Brain Abscess in Emergency Medicine 

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

Background

Although rare in developed countries, brain abscess is a serious, life-threatening emergency. Once having a dire outcome, morbidity and mortality have decreased because of advances in diagnostic modalities, antibiotic regimens, and earlier surgical interventions.[1, 2] However, changes in epidemiology, including new disease pathogens and predisposing factors, have renewed concern about the diagnosis and treatment of this condition.

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Pathophysiology

Brain abscess is a focal infection, which begins when organisms are inoculated into the brain parenchyma, usually from a site distant from the central nervous system (CNS). Abscess formation occurs through several stages. Inflammation during the "early cerebritis" stage evolves into a necrotic collection of pus, eventually surrounded by a well-vascularized capsule after 2 weeks.[3, 4]

The 3 mechanisms of entry into the brain are as follows:[2, 5, 6]

  • Direct extension: Infections stemming from the sinuses, teeth, middle ear, or mastoid may gain access to the venous drainage of the brain via valveless emissary veins that drain these regions. Because of improved antibiotic therapy for ear infections, this mechanism is decreasing in incidence, accounting for only approximately 12-25% of cases.[2, 7] However, in developing countries, this is still a significant source accounting for at least 50% of cases.[8]
  • Hematogenous: Seeding of the brain occurs from distant infection sites and often results in multiple brain abscesses.[9] This remains an important cause of brain abscess.
  • Following penetrating head injury or neurosurgery: Previously low in incidence, more brain abscesses are developing after head trauma and neurosurgical procedures. A case series found that 37% of brain abscesses were associated with head penetration.[2, 10]

Up to 30% of abscesses are cryptogenic and have no clear source.[2, 8, 9]

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Epidemiology

Frequency

United States

Brain abscess is rare in the general population; however, immunocompromised patients have increasing incidence of brain abscess, often with fungal or protozoan organisms.

In the United States, 1500-2500 cases are reported per year.[9]

Mortality/Morbidity

  • The mortality rate from brain abscess is currently approximately 10%.[1, 2, 8, 11, 12]
  • However, if the abscess ruptures into the ventricular system, the mortality rate may be 80%.[2]
  • Morbidity in survivors is generally due to residual neurologic defects, increased incidence of seizures due to scar tissue foci, or neuropsychiatric changes.[9]

Race

No compelling evidence exists for racial differences in the incidence of brain abscess.

Sex

Brain abscess occurs two to four times as often among men than women.[2, 4, 7, 8, 13, 14]

Age

Traditionally, brain abscesses were disproportionately diagnosed in the young. However, with changes in vaccination practices, treatment of pediatric infections, and the AIDS pandemic, current literature suggests a shift in peak incidence toward the third to fifth decades of life.[2, 14, 15] The minority of abscesses that do occur in children peak in the age range of 4-7 years.[16]

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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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