may take additional time. The patient may receive an antibiotic that does not match the infecting organism. Sometimes the infection may not be limited to a definite area in the brain, making diagnosis and treatment difficult. The small number of cases caused by fungal infection may take additional time to diagnose. A patient may also have a poor prognosis because there is more than one abscess, the location of the abscess may be deep within the brain, or the infection may have moved into many locations within the brain. Severe complications can result from brain abscess, including comma and brain rupture. In 80-100% of cases involving brain rupture, the patient dies.

Prevention
Brain abscess may be preventable by prompt and aggressive treatment of the infections which give rise to it, especially sinus and ear infections.

Key Terms

Biopsy
The removal of a tissue sample for examination.

Aspiration
Removal of fluid from a closed space through a needle.

For Your Information

Books
Harrison's Principles of Internal Medicine. Ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.
Rolak, Loren A. "Brain and Spinal Abscesses." In Office Practice of Neurology, ed. Martin Samuels and Steven Feske. New York: Churchill Livingstone, 1996.
Wispelwey, Brian, and Carole A. Sable. "Intracranial Suppuration." In Current Therapy of Infectious Disease, ed. David Schlossberg. St. Louis: Mosby-Year Book, 1996.