This is a non contrast CT of the brain of Mr.Alex 28 year old Previously Diagnosed to have Ventricular Septal Defect, was presented with Left Sided Headache which was worsened especially in the morning,Vomiting and  Fever for 2 weeks Duration.He  has also developed right sided focal seizure 2days back.Comment on this CT?

 

ANSWER - CEREBRAL ABSCESS IN THE PARIETAL LOBE

Brain abscess is a space occupying lesion in which there is a focal collection of pus within the brain parenchyma.
 
Causes
  • Haematogenous spread - usually, from a primary site in the heart, lung or distal bones
            Subacute bacterial endocarditis - usually causing multiple abscesses
            Cyanotic congenital heart disease - loss of pulmonary filtration of organisms
           Chronic pulmonary sepsis / bronchiectasis
           Dental caries / dental extraction
           liver abscess
           Infected needle sites
  • Direct implantation of organisms - usually Compound depressed fractures,Base of Skull Fractures, neurosurgery

  • Local extension from adjacent foci
          suppurative otitis media
          mastoiditis
          frontal sinusitis
          orbital cellulitis
          meningitis

  • Impaired immunity / diabetes

In the above case the patient has been having a VSD which may increase the risk of developing bacterial infective endocarditis which may ultimately
result in cerebral abscess formation.

CLINICAL PRESENTAION
Usually, the features of a brain abscess develop over 2-3 weeks 
In the immunosuppressed, onset is rapid
  • Signs of increased ICP (headache, vomiting, confusion)
  • symptoms & signs of an inflammatory reaction (pyrexia, rigors, and dehydration)
  • Focal Neurological Signs depending on where the Lesion is located.
  • Characteristics of the infective source - look for tenderness over the mastoid, sinuses; look for a discharging ear; other diagnostic signs - e.g. cardiac murmurs in SBE

INVESTIGATIONS
  •  Chest and skull x-ray - to identify pulmonary, sinus and mastoid infection
  •  Blood culture
  •  CT scanning is the investigation of choice:
         It shows central necrotic area of reduced radiodensity with surrounding area of cerebral oedema
           Iv contrast can be used to highlight the oedematous region, so demarcating the abscess
           A ring enhancing lesion on CT & has a smoother outline
           Ventricular compression and midline shift
  • Lumbar puncture is contraindicated as it increases the rissk of coning

TREATMENT 
  • IV Antibiotics
  • Abscess drainage(Burr hole Aspiration or open evacuation - involves craniotomy)
  • Treat the underlying cause
  • Steroids may reduce oedema
  • Prophylactic anticonvulsants

COMPLICATIONS
  •   Meningitis and empyema is the abscess drains outwards
  •   Ventriculitis is the abscess drains centrally
  •   Raised intracranial pressure
  •   Epilepsy 
  •   Hydrocephalus

PROGNOSIS
Despite considerable improvements in the management of cerebral abscess, this condition still carries a high mortality - 20-30% 

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6 comments

  1. Anonymous Says:
  2. Brain abscess

     
  3. Anonymous Says:
  4. brain abcess

     
  5. Anonymous Says:
  6. abscess i meta?

     
  7. Anonymous Says:
  8. brain abscess

     
  9. Anonymous Says:
  10. abcess

     
  11. yasser Says:
  12. fever , headache , neurological deficit >> classic tringle for brain abscess,, although minority present like this

     

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