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along venous channels also explains how an abscess may sometimes form at a considerable distance from the primary focus in the middle ear or paranasal sinuses About one-third of all brain abscesses are metastatic, ie, hematogenous A majority of these are traceable to acute bacterial endocarditis or to a primary septic focus in the lungs or pleura, as indicated above Other metastatic abscesses are traceable to a congenital cardiac defect or pulmonary arteriovenous malformation that permits infected emboli to bypass the pulmonary circulation and reach the brain Occasional cases are associated with infected pelvic organs, skin, tonsils, abscessed teeth, and osteomyelitis of noncranial bones Only rarely does an acute bacterial meningitis result in a brain abscess In about 20 percent of all cases of brain abscess, the source cannot be ascertained Metastatic abscesses are usually situated in the distal territory of the middle cerebral arteries, and they are frequently multiple, in contrast to otogenic and rhinogenic abscesses (Fig 32-1) Also, almost all deep cerebral abscesses for example, those within the thalamus have a systemic source It should also be noted that the clinical and radiologic features of a solitary abscess may mimic those of a brain tumor In regard to brain abscess, careful distinction should be made between the neuropathologic effects of subacute and acute bacterial endocarditis Subacute bacterial endocarditis (SBE), ie, the type caused by the implantation of streptococci of low virulence (alpha and gamma streptococci) or similar organisms on valves previously damaged by rheumatic fever or on a patent ductus arteriosus or ventricular septal defect, seldom gives rise to a brain abscess The cerebral lesions of SBE are due to embolic occlusion of vessels by fragments of vegetations and bacteria, which cause infarction of brain tissue and a restricted in ammatory response around the involved blood vessels and the overlying meninges ( cerebritis ) The cerebral symptoms of a stroke may be the rst clinical manifestations of the disease The CSF contains a moderate number of polymorphonuclear leukocytes and frequently red cells as well, but the glucose content is not lowered and suppuration in the brain or in the subarachnoid space does not occur It is theorized that the chronicity of the streptococcal infection allows the body to develop immunity to the organisms The meningeal pleocytosis is occasionally associated with headache, stiff neck, and rarely with alterations of consciousness Over time, the in amed artery may form an aneurysm (mycotic aneurysm) that later gives rise to parenchymal or subarachnoid hemorrhage (see page 727) In contrast, the more fulminant acute bacterial endocarditis ie, the type caused by Staph aureus, hemolytic streptococcus, gram-negative organisms, or the pneumococcus (organisms that may involve previously normal valves) frequently gives rise to multiple small abscesses in the brain and other organs of the body Purulent meningitis may also develop, or there may be infarcts or meningocerebral hemorrhages and, infrequently, ruptured mycotic aneurysms Rarely do the miliary abscesses progress to large ones, as illustrated in Fig 32-1 Rapidly evolving cerebral signs in patients with acute endocarditis (delirium, confusional state, mild focal cerebral signs) are nearly always caused by embolic infarction or hemorrhage It should be mentioned that anticoagulation has not been shown to reduce the incidence of embolization from endocarditis In patients with endocarditis on a prosthetic heart valve, anticoagulation may be continued, but cautiously, and this treatment is suspended if there is a hemorrhagic brain infarction It is estimated that about 5 percent of cases of congenital heart.

Figure 32-1 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

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disease are complicated by brain abscess (Cohen, Newton) Viewed from another perspective, in children, more than 60 percent of cerebral abscesses are associated with congenital heart disease The abscess is usually solitary; this fact, coupled with the potential correctability of the underlying cardiac abnormality, makes the recognition of brain abscess in congenital heart disease a matter of considerable practical importance For some unknown reason, brain abscess associated with congenital heart disease is rarely seen before the third year of life The tetralogy of Fallot is by far the most common anomaly implicated, but the abscesses may occur with any right-to-left intracardiac or pulmonary shunt that allows venous blood returning to the heart to enter the systemic circulation without rst passing through the lungs Pulmonary emboli, by increasing the back pressure in the right heart, may open (make patent) an occult foramen ovale A pulmonary arteriovenous malformation has a similar effect Nearly half of the reported cases of pulmonary arteriovenous stulas also have Osler-Rendu-Weber telangiectasia and neurologic symptoms When the ltering effect of the lungs is thus circumvented, pyogenic bacteria or infected emboli from a variety of sources may gain access to the brain, where, aided by the effects of venous stasis and perhaps of infarction, an abscess is established At least this is the current theory of its mechanism Etiology The most common organisms causing brain abscess are streptococci, many of which are anaerobic or microaerophilic These organisms are often found in combination with other anaerobes, notably Bacteroides and Propionibacterium (diphtheroids), and may be combined with Enterobacteriaceae, such as E coli and Proteus Staphylococci also commonly cause brain abscess, but pneumococci, meningococci, and H in uenzae rarely do In addition, the gram-positive higher bacteria Actinomyces and Nocardia and certain fungi discussed later notably Candida, Mucor, and Aspergillus are isolated in some cases The type of organism tends to vary with the source of the abscess; staphylococcal abscesses are usually a consequence of accidental or surgical trauma; enteric organisms are almost always associated with otitic infec-.

Summary

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