CNS abscess - CNS ABSCESSES CNS Gebre K Tseggay MD CNS...

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CNS ABSCESSES CNS ABSCESSES Nov 10, 2003 Gebre K Tseggay, MD
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CNS ABSCESSES CNS ABSCESSES Focal pyogenic infections of the central nervous system Exert their effects mainly by: Direct involvement & destruction of the brain or spinal cord Compression of parenchyma Elevation of intracranial pressure Interfering with blood &/or CSF flow Include: Brain abscess, subdural empyema, intracranial epidural abscess, spinal epidural abscess , spinal cord abscess
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BRAIN ABSCESS BRAIN ABSCESS Accounts for ~ 1 in 10,000 hospital admissions in US (1500-2500 cases/yr) Major improvements realized in diagnosis & management the last century, & especially over the past three decades, with:
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BRAIN ABSCESS BRAIN ABSCESS Was uniformly fatal before the late 1800’s Mortality down to 30-60% from WWII-1970’s Introduction of abx (penicillin, chloramphenicol...) newer surgical techniques Mortality down to 0-24% over the past three decades, with: Advent of CT scanning (1974) , MRI Stereotactic brain biopsy/aspiration techniques Further improvement in surgery Newer abx (e.g. cephalosporins, metronidazole..) Better treatment of predisposing conditions
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CHANGES IN EPIDEMIOLOGY OF BRAIN ABSCESS OF BRAIN ABSCESS (in the last 2-3 decades) (in the last 2-3 decades) Marked drop in mortality overall Lower incidence of otogenic brain abscesses improved treatment of chronic ear infections With increase in No. of immunosuppressed patients: increased incidence of brain abscess seen in that population (Transplant, AIDS,…) More incidence of brain abscess caused by opportunistic pathogens (fungi, toxo…)
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PATHOPHYSIOLOGY PATHOPHYSIOLOGY Begins as localized cerebritis (1-2 wks) Evolves into a collection of pus surrounded by a well-vascularized capsule (3-4 wks) Lesion evolution ( based on experimental animal models ): Days 1-3: “early cerebritis stage” Days 4-9: “late cerebritis stage” Days 10-14: “early capsule stage” > day14: “late capsule stage”
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PATHOGENESIS PATHOGENESIS Direct spread from contiguous foci (40-50%) Hematogenous (25-35%) Penetrating trauma/surgery (10%) Cryptogenic (15-20%)
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DIRECT SPREAD DIRECT SPREAD (from contiguous foci) (from contiguous foci) Occurs by: Direct extension through infected bone Spread through emissary veins, diploic veins, local lymphatics The contiguous foci include : Otitis media/mastoiditis Sinusitis Dental infection (<10%), typically with molar infections Meningitis rarely complicated by brain abscess (more common in neonates with Citrobacter diversus meningitis, of whom 70% develop brain abscess)
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HEMATOGENOUS SPREAD HEMATOGENOUS SPREAD (from remote foci) (from remote foci) Sources: Empyema, lung abscess, bronchiectasis, endocarditis, wound infections, pelvic infections, intra-abdominal source, etc… may be facilitated by cyanotic HD, AVM.
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