eMedicine Specialties > Emergency Medicine > Infectious Diseases

Brain Abscess: Follow-up

Author: Lisa Elizabeth Thomas, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital and Massachusetts General Hospital
Coauthor(s): Joshua N Goldstein, MD, PhD, FAAEM, Assistant Professor of Surgery (Emergency Medicine), Harvard Medical School; Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Sep 25, 2008

Follow-up

Further Inpatient Care

  • A combined medical and surgical approach is used for most brain abscesses to eradicate the invasive organism.
  • Duration of antibiotic treatment is unclear and is dictated by clinical response. Traditionally 6-8 weeks of intravenous antibiotics has been used followed by oral antibiotics for another 4-8 weeks to prevent relapse.2,4,7,28 A recent series reported clinical resolution in some patients with only 2 weeks of intravenous therapy,2 indicating that some patients may not need extended parenteral treatment.
  • Surgery is the only way to precisely isolate the causative organism and tailor antibiotic therapy. One study concluded that antibiotic pretreatment for up to 10 days does not alter culture positivity of intracerebral specimen.11 At present, most neurosurgeons use nonoperative management (ie, prolonged courses of parenteral antibiotics) only in rare cases, such as an abscess at an inoperable site or multiple abscesses.2,3
  • Surgical options include aspiration, incision and drainage, or excision depending on the location, size, number of sites, and other characteristics of the abscess as well as the patient's clinical status.2,3 The specific choice of surgical technique is less important than the basic principle of removing the pathogen.3
  • Many abscesses that were once inoperable can now be reached by stereotactic aspiration guided by precision mapping of the lesion's location by CT or MRI.3,28 Stereotactic aspiration is widely preferred to open craniotomy because it is minimally invasive, has low morbidity/mortality, and allows rapid drainage.2,6 Reports of magnetic resonance fluoroscopy to guide aspiration also exist.29
  • Some interest exists in the possible role of hyperbaric oxygen as an adjunct therapy to the initial phase of treatment with intravenous antibiotics. Reports in children30 and in adults31 suggest that such adjunct therapy may reduce the length of inpatient stay by decreasing the duration of antibiotics needed for clinical improvement; however, the number of cases studied to date is small.

Further Outpatient Care

Interval CT scans are recommended for inpatients and outpatients to followup for complications and resolution of abscess,3 ,4 as there is a risk of abscess reaccumulation or failure to resolve in some cases requiring reaspiration.2

Transfer

Lack of neurosurgical availability is an indication for transfer to a medical center that has such support.

Complications

  • Uncal or tonsillar herniation due to increased intracranial pressure (ICP)21
  • Rupture of abscess into ventricles or subarachnoid space is a complication. This is often lethal. High-risk features for this complication include an abscess that is deep seated, multiloculated, and/or close to the ventricular wall.32
  • Recurrence of abscess2
  • Long-term neurologic sequelae in up to 50% of patients (ie, hemiparesis, seizures)4,6,11,22

Prognosis

  • Survival rates for brain abscess are excellent.
  • Characteristics associated with an excellent prognosis include the following:
    • Young age11
    • Absence of severe neurologic defect on initial presentation11,33
    • Absence of neurologic deterioration during initial workup11,33
    • Absence of comorbid disease11,33
  • Worse prognosis of brain abscess is associated with the following:
    • Signs of herniation on initial presentation (Mortality rate exceeds 50%.11 )
    • Extent of brain lesion on radiology (ie, increased size, critical location, more lesions, increasing edema/midline shift)34
    • Short duration of symptom-onset before diagnosis4
    • Gram-negative infection35
    • Nocardial abscess (Mortality rate is 3 times that of bacterial abscess and can reach fatality rates as high as 50% in immunocompromised patients.13 )

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to obtain emergency neuroimaging in patients with headache and new neurologic defect
  • Discharging a patient without explaining a new neurologic finding
  • Failure to heed family concerns about unusual patient behavior when other symptoms suggestive of brain abscess are present.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William Ernoehazy, Jr, MD, to the development and writing of this article.



More on Brain Abscess

Overview: Brain Abscess
Differential Diagnoses & Workup: Brain Abscess
Treatment & Medication: Brain Abscess
Follow-up: Brain Abscess
References
[ CLOSE WINDOW ]

References

  1. Alderson D, Strong AJ, Ingham HR, et al. Fifteen-year review of the mortality of brain abscess. Neurosurgery. Jan 1981;8(1):1-6. [Medline].

  2. 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. Jan 2007;26(1):1-11. [Medline].

  3. Lu CH, Chang WN, Lui CC. Strategies for the management of bacterial brain abscess. J Clin Neurosci. Dec 2006;13(10):979-85. [Medline].

  4. Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis. Oct 1997;25(4):763-79; quiz 780-1. [Medline].

  5. Sáez-Llorens X. Brain abscess in children. Semin Pediatr Infect Dis. Apr 2003;14(2):108-14. [Medline].

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

  7. Mamelak AN, Mampalam TJ, Obana WG, et al. Improved management of multiple brain abscesses: a combined surgical and medical approach. Neurosurgery. 1995;36(1):76-85. [Medline].

  8. Yang KY, Chang WN, Ho JT, et al. Postneurosurgical nosocomial bacterial brain abscess in adults. Infection. Oct 2006;34(5):247-51. [Medline].

  9. Sennaroglu L, Sozeri B. Otogenic brain abscess: review of 41 cases. Otolaryngol Head Neck Surg. Dec 2000;123(6):751-5. [Medline].

  10. Gallitelli M, Lepore V, Pasculli G, et al. Brain abscess: a need to screen for pulmonary arteriovenous malformations. Neuroepidemiology. 2005;24(1-2):76-8. [Medline].

  11. Seydoux C, Francioli P. Bacterial brain abscesses: factors influencing mortality and sequelae. Clin Infect Dis. Sep 1992;15(3):394-401. [Medline].

  12. Vidal JE, Oliveira AC, Filho FB, et al. Tuberculous brain abscess in AIDS patients: report of three cases and literature review. Int J Infect Dis 9(4):201-7. 2005;9(4):201-7. [Medline].

  13. Kennedy KJ, Chung KH, Bowden FJ, et al. A cluster of nocardial brain abscesses. Surg Neurol. Jul 2007;68(1):43-9; discussion 49. [Medline].

  14. Wolf J, Curtis N. Brain abscess secondary to dental braces. Pediatr Infect Dis J. Jan 2008;27(1):84-5. [Medline].

  15. Gaïni S, Grand M, Michelsen J. Brain abscess after esophageal dilatation: case report. Infection. Feb 2008;36(1):71-3. [Medline].

  16. Roberts J, Bartlett AH, Giannoni CM, et al. Airway foreign bodies and brain abscesses: report of two cases and review of the literature. Int J Pediatr Otorhinolaryngol. Feb 2008;72(2):265-9. [Medline].

  17. Katragkou A, Dotis J, Kotsiou M, et al. Scedosporium apiospermum infection after near-drowning. Mycoses. Sep 2007;50(5):412-21. [Medline].

  18. Khouzam RN, El-Dokla AM, Menkes DL. Undiagnosed patent foramen ovale presenting as a cryptogenic brain abscess: case report and review of the literature. Heart Lung. Mar-Apr 2006;35(2):108-11. [Medline].

  19. Enany S, Higuchi W, Okubo T, et al. Brain abscess caused by Panton-Valentine leukocidin-positive community-acquired methicillin-resistant Staphylococcus aureus in Egypt, April 2007. Euro Surveill. Sep 27 2007;12(9):E070927.2. [Medline].

  20. Sifri CD, Park J, Helm GA, et al. Fatal brain abscess due to community-associated methicillin-resistant Staphylococcus aureus strain USA300. Clin Infect Dis. Nov 1 2007;45(9):e113-7. [Medline].

  21. Hakan T, Ceran N, Erdem I, et al. Bacterial brain abscesses: an evaluation of 96 cases. J Infect. May 2006;52(5):359-66. [Medline].

  22. Kao PT, Tseng HK, Liu CP, et al. Brain abscess: clinical analysis of 53 cases. J Microbiol Immunol Infect. Jun 2003;36(2):129-36. [Medline].

  23. Marshman LA, Connor S, Chandler CL. Persistent absence of ring-enhancement on CT with an encapsulated brain abscess. Br J Neurosurg. Aug 2004;18(4):377-82. [Medline].

  24. Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx. Apr 2005;2(2):324-32. [Medline].

  25. Lai PH, Hsu SS, Ding SW, et al. Proton magnetic resonance spectroscopy and diffusion-weighted imaging in intracranial cystic mass lesions. Surg Neurol. 2007;68 Suppl 1:S25-36. [Medline].

  26. Kimberly HH, Shah S, Marill K, et al. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med. Feb 2008;15(2):201-4. [Medline].

  27. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. Dec 13 2001;345(24):1727-33. [Medline].

  28. Boviatsis EJ, Kouyialis AT, Stranjalis G, et al. CT-guided stereotactic aspiration of brain abscesses. Neurosurg Rev. Jul 2003;26(3):206-9. [Medline].

  29. Unal O, Sakarya ME, Kiymaz N, et al. Brain abscess drainage by use of MR fluoroscopic guidance. Am J Neuroradiol. 2005;26(4):839-42. [Medline].

  30. Kurschel S, Mohia A, Weigl V, et al. Hyperbaric oxygen therapy for the treatment of brain abscess in children. Childs Nerv Syst. 2005;May 5:[Medline].

  31. Kutlay M, Colak A, Yildiz S, et al. Stereotactic aspiration and antibiotic treatment combined with hyperbaric oxygen therapy in the management of bacterial brain abscesses. Neurosurgery. Dec 2005;57(6):1140-6; discussion 1140-6. [Medline].

  32. Lee TH, Chang WN, Su TM, et al. Clinical features and predictive factors of intraventricular rupture in patients who have bacterial brain abscesses. J Neurol Neurosurg Psychiatry. Mar 2007;78(3):303-9. [Medline].

  33. Xiao F, Tseng MY, Teng LJ, et al. Brain abscess: clinical experience and analysis of prognostic factors. Surg Neurol. May 2005;63(5):442-9; discussion 449-50. [Medline].

  34. Demir MK, Hakan T, Kilicoglu G, et al. Bacterial brain abscesses: prognostic value of an imaging severity index. Clin Radiol. Jun 2007;62(6):564-72. [Medline].

  35. Prasad KN, Mishra AM, Gupta D, et al. Analysis of microbial etiology and mortality in patients with brain abscess. J Infect. Oct 2006;53(4):221-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

brain abscess, intracranial abscess, intracerebral abscess, cerebritis, cerebral abscess

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Lisa Elizabeth Thomas, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital and Massachusetts General Hospital
Lisa Elizabeth Thomas, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Joshua N Goldstein, MD, PhD, FAAEM, Assistant Professor of Surgery (Emergency Medicine), Harvard Medical School; Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
Joshua N Goldstein, MD, PhD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Stroke Association, and Society for Academic Emergency Medicine
Disclosure: CSL Behring Consulting fee Consulting; Genentech Consulting fee Consulting

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.