Management Topic

The Management of Intracranial Abscesses

M
ost UK neurosurgeons treat 1-4 patients with an Bacteroides. In patients with a primary skin infection or
intracranial abscess each year. Intracranial an abscess complicating recent neurosurgery,
abscesses can occur at any age. Contiguous Staphylococcus aureus is prevalent.
spread to the intracranial cavity may occur directly or via
emissary veins from infected paranasal sinuses, the mid- Investigations
dle ear and the mastoid. Such abscesses are usually locat- Serial white blood cell counts, ESR and CRP levels provide
ed in the frontal or temporal lobes, or in the cerebellum. useful parameters to monitor response to treatment –
Haematogenous spread of infection can occur from the although not infrequently such investigations may be nor-
skin, dental sources and the lungs. Sixty percent of mal and can result in a delayed diagnosis. Blood cultures
Peter Whitfield is a Consultant
patients have a pre-disposing condition including an may help determine the likely pathogen. However, a CT or Neurosurgeon at the South West
infective source (ear, sinus, teeth, lung), diabetes or an MRI scan of the brain +/- contrast secures the diagnosis Neurosurgical Centre in Plymouth.
immunocompromised state. Patients with cyanotic heart and should always be performed before a lumbar punc- He has previously worked in
Glasgow and Aberdeen in addition
disease are also at risk since circulating blood bypasses the ture is considered. An abscess appears as a ring-enhanc-
to his higher surgical training in
pulmonary bacterial filter. Abscesses with a haematoge- ing, space demanding process. The ring of enhancement is Cambridge. Peter has a PhD in the
nous origin are frequently located in the middle cerebral usually quite linear without the heterogeneous appear- molecular biology of cerebral
artery territory, presumably due to haemodynamic fac- ances characteristic of a malignant glioma. The most fre- ischaemia. His clinical interests
include vascular neurosurgery,
tors. Such abscesses are sometimes multiple. quent abscess locations are frontal, temporal or cerebellar.
image guided tumour surgery and
They are usually sub-cortical, but small abscesses may microsurgical spinal surgery. He
Presentation abut the grey-white matter interface in the middle cere- has a practical interest in medical
The clinical features in patients with an intracranial bral artery territory. A CT or MRI scan may also reveal an education and is involved in imple-
mentation of the Phase 2 teaching
abscess evolve with time and depend upon the host- infected source such as a paranasal sinus infection or an
in neurosciences at the Peninsula
pathogen interactions. From a brain perspective patients ear infection. The diagnosis is confirmed by examination Medical School.
have one or more of the following clinical scenarios: of pus obtained directly from the abscess. Once an abscess
1. Symptoms and signs of raised intracranial pressure has been identified, broad-spectrum antibiotics should be
Correspondence to:
(headache, impaired level of consciousness, slow men- commenced and urgent neurosurgical referral made.
Peter Whitfield,
tation, nausea, vomiting, papilloedema). South West Neurosurgery Centre,
2. Focal neurological deficits due to compression of neu- Surgical Options Derriford Hospital,
ronal pathways (e.g. hemiplegia, dysphasia, frontal Surgery is required to obtain pus from a solitary abscess. Plymouth PL6 8DH.
Email:
symptoms and signs, cerebellar syndrome). Sometimes this is non-diagnostic particularly if anti-
[email protected]
3. Seizures. These may by focal, Jacksonian or Grand Mal. biotics have been administered. Surgery also reduces the
bulk of an abscess providing symptomatic relief and min-
Constitutional symptoms and signs (pyrexia, rigors, dehy- imising the risks of abscess growth (intraventricular rup-
dration, neck stiffness) and clinical features due to an ture, herniation, venous sinus thrombosis). The surgical
infected source elsewhere in the body are surprisingly options include aspiration, craniotomy and complete
uncommon at the time of presentation. excision or craniotomy and marsupialisation.

Pathology Aspiration
Britt and Enzmann described a canine model of Image guided (CT or MRI) frameless stereotactic aspira-
Streptococcal abscess evolution with pathological phases tion has recently become the most commonly utilised sur-
that correlate with the clinical presentation in man.1 An gical technique to treat an abscess. For small and deep
initial acute inflammatory cerebritis (days 1-9) is followed abscesses (< 2cm) a stereotactic frame increases the accu-
by hyperaemic capsule formation (days 10-14) and racy of the localisation technique. In patients with multi-
fibroblastic maturation (after day 14). Necrotic liquifac- ple abscesses, the largest lesion is usually aspirated and
tion and inflammatory exudate accumulate in the abscess other lesions monitored with post-operative imaging.2,3
cavity. During expansion of the abscess, the medial wall is
usually thinner and less resistant and may result in ventri- Craniotomy
culitis. This is a poor prognostic indicator. A craniotomy can be performed as a primary procedure
or if abscess re-growth occurs after initial aspiration. In
Microbiology the majority of patients brain swelling is prominent and
The majority of intracranial abscesses contain several mannitol should be administered intraoperatively to min-
mixed pathogens. In many patients, particularly those imise this problem. If the abscess is located in non-elo-
with sinus or ear infections a variety of aerobic and quent brain the abscess wall is dissected from the sur-
microaerophilic Streptococcal species are found (e.g. rounding brain permitting enucleation of the lesion. If the
Strep millari; Strep pneumoniae, Strep pyogenes), often in abscess is in an eloquent region a trans-cortical approach
combination with Haemophilus influenzae and can be made through a 2 cm incision. An intersulcal
Pseudomonas aeriginosa and anaerobes such as approach shortens the distance to the lesion compared

Image guided (CT or MRI) frameless stereotactic aspiration

has recently become the most commonly utilised surgical
technique to treat an abscess

12 I ACNR • VOLUME 5 NUMBER 1 • MARCH/APRIL 2005

Management Topic

Figure 1a: Figure 1b: Figure 1c:

This 20 year old female presented to the neurologists with She represented 5 weeks later with similar symptoms. Her This Gadolinium enhanced MRI scan taken 4 weeks later
headaches and vomiting. An MRI scan showed frontal lobe CRP and white cell count were normal. This contrast shows involution of the abscess cavity. Intravenous
cerebritis and ethmoid congestion. Note the extensive changes enhanced CT scan shows the characteristic appearances of an ceftriaxone and metronidazole were continued for a further 3
on this T2W image. She was treated with intravenous intracerebral abscess with a thin walled cavity surrounded by weeks followed by 3 weeks of oral Augmentin. A repeat scan 1
antibiotics for 3 weeks, improved and was discharged. cerebral oedema. She underwent an emergency craniotomy to month later showed further involution of the cavity.
marsupialise the abscess. She also underwent bilateral
sphenoidectomies and a partial ethmoidectomy to treat the
infective source.

with the more traditional transgyral corticotomy. The within 48 hours of surgery serves as a useful baseline for
operative microscope is used to visualise and preserve cor- subsequent imaging. Provided the patient remains stable,
tical vessels within the sulcus. The abscess wall is then repeating the scan at weekly intervals for 2 weeks and then
encountered and opened widely (marsupialisation) to at fortnightly intervals for a further 1-month enables re-
permit complete aspiration of all pus (Figure 1a). The accumulation of the abscess to be detected at a pre-clini-
cavity is thoroughly irrigated with saline (some surgeons cal phase (Figures 1b, 1c).
use a dilute solution of hydrogen peroxide). The use of
haemostatic matrices (e.g. Surgicel) is limited to avoid Treatment of Primary Focus
colonisation of such materials. Following evacuation or To minimise the risk of recurrent or non-responsive
open drainage the brain swelling has usually improved intracranial infection any identifiable primary source
considerably permitting replacement of the bone flap requires aggressive treatment.4 This may include surgery
during closure. for paranasal, middle ear or dental sepsis, physiotherapy
and antibiotics for pulmonary infection and surveillance
Peri-Operative Care echocardigrams in patients with a cardiac source. The
Several factors need to be addressed. These include the timing of such interventions does not need to coincide
choice and duration of antibiotic treatments, the role of sur- with intracranial surgery but should be undertaken in an
veillance imaging, the treatment of any primary focus, the expert, timely fashion.
use of steroids and the use of prophylactic anticonvulsants.
Steroid Therapy
Antibiotic Treatment In general steroids are not used in brain abscess patients
The choice of antibiotics is governed by several factors due to the immunosuppression associated with these
including the appearances on an initial Gram stain, the drugs. However, extensive oedema may surround the
potential for mixed aerobic and anaerobic pathogens, and abscess and contribute to raised intracranial pressure. In a
antibiotic penetration. Expert microbiological advice is deteriorating clinical situation steroids can improve the
invaluable when selecting antimicrobials. For the majori- clinical status of patients when there appear to be few
ty of primary abscesses initial intravenous treatment with options remaining. This is probably due to a reduction in
a third generation cephalosporin and metronidazole is the inflammatory process reducing concomitant oedema.
appropriate. Cultures may subsequently refine the choice
of antibiotics. Prophylactic Anticonvulsants
Some antibiotics can be safely instilled during surgery Between 40-50% of patients who suffer from an intracra-
(e.g. Gentamicin 10mg), but direct instillation of peni- nial abscess will develop epilepsy. Prophylactic anticonvul-
cillin is unsafe and can cause seizures. The duration of sants should therefore be seriously considered. Patients
antibiotic treatment is controversial. If antibiotics are should contact the DVLA and refrain from driving.
administered for a short period (e.g. 2 weeks) there does
appear to be an increased risk of recurrence. Provided sur- Prognosis
veillance imaging is satisfactory a 4-week course of intra- In the pre-CT era the mortality of cerebral abscesses was
venous antibiotics, supplemented by a further 2 weeks of in the region of 30-40%. CT scanning and improved
oral treatment is recommended. localisation techniques have reduced this to less than 5%.
The use of modern treatment regimes with image-direct-
Surveillance Imaging ed neurosurgery may reduce this further. Risk factors for
MRI is preferred to CT scanning to abolish the risks of a poor outcome include deep-seated location, intraven-
radiation exposure. A post-operative MRI scan performed tricular abscess rupture causing ventriculitis and a poor

14 I ACNR • VOLUME 5 NUMBER 1 • MARCH/APRIL 2005

 Management Topic

Figure 2a:
Axial CT scan showing opacification of
the right maxillary sinus in a patient
with a subdural empyema. This source
of infection requires treatment.

Figure 2b:
Axial CT scan + contrast showing a
right parasagittal subdural empyema in
the same patient as figure 2a. This
requires surgical drainage and is best
performed through a parasagittal
craniotomy taking care to preserve
veins bridging from the cortex to the
superior sagittal sinus.

neurological status.5 Many patients with a neurological tain a mural “scolex” of larvae. Neurocysticercosis may be
deficit achieve significant recovery during the rehabilita- asymptomatic, cause epilepsy or result in a focal neuro-
tive phase of care. logical deficit. Management is directed at seizure control.7
Empirical treatment with the anti-helminthic agents
Rare Intracranial Infections albendazole or praziquantel is not mandatory in the late
“burnt-out” phase of the disease. Surgery is only required
Subdural empyema and extradural abscesses if seizures are not controlled medically or in rare instances
These are both rare. They are usually associated with con- when space occupation is problematic.
tiguous otological or sinus pathology and are identified on
CT scans (Figure 2a). While extradural abscesses are read- Summary
ily detected, subdural empyemas typically have a subtle Although the incidence of intracranial abscesses has
appearance on CT scans (Figure 2b). They are charac- decreased over the past 100 years the surgical principles
terised by a relatively thin, low attenuation mass with min- expostulated by MacEwen in 1881, namely debridement
imal enhancement associated with a profound clinical pic- and drainage, remain of paramount importance.
ture (impaired level of consciousness, neurological deficit Advances in neuronavigation techniques make stereotac-
and fits). Symptoms and signs of infection may not be pre- tic drainage a simple procedure that can be performed
sent. Early aggressive surgery targeted at the intracranial expeditiously for the majority of abscesses. The appropri-
mass and any source of infection is recommended. A cran- ate use of effective antibiotic therapy adds to the thera-
iotomy is the preferred option for an empyema due to the peutic armamentarium. Surveillance imaging with MRI
viscous nature of the pus that is not readily washed out of scans is now the follow-up modality of choice. These
the subdural space. Indeed, a fibrinous layer of tissue usu- changes in management have seen a significant reduction
ally adheres to the arachnoid and is best left undisturbed in the mortality of brain abscesses in the last 20 years.
after thorough irrigation under direct vision. The risk of a
neurological deficit and epilepsy in patients with a sub-
dural empyema exceeds 60%, probably due to multiple
small cortical venous infarctions.6

Tuberculosis
TB remains common in the Indian sub-continent and
cases of intracranial TB are seen in the UK. Symptoms of
raised ICP and/ or epilepsy should lead to the suspicion of
a tuberculoma. This is a calcified parenchymal lesion with
central caeseating necrosis. TB only rarely causes a typical
brain abscess appearance. Treatment options depend on References
the clinical status of the patient and lie between clinical 1. Britt RH, Enzmann DR. Clinical stages of human brain abscesses on
serial CT scans after contrast infusion. J.Neurosurg. 1983;59:972-989.
surveillance, empirical anti-tuberculous treatment with
2. Boviatsis EJ, Kouyialis AT, Stranjalis G, Korfias S, Sakas DE. CT-guid-
follow-up scans, image-guided aspiration combined with
ed stereotactic aspiration of brain abscesses. Neurosurgical Review
medical treatment and rarely surgical excision. 2003;26:206-209.
3. Barlas O, Sencer A, Erkan K, Eraksoy H, Sencer S, Bayindir C.
Neurocysticercosis Stereotactic surgery in the management of brain abscess. Surgical
This disease is endemic in most developing parts of the Neurology 1999;52:404-410.
world. The larvae of this ingested intestinal tapeworm 4. Sennaroglu L, Sozeri B. Otogenic brain abscess: review of 41 cases.
Otolaryngology - Head and Neck Surgery 2000;123:751-755.
hatch from eggs in the intestine and migrate to a variety
5. Takechita M, Kagawa M, Izawa M, Takakura K. Current treatment
of tissues including brain parenchyma, muscles, subcuta- strategies and factors influencing outcome in patients with bacterial
neous tissues and the eye. In many cases the host immune brain abscess. Acta Neurochirurgica 1998;140:1263-1270.
system eliminates the parasite expeditiously. However, CT 6. Cowie R, Williams B. Late seizures and morbidity after subdural
and MRI indicate that small-calcified parenchymal cystic empyema. J.Neurosurg. 1983;58:569-573.
lesions can persist. These may be multiple and may con- 7. Sotelo J. Neurocysticersosis. Br Med J 2003;326:511-512.

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