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PubMed1983

Current concepts of bacterial infections of the central nervous system. Bacterial meningitis and bacterial brain abscess.

Investigative work continues to provide guidance toward more rational management of bacterial meningitis and bacterial brain abscess. An increased understanding of the host's response in cases of bacterial meningitis has established that diffusibility of an antibiotic into the cerebrospinal fluid (CSF) is necessary, but is not sufficient for microbial cure. The antibiotic must also have a bactericidal effect on the pathogen. Meningitis after neurosurgery may be caused by Gram-negative aerobic bacilli. In some of these cases the newer cephalosporin antibiotics may be a useful advance. Meningitis complicating ventricular CSF shunts presents a paradigm for the problem of eradicating foreign body-related infections. Studies of the interaction of the host, the organism, and the shunt material offer some explanation for the limited efficacy of antibiotics observed in this setting. There have been advances in microbial definition of bacterial brain abscess. The identification of Bacteroides fragilis as a pathogen in certain brain abscesses has established a role for a newly available antibiotic, metronidazole. The study of the pathological distinction between cerebritis and frank abscess is clarifying two clinical characteristics of brain abscess: the limited success of antibiotic treatment and the increase in intracranial pressure. Computerized tomography has offered a valuable clinical "look" at brain abscesses; however, there are still problems in correlating the scan images with the evolving pathological process.

Adrenal Cortex Hormones↗
PubMed1980

Evolution of brain abscess in cats formation of capsule and resolution of brain edema.

Brain abscess evolution was studied in an experimental model in the cat correlating the computed tomographic scan appearance with intracranial pressure, brain edema and histopathological findings. Brain inflammation was produced by direct inoculation of Staphylococcus aureus into the white matter. Abscesses developed in all animals. The ring enhancement around the necrotic focus seen at an early stage after contrast-medium injection cannot be equated with capsule formation as long as the abscess diameter increased. Parallel to the acute stage of abscess, the intraventricular pressure increased due to the rising mass effect and the spreading edma. The morphological investigations revealed on the seventh day an extreme enlargement of extracellular spaces with immense amount of edema fluid, rich in protein and fibrin. Some blood vessels in the close vicinity of the abscess showed gaps within the endothelial cell layer. When encapsulation developed, ring enhancement became more homogeneous and decreased in diameter. In spite of encapsulation, a circumscribed disturbance of the blood-brain barrier persisted which was responsible for a belated resolution of edema and a slow decrease of intracranial pressure. Only therapy with dexamethasone could effect a marked change in the course of the disease.

Animals↗
PubMed2004

Characterization of Streptococcus constellatus strains recovered from a brain abscess and periodontal pockets in an immunocompromised patient.

BACKGROUND: There have been a number of reports of brain abscesses suggesting an odontogenic etiology. However, no efforts have been made to compare brain abscess isolates with isolates from the oral cavity using highly discriminative methods. We report a brain abscess caused by Streptococcus constellatus in an immunocompromised patient where oral infection (periodontitis) was suspected to be implicated. METHODS: The brain abscess and oral isolates were compared by means of one phenotypic and three genetic (restriction fragment length polymorphism [RFLP], ribotyping, and random amplified polymorphic DNA [RAPD]) fingerprinting techniques. RESULTS: The phenotypic method and RFLP showed identical profiles between brain and periodontal isolates, while ribotyping and RAPD showed very close similarity, with only one band difference in one of the three ribotypes and in one of the three polymorphic RAPD. CONCLUSIONS: Gene transfer by genetic recombinational events in the periodontal pocket might have been responsible for the emergence of a strain variant of S. constellatus that had the potential to cause an abscess at a distant site (brain). The importance of odontogenic sources as potential foci of infection for brain abscesses is discussed.

Brain Abscess↗
PubMed1991

Penetration of cefotaxime and desacetylcefotaxime into brain abscesses in humans.

Since clinical trials comparing the efficacies of different antibiotic regimens for treatment of brain abscesses are difficult to perform, the choice of antibiotics must rely on the antibacterial spectrum and the ability of the drug to penetrate into the abscess fluid. The aim of this investigation was to study the ability of cefotaxime and its active metabolite desacetylcefotaxime to penetrate into brain abscesses. Eight patients were given 3 g of cefotaxime intravenously every 8 h. Abscess fluid samples, obtained at surgery at various times after dosing, and blood samples were analyzed for their concentrations of cefotaxime and desacetylcefotaxime by using a newly developed microbiological assay. The brain abscess concentrations of cefotaxime and desacetylcefotaxime were 1.9 +/- 1.7 and 4.0 +/- 2.2 mg/liter, respectively. Simultaneous concentrations in plasma were 2.0 +/- 1.0 and 3.9 +/- 1.8 mg/liter, respectively. With increasing time following cefotaxime dosing there was a significant increase in the abscess:plasma concentration ratio of desacetylcefotaxime. Since both cefotaxime and desacetylcefotaxime penetrate well into the brain abscess, reaching concentrations above the MIC for probable bacteria except gram-negative anaerobes, it is concluded that cefotaxime in combination with metronidazole may be used as an alternative in the treatment of brain abscesses.

Adult↗
PubMed1999

Brain Abscess.

Optimal treatment of a brain abscess requires early clinical suspicion, and the diagnosis is usually made by identification of the abscess on contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). The immediate first step is to reduce the potentially life-threatening brain mass (abscess and surrounding cerebral edema) and secure the diagnosis with culture specimens. This is usually accomplished by reducing the increased intracranial pressure (ICP) through surgical aspiration with or without drainage of the abscess pus. The surgical procedure chosen depends on several factors, including the location and type of abscess, multiplicity, and the medical condition of the patient. In addition, dexamethasone and hyperventilation may be required if brain herniation is imminent. The dexamethasone dose should be reduced as soon as the ICP is reduced because steroid administration may retard abscess capsule formation and decrease antibiotic concentrations within the abscess cavity. Antibiotic therapy should be started as soon as the diagnosis is made. Penicillin G or third-generation cephalosporins plus metronidazole are commonly given to treat both anaerobic and aerobic bacteria. The initial choice of antibiotic will vary on the basis of the suspected source of the brain organisms, which is most often either contiguous spread from a sinus or mastoid infection or hematogenous spread from a pulmonary, gastrointestinal, cardiac, or dental infection. Isolation and determination of the antibiotic sensitivities of the organism from abscess pus allow definitive antibiotic therapy. Patients should be managed in an intensive care unit. Phenytoin is often given to prevent seizures, which could further elevate the ICP. The duration of antimicrobial treatment is 4 to 8 weeks, during which time the patient should be monitored clinically and with repeated neuroimaging studies to ensure abscess resolution.

Journal Article↗
PubMed2002

The multiple brain abscesses associated with congenital pulmonary arteriovenous malformations: a case report.

In this report, we describe a case of multiple brain abscesses associated with diffuse congenital pulmonary arteriovenous malformations (PAVM). Although the cases of brain abscesses associated with congenital PAVM are very rare, the brain abscess could be an initial clinical manifestation in asymptomatic PAVM as in the case presented in this report. PAVM may contribute to the development of a brain abscess by allowing easy bacterial access to systemic circulation through the right-to-left pulmonary vascular shunt, bypassing the filtering effect of the pulmonary capillaries. Hence, this association should be considered in cases with brain abscesses of undetermined etiologic factors.

Arteriovenous Malformations↗
PubMed1999

Postcraniotomy gas-containing brain abscess: a neurosurgical emergency. Case report.

BACKGROUND: Gas-containing brain abscesses are very rare, and the majority are caused by Clostridium perfringens. We report a case of gas-containing brain abscess that required urgent surgery after a craniotomy for a brain tumor. METHODS AND RESULTS: The patient was a 53-year-old male who presented with a cerebral neoplasm. A temporal lobectomy was performed and the diagnosis of low grade glioma was confirmed. Although the surgery was uneventful the postoperative course was complicated; the patient became agitated and febrile and deteriorated to a deep coma. A computed tomography scan demonstrated gas in the temporal fossa at the lobectomy site, producing mass effect. Urgent surgical debridement and drainage was performed and C. perfringens and mixed flora were found. Antibiotics were started and the patient's condition markedly improved. He was awake and alert, followed commands adequately and was extubated; however, after a week he suffered massive gastrointestinal bleeding and died. CONCLUSIONS: Early recognition of a gas-containing brain abscess is of great interest to immediately start the appropriate treatment. Urgent surgical debridement and broad spectrum chemotherapy are major components in the management of this entity.

Brain Abscess↗
PubMed2002

Rhodococcus equi brain abscess in an immunocompetent patient.

Rhodococcus equi brain abscesses usually occur in immunocompromised patients with prolonged and refractory pulmonary infections. Herein we report a case of R. equi brain abscess in a 67-y-old man without immunodepression. Our patient recovered after neurosurgical resection and prolonged antimicrobial therapy with vancomycin and trimethoprim-sulfamethoxazole.

Actinomycetales Infections↗
PubMedDate not supplied

Citrobacter diversus and neonatal brain abscess.

A 23-day-old infant presented with apnea and was found to have Citrobacter diversus meningitis and brain abscess. The organism persisted in brain abscess fluid for over 4 weeks despite adequate antibiotic therapy. Cranial computed tomography demonstrated persistent radiolucencies in both frontal lobes, and midline shift, long after completion of antibiotic therapy. Effective therapy of C. diversus meningitis and brain abscess may require use of an antibiotic active within phagocytes, and judicious surgical drainage. A high prevalence of brain abscess mandates cranial computed tomography for any infant with C. diversus meningitis.

Bacteriological Techniques↗
PubMed2002

Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses.

BACKGROUND: Diffusion-weighted MR imaging (DWI) has recently shown promise in differentiating ring-enhancing lesions such as brain abscess and malignant neoplasm. The ability of DWI to strongly suggest brain abscess enables a neurosurgeon to alter stereotactic planning to optimize diagnosis. We report our experience with DWI in 5 patients with lesions on MR imaging and review the literature to assess the usefulness of this technique in the preoperative evaluation of cerebral abscess. METHODS: The MR images of 5 patients presenting with ring-enhancing lesions that ultimately proved to be brain abscesses were retrospectively reviewed. In addition to standard MR sequences, trace DWI and apparent diffusion coefficient (ADC) calculations were performed on all patients. Additionally, 15 recently published articles or references in press concerning DWI in cerebral abscesses were reviewed. RESULTS: All lesions were markedly hyperintense on DWI and had diminished ADC. Thirty-eight of 39 previously reported abscesses were hyperintense on DWI with reduced ADC. Of 165 nonpyogenic lesions with DWI findings, 87 were hypointense or isointense, 78 lesions had variable hyperintensities, and few manifested the degree of hyperintensity observed with abscesses. Most of these included chordomas and epidermoids, which are not likely to be confused with abscesses. CONCLUSIONS: Restricted water diffusion, as indicated by hyperintensity on DWI and low ADC, in ring-enhancing lesions assists in differentiating brain abscess from necrotic tumor. This information facilitates stereotactic surgical planning: abscesses should be preferentially centrally aspirated, whereas necrotic brain tumors should have diagnostic tissue biopsied from cavity walls. Although not definitive for brain abscess, restricted water diffusion is an important MR imaging sign and is useful in neurosurgical treatment strategies for ring-enhancing lesions.

Adult↗
PubMed2004

[Recurrent brain abscess associated with congenital pulmonary arteriovenous fistula: a case report].

We report a rare case of recurrent brain abscess associated with congenital pulmonary arteriovenous fistula. A 52-year-old man was admitted to our hospital in October, 1999 because of a sudden stroke-like onset of right hemiparesis, right hemiparesthesia, dysarthria and sensory aphasia. He had a history of previous brain abscess in the right cerebellar hemisphere. It had been removed in 1991. CT scan at the time of the current admission disclosed a low-density area in the left parietal region. The mass was ring-enhanced after injection of contrast medium. On MRI the mass lesion was depicted as low-intensity on T1-weighted image and high-intensity on T2-weighted image. The mass was ring-enhanced after administration of Gd-DTPA. In spite of conservative treatment the size of the abscess increased considerably with marked surrounding edema. The brain abscess was successfully treated with aspiration and drainage, and the residual mass was resected. The patient also had a history of arteriovenous fistula in the lower lobe of his right lung. This had been excised in 1965. However, he had no signs, symptoms or family histories of hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). Contrast enhanced CT scan of the chest showed nodular lesions connected to vascular shadows in the right lower lung field. Pulmonary angiograms also revealed multiple arteriovenous fistulas in the lower lobe of the right lung. He was not dyspneic or cyanotic, but his hypoxia, polycythemia, and recurrent brain abscess were thought to be caused by pulmonary arteriovenous fistula. The fistulas were embolized with coils via a percutaneous catheter. Pulmonary arteriovenous fistula should be treated aggressively either by surgery and/or by coil embolization in order to prevent the complication of brain abscess.

Anti-Bacterial Agents↗
PubMed1981

[Inflammatory brain oedema and regional brain metabolism in experimental brain abscess in cats (author's transl)].

Brain abscess were produced in cats, by inoculating an agar-bouillon mixture with Staphylococcus aureus into the white matter of the right cerebral hemisphere. The accompanying oedema, which can be regarded as vasogenic, extended outwards from the site of inflammation and by the seventh day had involved the entire right hemisphere. As the abscess became encapsulated the oedema at the periphery subsided but it persisted, however, in the close proximity of the causative organisms to the tissue. The changes in the regional brain metabolism were most obvious at the time when the oedema was maximal. This tended to become normal with the increasing encapsulating which took place from the seventh day onwards.

Animals↗
PubMed1984

Experimental anaerobic brain abscess. Computerized tomographic and neuropathological correlations.

The neuropathological progression of brain abscess formation induced by a mixed anaerobic culture of Bacteroides fragilis and Staphylococcus epidermidis was studied experimentally in dogs. Histological findings were correlated with computerized tomographic (CT) brain scans. The evolution of brain abscess formation could be divided into three stages based on histological criteria: early cerebritis (Days 1 to 3); late cerebritis (Days 4 to 9); and capsule formation (Day 10 and later). Capsule formation could not be divided into early and late stages because encapsulation was delayed compared with a previously reported model of alpha-Streptococcus brain abscess. Histologically, there was evidence for a very virulent infection. Leptomeningitis was significant even in the late stages. Early ventricular rupture occurred in 25% of the animals. A pattern of extensive purulent encephalitis was seen in 25% of the animals. In the early cerebritis stage, blood vessels near the necrotic center were engorged and were surrounded by hemorrhage and/or protein-rich fluid. Cerebral edema was extensive. Although fibroblasts appeared in late cerebritis, there was marked delay of capsule formation. Three-week-old lesions still had areas of incomplete capsule formation and foci of uncontrolled infection. In the cerebritis stages, CT scans showed an area of ring enhancement which was incomplete on early scans (at 5 minutes after injection of contrast material) but partially filled in and thickened on delayed scans (at 20 to 45 minutes). On even later delayed scans there was no decrease in intensity of ring enhancement. Lesions in which capsule formation occurred also showed ring enhancement, but delayed scans showed a decrease in the intensity of enhancement. The lesions that ruptured into the ventricular system showed atypical CT findings, with either lack of contrast enhancement (histologically there was minimal cerebritis adjacent to the abscess cavity) or a marked delay in contrast enhancement (cerebritis was more extensive and corresponded to the width of ring of enhancement). This study suggests that Bacteroides fragilis is a virulent organism in the brain. The developing abscesses enlarged quickly, were prone to early ventricular rupture, and showed incomplete and delayed encapsulation.

Animals↗
PubMed1981

Multiple brain abscesses.

A young woman with 12 separate brain abscesses was treated medically after aspiration of one abscess for diagnostic bacteriological examination. She made an excellent recovery with only minimal residual neurological dysfunction. Surgical aspiration for detailed bacteriological studies followed by appropriate antimicrobial therapy is an effective way of treating multiple brain abscesses in the neurologically stable patient.

Adult↗
PubMed1997

Diagnostic and staged stereotactic aspiration of multiple bihemispheric pyogenic brain abscesses.

BACKGROUND: Empiric antibiotic therapy for multiple brain abscesses is not advised, as biopsy to rule out other causes and material for cultures can be obtained with minimal morbidity using computed tomography (CT)-guided stereotaxy. METHODS: We report a good outcome following treatment of this 60-year-old nonimmunocompromised patient with six pyogenic cerebral abscesses. CT-guided stereotactic aspiration of two abscesses were done on the first occasion and appropriate antibiotics were administered. Serial CT scans were done and the abscesses that recollected or enlarged were again aspirated. RESULTS: Group A beta hemolytic streptococci were grown from the pus. Two abscesses recollected and one enlarged during antibiotic therapy. These were aspirated on the second and third occasions, 1 week and 2 weeks after the first procedure. The abscess less than 3 cm resolved with antibiotics alone. Intravenous crystalline penicillin, chloroamphenicol, and metronidazole were given for 2 weeks followed by oral ampicillin and cotrimoxazole for 10 weeks. There was no morbidity related to the multiple procedures and the patient had a good outcome at the end of 16 weeks. CONCLUSIONS: CT-guided stereotactic aspiration of multiple brain abscesses is known to have a low morbidity and mortality. We highlight the additional option of multiple, staged aspirations for those abscesses not readily responding to antibiotic therapy.

Brain Abscess↗
PubMed1997

Diagnosis of brain abscess by magnetic resonance spectroscopy. Report of two cases.

Two cases of brain abscess were diagnosed by combining magnetic resonance spectroscopy (MRS) and magnetic resonance (MR) imaging. The resonances observed in vivo were assigned by means of an in vitro MRS study of the exudates extracted during surgical aspiration of the abscesses. The technique of MRS was demonstrated to be very powerful in the differential diagnosis of brain abscesses from other brain pathologies such as neoplasms. Amino acids, probably originating from extracellular proteolysis, and other compounds, such as acetate, arising from bacterial metabolism, were visible in the MRS spectra of the abscess, whereas they are not present in spectra of neoplasms. In this sense, MRS complemented the information provided by MR imaging to achieve a correct diagnosis of brain abscesses and could be added to routine MR examinations with only a small increase in cost and time.

Adult↗
PubMed2001

Differentiation of tuberculous from pyogenic brain abscesses with in vivo proton MR spectroscopy and magnetization transfer MR imaging.

BACKGROUND AND PURPOSE: MR imaging features are nonspecific with respect to the causative organism for patients with brain abscesses. On the basis of the hypothesis that the biochemical environment depends on the infecting organism and might be different in tuberculous compared with pyogenic brain abscesses, this study attempted to determine whether pyogenic brain abscesses can be differentiated from tuberculous brain abscesses by use of magnetization transfer (MT) MR imaging and in vivo proton MR spectroscopy. METHODS: Twenty-seven patients with a total of 33 pyogenic brain abscesses and three patients with a total of 12 tuberculous abscesses were evaluated with in vivo MR spectroscopy and MT MR imaging. The diagnosis in all cases was based on the culture of the causative organisms and histopathology whenever done as a part of clinical management. RESULTS: All 27 patients with pyogenic brain abscesses had lipid and lactate levels of 1.3 ppm and amino acid levels of 0.9 ppm with or without the presence of succinate, acetate, alanine, and glycine, while the three patients with tuberculous abscesses showed only such lipid and lactate levels. The MT ratio from the wall of the pyogenic abscesses was significantly higher (P <.001) than that from the tuberculous abscess wall. CONCLUSION: It might be possible to differentiate tuberculous abscesses from pyogenic abscesses by using MT MR imaging and in vivo MR spectroscopy, which could be of value in influencing the management of such cases.

Adolescent↗