A brain abscess is a pocket of pus in the brain.
An abscess may form in the brain when bacteria from an infection elsewhere in the head or in the bloodstream or from a wound enter the brain.
Headache, sleepiness, nausea, weakness on one side of the body, or seizures may result.
Imaging of the head is required.
Antibiotics are given, usually followed by drainage of the abscess with a needle or surgery to remove it.
(See also Overview of Brain Infections.)
Brain abscesses are fairly uncommon.
Fluid collects in the tissue around a brain abscess. As a result, the surrounding brain tissue swells, and pressure within the skull increases. The larger the abscess, the greater the swelling and the pressure. If the abscess leaks or breaks and pus enters the cerebrospinal fluid (which flows through the tissues that cover the brain and spinal cord), acute meningitis results.
Causes of a Brain Abscess
Brain abscesses can result from
An infection that spreads from somewhere else in the head (such as a tooth, the nose, or an ear)
An infection that spreads from another part of the body through the bloodstream to the brain
Bacteria that enter after a head wound that penetrates the brain, including incisions that are made during brain surgery
Sometimes the cause is unknown.
Many types of bacteria, including Streptococcus bacteria, Staphylococcus aureus, and Bacteroides fragilis, can cause a brain abscess. The protozoa Toxoplasma gondii (which causes toxoplasmosis) and fungi, such as aspergilli, are common causes of brain abscesses in people who have a weakened immune system. The immune system may be weakened by disorders such as human immunodeficiency virus (HIV) infection, which leads to end-stage HIV infection (AIDS), or by medications that suppress the immune system (immunosuppressants). Immunosuppressants may be used to prevent rejection of a transplanted organ or to treat cancer or autoimmune disorders.
Symptoms of a Brain Abscess
A brain abscess can cause many different symptoms, depending on its location, its size, and the extent of inflammation and swelling around the abscess.
A fever and chills may occur at first but then disappear.
People with a brain abscess may have a headache, feel nauseated, vomit, become unusually drowsy, and then lapse into coma (which often occurs when pressure within the brain continues to increase). Seizures may occur, one side of the body may become weak, or thinking may be impaired. Symptoms can develop over days or weeks. However, in some people, fever and chills are mild, do not occur until late in the infection, or do not occur at all.
Diagnosis of a Brain Abscess
Magnetic resonance imaging or computed tomography
Withdrawal and testing of a sample of pus from the abscess
If doctors suspect a brain abscess, magnetic resonance imaging (MRI) is done before and after gadolinium is injected intravenously. Gadolinium (an MRI contrast agent) makes abscesses easier to see on MRI scans. If MRI is unavailable, computed tomography (CT) can be done after a radiopaque contrast agent (which makes abscesses easier to see on CT scans) is injected intravenously. MRI has higher resolution and can show early abnormalities better than CT. However, additional tests may be needed to establish the diagnosis because a brain tumor or damage due to a stroke or multiple sclerosis can resemble a brain abscess.
To identify the causative organism and thus determine which medications would be most effective, doctors withdraw a sample of pus from the abscess with a needle. It is examined under a microscope and sent to a laboratory to grow (culture) bacteria in the fluid so that they can be identified. MRI or CT is used to guide the needle into the abscess. For this procedure (called stereotactic needle aspiration), a frame is attached to the skull. The frame provides reference points that can be identified on the MRI or CT scan. Thus, after drilling a small hole through the skull, doctors can guide the needle precisely into the abscess.
However, doctors do not wait to get the result of culture to start treatment.
Treatment of a Brain Abscess
Antibiotics
Usually, drainage of the pus with a needle or surgery to remove the abscess
Sometimes drugs to reduce swelling and pressure
A brain abscess is fatal unless treated with antibiotics and possibly surgery. Medical management is an option for deep-seated, small abscesses (< 2 cm), cases with coexisting meningitis, and a few other selected instances. Usually, a combination of medical and surgical approaches is considered. The most commonly used antibiotics are
These antibiotics may be used together until doctors determine which specific antibiotic is most effective against the organism causing the abscess. Typically, large abscesses (>2 cm) are considered for aspiration or excision. The approach for multiple abscesses includes a prolonged course (4 to 8 weeks) of high-dose antibiotics with or without aspirations, guided by weekly CT scanning.
For large abscesses and abscesses that become larger despite antibiotic treatment, a surgeon drains the abscess with a needle (using stereotactic techniques to guide placement of the needle) or does open surgery to remove the entire abscess.
Recovery may be quick or slow depending on
How successful surgery is
How many abscesses are present
How well the person’s immune system is functioning
If people with a weakened immune system have an abscess due to Toxoplasma gondii or a fungus, they may have to take antibiotics for the rest of their life.
Antiseizure medications may be given to prevent seizures.
