Brain Abscess in Emergency Medicine Treatment & Management

Updated: May 18, 2017
  • Author: Naomi George, MD; 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. If rupture is suspected, 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. [45] 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. [37] 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, 80] If used, steroids are typically given for a short course.

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Consultations

Special patient populations include individuals with HIV/AIDS and those with immunocompromised status; these 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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