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Brain abscess

Kiking Ritarwan

Definition
Brain abscess is a focal intracerebral infection that begin as a localized area of cerebritis and develops into a collection of pus surrounded by a weil-vascularized capsule. Abscess of the brain has been known for over 200 years, and surgical treatment started with MacEwen in 1893 [published: pyogenic infective disease of the Brain].

Parenchymal brain infection can arise from hematogenous delivery of infected material, which often results in multiple abscess. Especially at risk are patients with congenital heart disease or valve infection. Pathogenesis: abscess begin with local cerebritis, causing necrosis and surronding edema. Epidemiology: 0,3 1,3 per 100.000 / tahun Male to female ratio of 2:1 to 3:1

Common etiologic factors


Common etiologic factors Middle ear,paranasal sinus, or mastoid infection
Metastatic embolic from lung, pulmonary abscess, bronchietasis, or chronic empyema

Distingushing characteristics
Ear inf: temporal lobe abscess, sinus inf: frontal lobe abscess, mastoid inf: cerebellar abscess

Multiple abscess
Gunshot wounds are the most common head trauma assc. With abscess

Head trauma or Neurosurg. Endocarditis


Rare cause: dental procedures, Metastatic emboli from abdominal inf. Or PID, osteomyelitis of skull

Drug abuser

Common etiologic factors Microorgnism involved Aerobes Anaerob Streptococci, Streptococci Middle ear,paranasal Staph aureus Bacteriodes sinus, or mastoid infection
Metastatic embolic from lung, pulmonary abscess, bronchietasis, or chronic empyema
Staph aureus, Klebsiela S.Pneumoniae Streptococci, Fusobacteria

Head trauma or Neurosurg. Endocarditis


Rare cause: dental procedures, Metastatic emboli from abdominal inf. Or PID, osteomyelitis of skull

Staph aureus, Pseudomonas

streptococci

Staph aureus

Neuropatologi (4 stages)
1. Early cerebritis ( days 1-3) infection of the brain with surronding white matter edema. 2. Late cerebritis ( days 4-9) The core of the cerebritis becomes necrotic and enlarges and capsular fibroblasts begin to form. 3. Early capsule formation ( days10-13) The capsule is well developed, with proliferation of fibroblasts, a surronding astrocytic proliferation, and edema 4. Late capsule formation (days 14 or more). A mature, thick capsule surronds the central cavity containing debris and PMN cells. There is usually marked cerebral edema in the surronding brain tissue in the presence of a mature abscess.

Gejala dan tanda klinis:


Sakit kepala (70-90%) Muntah (25-50%) Kejang(30-50%) Gejala pusing, vertigo, ataksia ( pd abses cerebelli) Ggn bicara (19,6%), hemianopsia (31%), unilateral midriasis (20,5%) Gejala fokal (61%) pd penderita abses supratentorial.

Pemeriksaan utk Diagnosa:


Glasgow coma scale : utk kesadaran penderita Rontgen foto kepala, sinus, mastoid, thoraks. EEG CT Scan/ MRI Angiografi : utk menentulan lokasi abses (24%). Lab: jlh leukosit 10.000-20.000/ cm3 (60-70%) LED meningkat 45 mm/jam (75-90%).

Head Ct San

A. Multiple brain abscesses associated with bacterial endocarditis (Staphylococcus aureus) in a 55-year-old man. The large abscess in the left hemisphere shows a characteristic ring enhancement. B. Contrastenhanced CT scan 4 months after institution of antibiotic treatment. The abscesses have resolved.

Komplikasi Abses Otak


Robeknya kapsul abses kedalam ventrikel atau keruangan subarakhnoid. Penyumbatan cairan serebrospinal hidrosefalus Edema otak Herniasi tentorial oleh massa abses otak.

Pengobatan abses otak


Konservatif:
mengecilkan abses. - Prinsip pemberian AB: bakterisid thdp organisme hasil kultur, dapat melewati BBB. - Pemberian kortikosteroid: dewasa : loading dose 10-12 mg secara IV maintenance dose 4 mg secara IV setiap 6 jam anak : loading dose 10-12 mg/kg diberikan satu kali IV maintenance dose 1-1,5 mg/kg/hari IV - Pemberian antikonvulsan Operatif: Aspirasi dan eksisi. konsul Bedah Saraf , jika terapi konservatif gagal.
- Pemberian AB yg tepat : 6-8 mgg

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Antibiotic treatment for brain abscess


Ear, mastoid, sinus Streptococcal species, Ps anaerobes,
Enterobaceteriacea

Lung

S. pneumoniae

Metronidazole 7.5 mg IV every 6 h + Cefepime 2 gr IV every 6 h or meropenem 2gr IV every 8 h Same as above

AB treatment
Teeth, mouth Anaerobic streptococci, Eikenella, Prevotella, Actinomyces Metro 7,5 mg/kg IV every 12 h + PNC G 4million units IV every 4 h or ceftizoxime 3 gr IV every 6 h Cefepime 2 gr IV every 8 h, or Nafcillin or oxacillin 2 g IV every 4 h

Post operative infection, furuncles or decubiti

Staphiloc