BRAIN AND SPINAL ABSCESSES

• A brain abscess is a free or encapsulated collection of

infectious material of brain parenchyma, between the dura
and the arachnoid linings (subdural abscess) or between the
dura and the skull (epidural abscess). Spinal abscesses
typically occur in the epidural region.
Etiology
• Intracranial subdural abscesses, usually due to a streptococcus organism, are
caused by purulent drainage between the dura and arachnoid. It can result
from pus from the meninges, middle ear or mastoid, sinuses, septicemia, or
skull fracture. It occurs most frequently in children and young adults.
• Intracranial epidural abscesses, typically involving an infection of the cranium,
commonly occur due to chronic mastoiditis or sinusitis, head trauma, or
craniotomy. Abscesses may be related to a subdural empyema (collection of
purulent drainage originating from nasal sinuses, meninges, middle ear, or
skull osteomyelitis), meningitis, or intraparenchymal abscess.
• Spinal epidural abscesses occur in the spinal canal external to the dura.
Epidural penetration may seed through the blood and occur from infected
adjacent tissue (eg, infected pressure ulcer), from another infected site (eg,
skin), or contamination from spinal surgery or spinal instrumentation (eg,
lumbar puncture). S. aureus is a frequent causative agent and the midthoracic
vertebrae are most commonly affected.
• Intermedullary abscesses are more common in the pediatric population, and
are associated with lumbosacral dermal sinuses. Approximately 20% to 30%
are “cryptic” abscesses with no apparent source of infectious seeding.
• In the initial inoculation period, organisms invade the brain parenchyma
resulting in local inflammation and edema. The resulting cerebritis develops
into a necrotic lesion and then becomes encapsulated.
• Fungal brain abscesses are commonly seen in HIV-positive patients and other
populations that are immunosuppressed. Diffuse microabscesses may occur
with infections caused by Candida species.
• M. tuberculosis may cause abscesses of pus containing acid-fast bacilli (AFB)
surrounded by a dense capsule. These abscesses are also found in patients
who are HIV-positive or have other immunosuppressive diseases.
Clinical Manifestations
• Headache is poorly localized with a dull ache.
• Increased ICP may result in nausea, vomiting, decreased LOC.
• Fever is found in less than 50% of cases.
• Neurologic findings such as hemisensory and paresis deficits, aphasia, ataxia
may be present.
• Seizures are frequently present.
• Dental abscess, sinusitis, and otitis media may be present.
• Signs and symptoms of a cerebral subdural empyema include severe
headache, fever, nuchal rigidity, and Kernig's sign.
• Patients with intracranial epidural abscess commonly present with fever,
lethargy, and severe headache.
• Spinal epidural abscesses may be evidenced by severe back pain, fever,
headache, lower extremity weakness or paralysis, nuchal rigidity, Kernig's
sign, and local tenderness.
Diagnostic Evaluation
• CT scan, MRI with contrast locate the sites of abscess, and follow evolution and resolution of
the suppurative process.
• In the inflammatory stage of cerebritis, imaging reveals a high signal intensity centrally
(inflammation) and peripherally (edema). When an abscess develops, the capsule becomes
isointense.
• There may be decreased ring enhancement with patients who are immunosuppressed, which
may be due to a lack of inflammatory response.
• Microabscesses may not be detected by the CT scan or MRI.
• MRI with gadolinium enhancement should be considered to detect spinal epidural abscesses.
• Blood cultures are obtained to identify the organism, positive Gram's stain, leukocytosis, and
elevated erythrocyte sedimentation rate (ESR).
• Cultures are obtained from the suspected source of infection, using stereotaxic needle aspiration or
brain surgery, to identify the organism and sensitivity to antimicrobials.
• A metastatic brain abscess may be differentiated from a metastatic tumor by CT scan or MRI.
Abscesses have hypodense centers with a smooth surrounding capsule, whereas tumors may have
irregular borders and diffuse enhancement.
• EEG detects seizure disorders.
• Findings in cerebral subdural empyema include increased WBC and increased pressure of the CSF.
• In intracranial epidural abscesses, CT or MRI scans are useful; MRIs are usually more sensitive.
Findings from the CSF may not be definitive. To avoid transtentorial herniation, lumbar puncture is not
indicated until large cranial masses are ruled out.
• Diagnostic findings in spinal epidural abscesses may include increased WBC and ESR. The CSF may
be cloudy. Myelography is typically abnormal.
Management
• With cerebral subdural empyema or intracranial epidural abscesses, management consists of trephining
(drilling through skull to evacuate purulent material), systemic antibiotics, and treatment of cerebral edema.
• Spinal epidural abscesses may be managed with a laminectomy and surgical drainage, with antibiotics
before and after the procedure. The abscess site is thoroughly irrigated with antibiotic solution and aerobic
and anaerobic cultures are taken.
• Closed stereotaxic needle biopsy, under CT guidance, may be used for drainage evacuation instead of
craniotomy.
• Radical surgical debridement, especially with fungal infections, may be indicated with antimicrobial therapy.
• Initiation of empiric antimicrobial therapy is based on Gram's stain and the suspected site of origin.Because
brain abscesses are frequently caused by multiple organisms, antimicrobial therapy is directed toward the
most common etiologic agents: streptococci, anaerobic bacteria (eg, Bacteroides species).
• S. aureus may be suspected if surgical procedures have been performed.
• Gram-negative bacteria (eg, Clostridium species) should be suspected if a cranial wound has
been contaminated with soil.
• A 6- to 8-week course of parenteral antibiotics is typical, followed by a 2- to 3-month course of
oral antimicrobial therapy.
• Penicillin G, metronidazole, and third-generation cephalosporins are common therapeutic agents.
• Antifungal therapy, such as amphotericin B, is initiated for candidiasis and other fungal infections.
• Antituberculosis pharmacotherapy, such as rifampin, isoniazid, and pyrazinamide, should be
used to treat abscesses containing AFB.
• Adjunctive therapy includes corticosteroids and osmotic diuretics to reduce cerebral edema, and
anticonvulsants to manage seizures.
Complications
• The brain abscess can rupture into the ventricular space, causing a sudden
increase in the severity of the patient's headache. This complication is often
fatal.
• Papilledema may occur in less than 25% of cases, indicating intracranial
hypertension.
• Lumbar puncture may be dangerous due to the possibility of brain stem
herniation. Lumbar puncture is also contraindicated if there is a spinal epidural
abscess because pus may be transferred into the subarachnoid space.
Cervical puncture should be considered in such patients.
• Permanent neurologic deficits, such as seizure disorders, visual defects,
hemiparesis, and cranial nerve palsies, may be present.
• There is greater mortality if the patient has symptoms of short duration, has severe
mental status changes, and has rapid progression of neurologic impairment.
• Delayed treatment of a spinal epidural abscess may result in transaction syndrome,
in which flaccid paraplegia with sensory loss occurs at the level of the abscess.
• In chronic otitis media, intracranial and intratemporal complications frequently
result from progressive bony erosion, which may expose the dura, labyrinth, and
facial nerves.
• Nursing Assessment
• Obtain history of previous infection, immunosuppression, headache, and
related symptoms.
• Perform neurologic assessment, including cranial nerve evaluation, motor, and
cognitive status.
• Nursing Diagnoses
• Acute Pain related to cerebral mass
• Disturbed Thought Processes related to disease process
• Risk for Injury related to neurologic deficits
• Anxiety related to surgery, prognosis, and relapse
Nursing Interventions
Relieving Pain
• Administer pain medications as ordered.
• Provide comfort measures, such as quiet environment, positioning with head
slightly elevated, and assistance with hygiene needs.
• Provide passive relaxation techniques, such as soft music and backrubs.
Promoting Thought Processes
• Frequently monitor vital signs, LOC, orientation, and seizure activity.
• Report changes, which can signal increased ICP, to health care provider.
• Administer medications as ordered, noting response and adverse reactions.
• Prepare patient for repeated diagnostic tests to evaluate response to therapy
and surgery.
Minimizing Neurologic Deficits
• Maintain a safe environment with side rails up, call light within reach, and
frequent observation.
• Evaluate other cranial nerve function, and report changes.
• Refer to occupational therapy, speech therapist, or other rehabilitation
specialist to provide adjunct to nursing rehabilitation.
Reducing Anxiety
• Prepare patient and family for surgery when indicated. Encourage discussion
with surgeon to understand risks, benefits of the procedure.
• Explain postoperative progression and nursing care.
Community and Home Care Considerations
• Patient follow-up is essential for sinusitis, otitis media, respiratory infections,
and other infectious processes that may result in a brain abscess.
• Continue with rehabilitation to regain or compensate for neurologic deficits.
• Continue with pharmacologic regimen in community setting.
• Observe for recurrence of brain and spinal abscesses.
Patient Education and Health Maintenance
• Maintain wellness with vaccinations, immunizations, and overall health.
• Reinforce need for dental procedure prophylaxis to avoid dental abscesses.
• Instruct in need for immediate assessment of head wounds.
Evaluation: Expected Outcomes
• Verbalizes reduced pain
• Oriented to person, place, and time; follows simple commands
• No injury related to neurologic deficits
• Reduced anxiety regarding disease process and procedures