Brain Abscess in Emergency Medicine Follow-up

  • Author: Lisa Elizabeth Thomas, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 13, 2010
 

Further Inpatient Care

  • A combined medical and surgical approach is used for most brain abscesses to eradicate the invasive organism.[12]
  • 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, 9, 43] One 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.[14] However, other series show that up to 40% of abscess cultures may be negative,[8] presumably due to early empiric antimicrobial therapy.
  • At present, most neurosurgeons use nonoperative management (ie, prolonged courses of parenteral antibiotics) only in rare cases. Indications may include patients with the following:[2, 3, 44]
    • Single abscess smaller than 2 cm
    • Multiple abscesses
    • Critical illness at a terminal stage
    • Abscess in an inaccessible location
  • 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, 45] 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, 43] 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.[46]
  • 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 children[47] and in adults[48] 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.
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Further Outpatient Care

Interval CT scans are recommended for inpatients and outpatients to follow up 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, 12]

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Transfer

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

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Complications

Complications of brain abscess may include the following:

  • Uncal or tonsillar herniation due to increased intracranial pressure (ICP)[30]
  • 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.[49]
  • Recurrence of abscess[2]
  • Long-term neurologic sequelae in up to 50% of patients (ie, hemiparesis, seizures)[4, 6, 14, 31]
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Prognosis

  • Survival rates for brain abscess are excellent.[12]
  • Characteristics associated with an excellent prognosis include the following:
    • Young age[14]
    • Absence of severe neurologic defect on initial presentation[14, 50]
    • Absence of neurologic deterioration during initial workup[14, 50]
    • Absence of comorbid disease[14, 50]
  • Worse prognosis of brain abscess is associated with the following:
    • Signs of herniation on initial presentation (Mortality rate exceeds 50%.[14] )
    • Altered sensorium at time of presentation[8]
    • Extent of brain lesion on radiology (ie, increased size, critical location, more lesions, increasing edema/midline shift)[51]
    • Short duration of symptom-onset before diagnosis[4]
    • Delay in surgical intervention[45]
    • Gram-negative infection[52]
    • Nocardial abscess (Mortality rate is 3 times that of bacterial abscess and can reach fatality rates as high as 50% in immunocompromised patients.[19] )
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Patient Education

For excellent patient education resources, visit eMedicine's Infections Center, Brain and Nervous System Center, and Brain and Nervous System Center. Also, see eMedicine's patient education articles Brain Infection, Antibiotics, and Brain Infection.

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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, 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, Neurocritical Care Society, and Society for Academic Emergency Medicine

Disclosure: CSL Behring Consulting fee Consulting

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Barry J Sheridan, DO  Chief Warrior in Transition 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.

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

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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