Brain Abscess in Emergency Medicine Treatment & Management

Updated: May 06, 2020
  • Author: Melissa Kohn, MD, MS, FACEP, EMT-PHP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Treatment

Prehospital Care

Although brain abscess is rare, the emphasis of prehospital care should be on expedient transport of the patient to the hospital. Given the typical vague presentation, early suspicion in the prehospital setting is often unlikely. If rupture is suspected as there may be some preceding symptoms, urgency in transport is even greater.

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Emergency Department Care

Initial management is a function of the severity of the patient’s presentation. Goals of initial therapy include stabilizing the patient and minimizing neurological impairment. Evaluation begins with the primary survey and confirmation of the patient’s airway, breathing, and circulatory function, followed by rapid initial assessment of the patient’s neurological function.

If the patient is unable to protect his or her airway, has unstable respiratory function, or is obtunded, emergent intubation is require, and, therefore, rapid-sequence intubation should use cerebroprotective medications.

After initial stabilization, patients in whom brain abscess is suspected should undergo neuroimaging. Contrast CT of the brain is of greater utility in this population than noncontrast scanning.

Frequent neurological evaluation is recommended, particularly when intraventricular rupture is suspected.

Antibiotics are the first-line treatment for brain abscess. High-dose, broad-spectrum, intravenous antibiotics should be administered as early as possible in the patient's course. Emergent consultation with neurosurgery is recommended; however, delay in consultation should not delay antibiotic administration. Attempt to obtain blood and other cultures prior to antibiotic administration; however, it is not advisable to delay administration.

Seizure prophylaxis with anticonvulsants is typically indicated in patients with suspected brain abscess, given the high risk of seizure, which often exacerbates intracranial pressure. [57] Patients presenting with active seizure should be treated aggressively in order to avoid worsening intracranial pressure.

The use of glucocorticoids is controversial and they should not be routinely administered. Patients who are rapidly decompensating may warrant corticosteroid therapy in order to reduce the life-threatening effects of vasogenic edema. [50] However, this approach is controversial given the risk that steroids can worsen inflammation, prevent abscess formation during cerebritis stage, exacerbate necrosis, and increase the risk of ventricular rupture. [1, 93, 94] If used, steroids are typically given for a short course but are not yet noted to be associated with increased mortality. [95]

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Consultations

A neuroradiologist and neurosurgeon must be consulted quickly once the diagnosis is suspected and made. A neurologist should also be consulted to continually reevaluate any neurological symptoms. Special patient populations include individuals with HIV/AIDS and those with immunocompromised status. This set of immunocompromised patients may require early consultation with infectious disease specialists. Although the prevalence is decreasing, patients with suspected brain abscess due to maxillofacial, otogenic, or odontogenic infections require additional consultation with an oromaxillofacial surgeon or otolaryngologist, as appropriate.

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Long-Term Monitoring

Serial neuroimaging, either with CT or MRI, is typically recommended in order to follow treatment successfully to resolution of the abscess. Management may vary from weekly to monthly reimaging, depending on local practice patterns, as well as the patient’s course and symptomatic resolution. Enhancement of the lesion on neuroimaging may persist for months. Data on the precise interval for when to obtain reimaging studies are currently insufficient. In some patients, brain abscess fails to respond to antimicrobial therapy, while in others the response is not durable and the abscess reaccumulates; in these instances, reaspiration may be necessary. [41]  If the patient developed neurological deficits, outpatient therapy with physical medicine and rehabilitation should be established in order to regain as much function as possible. Follow-up with a neurologist for seizure prophylaxis should continue for at least 3 months or until seizure activity has no longer been noted on electroencephalography (EEG). [96]

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Further Inpatient Care

Despite considerable reductions in morbidity and mortality, brain abscess is a serious infection with potentially profound prognostic implications. Modern medical care of these patients often requires a swift, multidisciplinary approach. [41]

Initial management steps include confirmation of the size, location, and number of intracranial abscesses using CT with intravenous contrast, MRI, or both.

The decision to surgically manage the disease may vary with the characteristics of the abscess, and numerous practices are used. Typically, abscesses larger than 2.5 cm are excised or aspirated, often during emergent surgery. Patients in the early cerebritis stage or those with abscesses that are smaller than 2.5 cm may undergo aspiration for diagnosis only. Some neurosurgeons may prefer complete evacuation of the abscess capsule, while others may plan to reaspirate the lesions. [2, 53, 47]

Stereotactic CT or MRI-guided needle aspiration is a key procedure in facilitating expedient identification of the pathogen and may be a preferable approach compared with open craniotomy, with benefits of reduced morbidity and mortality. [97]  Culture data collected during aspiration are beneficial for targeting and narrowing antimicrobial regimens.

Empiric intravenous antibiotics given for several days have an unclear effect on the success of brain abscess aspiration culture data. A major trial looking at the use of antibiotic therapy for up to 10 days prior to aspiration showed that this practice does not alter culture growth. [39]  However, a second large study showed that approximately 40% of abscess cultures had no growth after empiric antibiotic therapy. [17]

The duration of intravenous antibiotic treatment is frequently 4-8 weeks or longer, with subsequent transition to oral antibiotics for another 4-8 weeks in order to ensure complete resolution and prevent relapse. [98]

A small body of literature on the effects of hyperbaric oxygen therapy as adjunctive therapy for brain abscess exists. Primary outcomes include reduction in length of stay and decreased duration of antibiotics therapy; however, at this time, evidence is insufficient. [99]

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Transfer

These patients frequently require neurosurgical management; thus, prompt transfer to a neurosurgical-capable hospital is appropriate if unavailable at the initial treating facility. Patients may also require ICU level of care, which is another indication for transfer.

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