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Abscess of the Brain

by John E. Greenlee, MD

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, sometimes followed by surgery.

Brain abscesses are fairly uncommon. They can result from an infection that spreads from somewhere else in the head (such as a tooth, the nose, or an ear) or that spreads from another part of the body through the bloodstream to the brain. An abscess may form when bacteria 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 (see 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 AIDS, or by drugs that suppress the immune system. Such drugs may be used to prevent rejection of a transplanted organ or to treat cancer or autoimmune disorders.

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.

Symptoms

A brain abscess can cause many different symptoms, depending on its location, its size, and the extent of inflammation and swelling around the abscess. People 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. A fever and chills may occur at first but then disappear.

Diagnosis

If doctors suspect a brain abscess, magnetic resonance imaging (MRI) is done 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 dye (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 can resemble an abscess.

To identify the causative organism, 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 aspiration or biopsy), a frame is attached to the skull. The frame provides reference points that can be identified on the MRI or CT scan and enable doctors to guide the needle precisely into the abscess.

Treatment

A brain abscess is fatal unless treated with antibiotics and possibly surgery. The most commonly used antibiotics are cephalosporins (such as cefotaxime or ceftriaxone), vancomycin (or nafcillin), and metronidazole. An antibiotic is usually given for 4 to 6 weeks, and MRI or CT is repeated every 2 weeks to monitor the response to treatment. If the abscess does not shrink, a surgeon may have to drain the abscess with a needle (using stereotactic techniques to guide placement of the needle) or do open surgery to remove the entire abscess. Large abscesses usually need to be drained immediately.

Recovery may be quick or slow depending on how successful surgery is, how many abscesses are present, and 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 must take antibiotics for the rest of their life.

Doctors treat the swelling and increased pressure within the skull aggressively because these effects can permanently damage the brain. Corticosteroids (such as dexamethasone) and other drugs that reduce swelling and pressure (such as mannitol) may be used.

Anticonvulsants may be given to prevent seizures.

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • OSMITROL, RESECTISOL
  • FLAGYL
  • OZURDEX
  • NALLPEN IN PLASTIC CONTAINER
  • ROCEPHIN
  • VANCOCIN
  • CLAFORAN