BRAIN ABSCESS

DEFINITION
A brain abscess is a collection of infectious material within the tissue of the
brain.Bacteria is the most common causative organisms.The most common
predisposing factors for abscess among immunocompetant people are ottitis
media and sinusitis.

ETIOLOGY
o

Ottitis media and sinusitis.

Intracranial surgery ,penetrating injury or tongue piercing.

Wound or intra abdominal infection.

Ottitis media, sinusitis,mastoiditis,dental infections and systemic

infections.

CLINICAL MANIFESTATIONS
o

Head ache usually worse in the morning

Fever,vomiting and focal neurological deficits.(weakness and decreasing

vision reflects the area which is involved)

Increased ICP and decreased level of consciousness

PATHOPHYSIOLOGY

The mechanisms to the entry of the micro organisms are as follows:

o

Direct extension-Infections stemming from the sinus,middle ear or

mastoid may gain access into the venous drainage of the brain via
valveless emissary veins and drain into this region. Because of the
antibiotic therapy for this infections incidence rate due to this type of spread
has been decreased to a greater extent

Haematogenous spread-This includes the spread via blood

Following penetrating head injury or neurosurgery-Most cases can

also occur as a result of penetrating head injury or trauma.

ASSESSMENT AND DIAGNOSTIC FINDINGS

o

History collection and physical examination

MRI and CT scan demonstrates a ring around the hypodense area.

Aspiration of the abscess guided by CT scan or mRI helps to identify the

organism

Blood cultures if the origin of the abscess is from a distant sourse

Chest X-ray to rule out predisposing lung infections

CT Scan to evaluate the bony structure of the ear and the sinus

MEDICAL MANAGEMENT
o

The goal of the treatment is to drain the abscess and to provide antibiotic
therapy for the infection detected.

Large IV doses of antibiotics are given to penetrate the blood brain barrier
and to reach the site of infection.

The choice of the antibiotic depends on the causative organism being

identified by culture.

Corticosteroids are prescribed to reduce the inflammatory cerebral edema.

Antiseizure medications(Phenytoin and phenobarbitone )is prescribed to

prevent or to reduce seizure.

NURSING MANAGEMENT

Nursing care focuses on the assessment of neurological

status,administering the medication,assessing the response to the
treatment and providing supportive care.

Blood laboratory test results especiallyblood glucose and serum

potassium levels has to be monitored and corticosteroids are prescribed.

Administration of insulin or electrolyte replacement is required to return

this values to the normal state.

The level of consciousness and the physical status has to be monitored

constantly

Observe for neurological deficits like hemiparesis,seizures,visual deficits

etc..

Cerebral Edema
- Is an increase in the water content of the brain tissue. When cerebral edema
occurs as a result of trauma, hemorrhage, tumor, abscess or ischemia, an
increase in ICP occurs.
Herniation
- When the pressure exerted by a mass in the brain is not equally divided,
result in shifting or herniation of the brain from one compartment of high
pressure to one of lower pressure.
Clinical Manifestations

- Change in level of consciousness is the most sensitive and important indicator

of neuro status
- Early signs may be nonspecific: restlessness, irritability, generalized lethargy
- Determine the level of stimulus needed to arouse the patient (verbal, touch,
shaking?)
- Content of consciousness: orientation
- Speech: clear, coherent, slurred, distorted, aphasic, incomprehensible sounds,
no effort to speak
- Report changes immediately.
- Changes in vital signs- Increasing systolic blood pressure
- Widening pulse pressure
- Bradycardia
- Pulse slowing and is bounding

- Irregular respiratory pattern

- May also have a change in temperature
- Ocular signs
- Pupil changes are from pressure on third cranial oculomotor nerve result in
dilation of pupil
- Pupils become sluggish, unequal. This is because of brain shift. May also be
pressure on other cranial nerves
- A fixed, unilaterally dilated pupil indicates herniation of the brain
- Motor ability is controlled by nerve tracks originating in the frontal lobes of
the brain.
- Distortion of brain tissue along these pathways can cause motor dysfunction.
- Patient may exhibit localization to painful stimulus or withdraw from it.
- Motor strength and tone are assessed in all 4 extremities.
- Decorticate posturing now called abnormal flexion,
- Decerebrate posturing now called abnormal extension.
- Decrease in motor function
- May have hemiparesis or hemiplegia
- May see posturing either decorticate or decerebrate
- Decerebrate more serious from damage in midbrain and brainstem
- Decorticate from interruption of voluntary motor tracts
- Headache
- From compression on the walls of cranial nerves, arteries and veins
- Straining and movement makes worse
- Vomiting
- NOT preceded by nausea- unexpected
- May be projectile
Diagnostic Tests
- CT
- MRI
- Cerebral angiography
- EEG
- No lumbar puncture if there is ICP because sudden release of pressure can
cause brain to herniate
- ABGs keep O2 at 100% and PCO2 as related to ICP (25-35)
Drug Therapy
- Mannitol Rapid short acting diuretic that decreases ICP. Decreases total
brain water content
- Watch fluids and electrolytes closely (I and O and labs)
- Dont give in cases of renal failure or if serum osmolality increased
Drug Therapy
- Barbiturates causes decrease in metabolism and ICP. Causes reduction in
cerebral edema and blood flow to brain.
- Skeletal muscle paralyzers may be used (Pavulon)
- Antiseizure drugs Dilantin
- Loop diuretics reduce blood volume and tissue volume
Nutrition
- Fluid balance is controversial
- Give saline either .45% or normal saline not glucose to help prevent
additional cerebral edema
- Watch sodium if on Mannitol may need to give additional salt.

- Also may need additional free water if dehydrated watch I and O closely.
Nursing Interventions
- Airway and respiratory suction only as needed and for 10 seconds at a time,
only 2 passes. Give 100% O2 prior to suctioning.
- Avoid abdominal distention may need NG tube to decompress stomach
- Sedate with care if not on a ventilator, use sedation that will not interfere
with respiration or mask any neuro changes
* Posture and head position
Avoid jugular vein compression
- Head should be in neutral position
- Cervical collars should not be too tight
Elevation of the head and trunk may improve jugular venous return.
- Keep head in alignment to prevent cutting off venous flow from the head
- Dont elevate knees this will increase intrathoracic pressure
- Turn gently from side to side if turning raises ICP, client will need to stay on
back
- If client is posturing frequently during care, will need to sedate first and then
do only one thing at a time. Minimize stimulation
- These clients can become agitated and aggressive avoid over stimulating
them
- Restraining them will make them MORE AGITATED and RAISE THEIR ICP!
- NO TV IN ROOM
- Keep room darkened if needed
- Hyperventilation (PaCO2 < 35 mmHg) works by decreasing blood flow and
should be reserved for emergency treatment and only for brief periods
- May need eye drops to moisten eyes
- Client may benefit from rehab to help him adapt and progress
- Keep body temperature within normal limits
- Do not use ice on client
- Prevent infection
- Protect from injury
- Avoid factors that increase ICP
- Psychological support