Brain Abcess

Introduction 

A brain abscess is a pus-filled swelling in the brain caused by an infection. It is a rare and life threatening condition.

It happens when bacteria or fungi enter the brain tissue.

Symptoms of a brain abscess include:

• Headache – which is often severe and cannot be relieved by taking painkillers
• Changes in mental state such as appearing very confused
• Weakness or paralysis on one side of the body
• A high temperature (fever) of or above 38C (100.4F)
• Seizures (fits)

What causes a brain abscess?

There are three main ways that a brain abscess can develop:

• An infection in another part of the skull, such as an ear infection, sinusitis or dental abscess, spreads directly into the brain
• An infection in another part of the body, such as the lung infection pneumonia, spreads into the brain via the blood
• Trauma, such as a severe head injury, that cracks open the skull allowing bacteria or fungi to enter the brain

Although in around 1 in 7 cases the source of the infection remains unknown.

Treating a brain abscess

A brain abscess is regarded as a medical emergency. This is because the swelling caused by the abscess can disrupt the blood and oxygen supply to the brain. There is also a risk that the abscess may burst (rupture). If left untreated, a brain abscess can cause permanent brain damage and can be fatal.

A brain abscess is usually treated using a combination of antibiotics (or in some cases, antifungals) and surgery. Dr. B C Shah will usually open the skull and drain the pus from the abscess or remove the abscess entirely.

The sooner the condition is diagnosed and treated the lower the chance a person has of developing long-term complications.

Complications

Any damage to the tissue of the brain can result in long-term complications, such as:

• Brain damage – which can range from mild to severe
• Epilepsy – where a person has repeated seizures (fits)

Who is affected

Brain abscesses tend to only be significant problem in parts of the world where access to antibiotics is limited.

Brain abscesses can occur at any age, but most cases are reported in people aged 40 or younger. They are more common in men than women. It is not clear why this should be the case.

Outlook

Because of advances in diagnostic and surgical techniques, the outlook for people with brain abscesses has improved dramatically. Nowadays, deaths only occur in an estimated 1 in 10 of cases. Many people make a full recovery.

Symptoms of a brain abscess

The symptoms of a brain abscess can develop quickly or slowly.

In around two-thirds of people, symptoms are present for two weeks or less before they escalate to the point where the person needs to be admitted to hospital.

Common symptoms include:

• Headache - the headache is often severe, located in a single section of the head and cannot be relieved with painkillers
• Changes in mental state, such as confusion or irritability
• Problems with nerve function, such as muscle weakness, slurred speech or paralysis on one side of the body
• A high temperature (fever) of or above 38C (100.4F) 
• Seizures (fits)
• Nausea and vomiting
• Stiff neck
• Changes in vision, such as blurring, greying of vision or double vision (because of the abscess putting pressure on the optic nerve)

When to seek medical advice

Any symptoms that suggest a problem with the brain and nervous system, such as slurred speech, muscle weakness or paralysis, or seizures occurring in a person who had no previous history of seizures should be treated as a medical emergency.

Any symptoms that suggest a worsening infection, such as fever and vomiting, should be reported to Dr. B C Shah immediately.

Causes of a brain abscess

An abscess is a pus-filled swelling caused by infection with either bacteria or fungi.

The abscess is created by your immune system as a defence mechanism. If the immune system is unable to kill an infection, it will try to limit its spread. Your immune system will use healthy tissue to form a wall around the source of infection to stop the pus infecting other tissue.

The routes for brain infection

Infections of the brain are rare because the body has evolved a number of defences to protect this vital organ. One of these is the blood-brain barrier, which is a thick membrane that filters out impurities from blood before allowing it into your brain.

However, in some people, for reasons not always entirely clear, germs can get through these defences and infect the brain.

The three most common routes for germs to enter the brain are:

• Germs have already infected one of the nearby cavities in the skull (such as the ears or nose) and go on to infect the brain.
• Germs have already infected another part of the body, get into the bloodstream, bypass the blood-brain barrier and then infect the brain.
• Germs pass through the skull and enter the brain after the skull is damaged, for example after being hit by a blunt object or after a gunshot wound.

Though in around 1 in 7 cases no obvious cause for the infection can be found.

The causes of a brain abscess are explained in more detail below.

Germs from another infection in the skull

In up to a half of cases, the brain abscess occurs as a complication of a nearby infection in the skull, such as:

• A persistent middle ear infection (otitis media)
• Sinusitis (an infection of the sinuses, which are the air-filled cavities inside the cheekbones and forehead)
• Mastoiditis (an infection of the bone behind the eye)

This used to be a major cause of brain abscesses, but because of improved treatments for infections, a brain abscess is now a rare complication of these kinds of infection.

Germs invading the brain through the bloodstream

Infections spread through the blood are thought to account for around 1 in 4 cases of brain abscesses.

People with a weakened immune system have a higher risk of developing a brain abscess from a blood-borne infection. This is because their immune system may not be capable of fighting off the initial infection.

You may have a weakened immune system if you:

• Have a medical condition that weakens your immune system, such as HIV or AIDS
• Receive medical treatment known to weaken the immune system, such as chemotherapy
• Have an organ transplant and take immunosuppressant drugs to prevent your body rejecting the new organ

The most commonly reported infections and health conditions that may cause a brain abscess are:

• Cyanotic heart disease, a type of congenital heart disease (a heart defect present at birth) where the heart is unable to carry enough oxygen around the body (this lack of a regular oxygen supply makes the body more vulnerable to infection) 
• Pulmonary arteriovenous fistula – a rare condition in which abnormal connections develop between blood vessels inside the lungs; this can allow bacteria to get into the blood and then into the brain,
• Lung infections, such as pneumonia or bronchiectasis
• Infections of the heart, such as endocarditis
• Skin infections
• Infections of the abdomen, such as peritonitis (an infection of the lining of the bowel)
• Pelvic infections such as infection of the lining of the bladder (cystitis)

Germs invading the brain after a head injury

Direct trauma to the skull can also lead to a brain abscess and is thought responsible for 1 in 10 cases.

The most commonly reported causes include:

• Skull fracture caused by penetrating injury to the head
• Gunshot or shrapnel wound

In rare cases, a brain abscess can develop as a complication of surgery.

Diagnosing a brain abscess

An initial assessment will be made based on your physical symptoms and medical history, such as whether you have had a recent infection or a weakened immune system.

Blood tests 

Blood tests will be carried out to check for the presence of infection. A high level of white blood cells in your blood indicates the presence of a serious infection.

Scans

If a brain abscess is suspected, the diagnosis can be confirmed using a brain scan.

Computerised tomography (CT) scan

A computerised tomography (CT) scan involves a series of X-rays taken of your body at different angles. This produces a detailed image of the inside of your body.

A CT scan can often detect the presence of the abscess and any associated swelling inside the brain.

Magnetic resonance imaging (MRI) scan

A magnetic resonance imaging (MRI) scan uses strong magnetic fields and radio waves to produce a detailed image of the inside of your body.

A MRI scan can provide a more detailed image than a CT scan so is sometimes used if the results of the CT scan are inconclusive. 

CT-guided aspiration

If an abscess is found, Dr. B C Shah can use a CT scan to guide a needle to the site of the abscess and remove a sample of pus for further testing. This is known as CT-guided aspiration. The sample of pus should indicate the type of germ causing the abscess.

Treatment with broad-spectrum antibiotics will usually begin as soon as possible, even before a CT-guided aspiration is carried out, because it can be dangerous to wait for the results.

Broad-spectrum antibiotics can be used against a wide range of bacteria. They will be used before a specific diagnosis is made because there is a high chance they will be effective if the infection is caused by bacteria.

If the test reveals the abscess is caused by a fungus, the treatment plan can be changed and antifungal medication given.

Treating a brain abscess

Treatment for a brain abscess will depend on the size and number of brain abscesses present. A brain abscess is a medical emergency, so you will need treatment in hospital and will stay there until your condition is stable.

Medication

Surgery will be avoided if thought too risky or if an abscess is small and could be treated by medication alone.

Medication is recommended over surgery if you have:

• Several abscesses
• A small abscess (less than 2cm)
• An abscess deep inside the brain
• Meningitis (an infection of the protective membranes that surround the brain) as well as an abscess
• Hydrocephalus (a build-up of fluid on the brain)

You will normally be given antibiotics or antifungal medication through a drip (directly into a vein). Dr. B C Shah will aim to treat the abscess and the original infection that caused it.

Surgery

If the abscess is larger than 2cm, it is usually necessary to drain the pus out of the abscess.

There are two surgical techniques for treating a brain abscess:

• Simple aspiration
• Craniotomy

Simple aspiration involves using a CT scan to locate the abscess and then drills a small hole known as a burr hole into the skull. The pus is then drained through the hole and the hole sealed.

A simple aspiration takes around one hour to complete.

Open aspiration and excisions are usually carried out using a surgical procedure known as a craniotomy.

Craniotomy

A craniotomy may be recommended if an abscess does not respond to aspiration or reoccurs at a later date.

During a craniotomy, Dr. B C Shah will shave a small section of your hair and then remove a small piece of your skull bone (a bone flap) to gain access to your brain.

The abscess will then be drained of pus or totally removed. A CT-guided localisation system may be used during the operation, which allows Dr. B C Shah to more accurately locate the exact position of the abscess.

Once the abscess has been treated, the bone is replaced. The operation usually takes around three hours which includes recovery from the general anaesthetic (where you are put to sleep).

Complications of a craniotomy

As with all surgery, a craniotomy carries risks, but serious complications are uncommon.

Possible complications of a craniotomy are:

• Swelling and bruising around your face, which is common after a craniotomy. This will die down after the operation.
• Headaches. These are common after a craniotomy and may last several months, but should eventually settle down.
• A blood clot in the brain (further surgery may be required to remove it).
• Stiff jaw. During a craniotomy, Dr. B C Shah may need to make a small cut to a muscle that helps with chewing. The muscle does heal, but can become stiff for a few months, causing your jaw to feel stiff. Exercising the muscle by regularly chewing sugar-free gum should help relieve the stiffness.
• Movement of the bone flap. The bone flap in your skull may feel like it moves and you may experience a clicking sensation. This can feel strange, but it is normal and not dangerous. It will stop as the skull heals.

The site of the cut (incision) in your skull can become infected, although this is uncommon. You are usually given antibiotics around the time of your operation to prevent infection.

Recovering from surgery

Once your brain abscess has been treated, you will probably stay in hospital for several weeks so your body can be supported while you recover. 

You will also receive a number of CT scans, to make sure the brain abscess has been completely removed.

Most people will then need a further 6 to 12 weeks rest at home before they are fit enough to return to work or full-time education.

After treatment for a brain abscess, avoid any contact sport where there is a risk of injury to the skull, such as boxing, rugby or football.

Complications of a brain abscess

Possible complications of a brain abscess are outlined below.

Brain damage

Brain damage can range from mild through moderate to severe.

Mild brain damage can result in:

• Headaches
• Memory problems

Moderate brain damage can result in:

• Changes in mood such as feeling restless or agitated
• Problems with tasks that require high-level thinking such as planning and decision making
• Difficulties with balance and coordination – the medical term for this is ataxia

Severe brain damage can result in:

• Weakness in certain parts of the body
• And in the most serious of cases – coma or persistent vegetative state

Mild to moderate brain damage often improves with time. Severe brain damage is likely to be permanent.

Brain damage is more of a risk when the diagnosis of a brain abscess was delayed and treatment did not begin quickly enough. Brain abscesses can now be diagnosed very easily with a CT or MRI scan, so the risk of serious brain damage is now low.

Epilepsy

A common complication of brain abscesses is epilepsy, a condition that causes repeated fits or seizures. Epilepsy is a long-term condition and symptoms can usually be controlled using medication..

Meningitis

In some cases, especially those involving children, a brain abscess can develop into bacterial meningitis, a life-threatening infection of the protective membranes that surround the brain.

Symptoms of meningitis include:

• Severe headache
• Vomiting
• High temperature (fever) of 38ºC (100.4ºF) or over
• Stiff neck

Someone with bacterial meningitis will require urgent treatment in hospital; usually an intensive care unit (ICU).

Antibiotics will be used to treat the underlying infection. These will be given intravenously (through a vein in the arm).

At the same time a person may also be given:

• Oxygen
• Intravenous fluids (through a vein)
• Steroids or other medication to help reduce the inflammation (swelling) around the brain