Brain Abscess

Risk Factors & Pathophysiology

Presented by Ri

Definition

A focal, intracerebral infection that begins as a localized area of cerebritis ->a collection of pus surrounded by a well-vascularized capsule

~Clin Infect Dis. 1997 Oct;25(4):763-79

Pathophysiology

The brain is remarkably resistant to bacterial and fungal infection -> abundant blood supply -> blood-brain barrier Animal model: inoculation vs. induced bacteremia

Common Sources of Brain Abscess

1.

2. 3. 4.

Direct or indirect infection from paranasal sinuses, middle ear, and teeth (via valveless emissary veins to cavernous sinus) Penetrating brain injury (low incidence) Metastatic seeding from distant extracranial sources Cryptic (20%~30%) : PFO?

Clin Microbiol Infect 2003;9;803-809

Clin Microbiol Infect 2003;9;803-809

PREDISPOSING FACTORS
IVDA (2.5%) Congenital heart disease (6.1%) HIV infection (1.2%) Immunosuppression (3.7%) Diabetes mellitus (3.1%)

Stages
1. Early cerebritis stage (D1-3):focal area of inflammation and edema 2. Late cerebritis stage (D4-9):development of a necrotic central focus 3. Early capsule stage (D10-14):ring-enhancing capsule of well-vascularized tissue with early appearance of peripheral fibrosis 4. Late capsule stage (>D14):host defenses lead to a well-formed capsule ~Clin Infect Dis. 1997 Oct;25(4):763-79

IMAGING STUDIES
1.

Contrasted CT focal hypodensity->enhances after iv contrast->ring-enhanced lesion Frequently located in watershed areas, regular thin-walled capsule with peripheral enhancement Brain tumor: irregular border & diffuse enhancement

2. MRI T1: hypointense with ring-enhancement T2: hyperintense central area of pus surrounded by a well-defined hypointense capsule & edema-> surgery 3. Radionuclide scan D/D brain abscess from tumor

CLINICAL PRESENTATION

Successful non-surgical treatment of brain abscess and necrotizing fasciitis caused by Bacillus cereus. ~Internal Medicine. 41(8):671-3, 2002 Aug.

Patent Foramen Ovale as a Possible Risk Factor of Brain Abscess

~Neurosurgery. 2001 Jul;49(1):204-6

Autopsy studies: 20%-35% adults have PFO Under increased pressure in RA eg. Valsalva maneuver, pulmonary hypertension->R to L shunt->paradoxical emboli from v to a Associated with cryptogenic ischemic stroke (higher prevalence)

Case Reports

Patient 1 63 y/o male->headache & fever for 5 days->CT:hypodense lesion with ringenhancement in lt thalamus->B/C(-)->no pulmonary AVF, CHD, endocarditis->TEE with valsalva maneuver showed PFO->no other distant extracranial lesion except pyorrhea alveolaris without focal orofacial inflammatory signs

Patient 2: 36 y/o man->headache & fever-> no risk factors->MRI T1:hypointense lesion with ring enhancement in lt occipital region>TEE: valsalva maneuver revealed PFO>severe periodontitis without any focal orofacial inflammation

Conclusion

PFO may be a predisposing factor of brain abscess caused by hematogenous spread from a distant infectious focus

Thanks for your attention!