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late stages, consciousness becomes impaired as a result of direct compression of the upper brainstem or from hydrocephalus; both are ominous signs Although slight fever is characteristic of the early invasive phase of cerebral abscess, the temperature may return to normal as the abscess becomes encapsulated The same is true of leukocytosis The sedimentation rate is usually elevated In the early stages of abscess formation, the CSF pressure is moderately increased; the cell count ranges from 20 to 300 per cubic millimeter, occasionally higher or lower, with 10 to 80 percent neutrophils; and the protein content is modestly elevated, rarely more than 100 mg/dL Glucose values are not lowered and the CSF is sterile unless there is a concomitant bacterial meningitis As already mentioned, the combination of brain abscess and acute bacterial meningitis occurs only rarely However, in some patients abscess is combined with subdural empyema; in these instances the clinical picture can be very complicated, although headache, fever, and focal signs again predominate In a small number of cases, especially partially treated ones, there are no spinal uid abnormalities and the sedimentation rate may be normal It is apparent from this overview that the clinical picture of brain abscess is far from stereotyped Whereas headache is the most prominent feature in most patients, seizures or certain focal signs may predominate in others, and a considerable number of patients will present with only signs of increased intracranial pressure In some instances the symptoms evolve swiftly over a week, new ones being added day by day In others, the invasive stage of cerebral infection is inconspicuous, and the course is so indolent that the entire clinical picture does not differ from that of malignant brain tumor In such cases the abscess may become apparent only when cerebral imaging performed for the evaluation of headache or other symptoms discloses a ring-enhancing mass Even then, the radiologic distinction between tumor and abscess is not straightforward, depending often on the presence of a uniform, enhancing capsule that is typical of a mature abscess (see below) Another impressive feature of cerebral abscess is the unpredictability with which the symptoms may evolve, particularly in children Thus, a patient whose clinical condition seems to have stabilized may, in a matter of hours or a day or two, advance to an irreversible state of coma Often this is due to rupture of the abscess into the subarachnoid or ventricular CSF Diagnosis CT and MRI are the most important diagnostic procedures In the CT scan, the capsule of the abscess enhances and the center of the abscess and surrounding edematous white matter are hypodense (Fig 32-1) With MRI, in T1-weighted images, the capsule enhances and the interior of the abscess is hypointense; in T2-weighted images, the surrounding edema is apparent and the capsule is hypointense Suppurative encephalitis (cerebritis) appears as dot-sized areas of decreased density that enhance with gadolinium Practically all abscesses larger than 1 cm produce positive scans There is almost no likelihood of cerebral abscess if enhanced CT and MRI studies are negative Blood cultures, sedimentation rate and chest x-ray are indispensable in the complete diagnosis of brain abscess, although it must be acknowledged that blood cultures are likely to be unrevealing except in cases of acute endocarditis If there is no apparent source of infection and there are only signs and symptoms of a mass lesion, the differential diagnosis includes tuberculous or fungal abscess, glioma, metastatic carcinoma, toxoplasmosis, subdural hematoma, subacute infarction of.

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the basal ganglia or thalamus, and resolving cerebral hemorrhage or infarction Sometimes only surgical exploration will settle the issue, but one must be cautious in interpreting the stereotactic biopsy if only in ammatory and gliotic tissue is obtained, since these changes may appear in the neighborhood of either abscess or tumor Treatment During the stage of cerebritis and early abscess formation, which is essentially an acute focal purulent encephalitis, intracranial operation accomplishes little and probably adds only further injury and swelling of brain tissue and possibly dissemination of the infection Some cases can be cured at this stage by the adequate administration of antibiotics Even before bacteriologic examination of the intracerebral mass, certain antibiotics can be given 20 to 24 million units of penicillin G and either 4 to 6 g of chloramphenicol, or metronidazole, a loading dose of 15 mg/kg followed by 75 mg/kg every 6 h These drugs are given intravenously in divided daily doses Metronidazole is so well absorbed from the gastrointestinal tract that it can be taken orally, 500 mg every 6 h This choice of antimicrobial agents is based on the fact that anaerobic streptococci and Bacteroides are likely to be the preponderant causative organisms Evidence of staphylococcal infection can be presumed if there has been recent neurosurgery or head trauma or a demonstrable bacterial endocarditis with this organism These circumstances call for the use of a penicillinaseresistant penicillin, such as nafcillin, 15 g every 4 h intravenously In patients sensitive to penicillin, or if methicillin-resistant staphylococci are isolated or known to be common as local nosocomial organisms, the drug of choice is vancomycin 1 g every 12 h, the dose being adjusted to maintain a serum concentration of 20 to 40 mg/mL and trough levels of 10 mg/mL Abscesses due to bacteria of oral origin do not respond well to any of these regimens because of the frequency of gram-negative organisms; a third- or fourthgeneration cephalosporin, such as cefotaxime, 2 g every 4 h intravenously, is then recommended In all cases, several weeks of treatment are advised The initial elevation of intracranial pressure and threatening temporal lobe or cerebellar herniation should be managed by the use of intravenous mannitol and dexamethasone, 6 to 12 mg every 6 h If improvement does not begin promptly, it becomes necessary to aspirate the abscess stereotactically or remove it by an open procedure for precise etiologic diagnosis (Gram s stain and culture) The decision regarding aspiration or open removal of the abscess is governed by its location and the course of clinical signs and by the degree of mass effect and surrounding edema as visualized by repeated scans Only if the abscess is solitary, super cial, and well encapsulated or associated with a foreign body should total excision be attempted; if the abscess is deep, aspiration performed stereotactically and repeated if necessary is currently the method of choice If the location of the abscess is such that it causes obstructive hydrocephalus for example, in the thalamus adjacent to the third ventricle or in the cerebellum it is advisable to remove or aspirate the mass and to drain the ventricles externally for a limited time While it has been our practice to recommend either complete excision for posterior fossa and fungal abscesses or aspiration if they are deep, there is still a lack of unanimity as to the optimal surgical approach It is customary to instill antibiotics into the abscess cavity following aspiration, but the ef cacy of this treatment is dif cult to judge The combination of antimicrobial therapy and surgery has greatly reduced the mortality from brain abscess The least satis-.

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