Background

Intracranial abscesses are uncommon, serious, life-threatening infections. They

include brain abscess and subdural or extradural empyema and are classified
according to the anatomical location or the etiologic agent. The term brain abscess is
used in this article to represent all types of intracranial abscesses.[1]
Intracranial abscesses can originate from infection of contiguous structures (eg, otitis
media, dental infection, mastoiditis, sinusitis) secondary to hematogenous spread
from a remote site (especially in patients with cyanotic congenital heart disease),
after skull trauma or surgery, and, rarely, following meningitis. In at least 15% of
cases, no source can be identified.[2]
In recent years, the complex array of etiologic agents that cause brain abscess has
become better understood.

Pathophysiology
Brain abscess is caused by intracranial inflammation with subsequent abscess
formation. The most frequent intracranial locations (in descending order of
frequency) are frontal-temporal, frontal-parietal, partial, cerebellar, and occipital
lobes.[3] In at least 15% of cases, the source of the infection is unknown
(cryptogenic).[4]
Infection may enter the intracranial compartment directly or indirectly via 3 routes.

Contiguous suppurative focus (45-50% of cases)

Direct extension usually causes a single brain abscess and may occur from necrotic
areas of osteomyelitis in the posterior wall of the frontal sinus, the sphenoid and
ethmoid sinuses, mandibular dental infections, as well as from subacute and chronic
otitis media and mastoiditis.[5] This direct route of intracranial extension is more
commonly associated with subacute and chronic otitic infection and mastoiditis than
with sinusitis.[6]
Subacute and chronic otitis media and mastoiditis generally spread to the inferior
temporal lobe and cerebellum. Frontal or ethmoid sinus spread to the frontal lobes.
Odontogenic infections can spread to the intracranial space via direct extension or a
hematogenous route. Mandibular odontogenic infections also generally spread to the
frontal lobe.
The frequency of brain abscesses resulting from ear infections has declined in
developed countries. However, abscesses complicating sinusitis has not decreased in
frequency.[7] Contiguous spread could extend to various sites in the central nervous

system, causing cavernous sinus thrombosis; retrograde meningitis; and epidural,

subdural, and brain abscess.
The valveless venous network that interconnects the intracranial venous system and
the vasculature of the sinus mucosa provides an alternative route of intracranial
bacterial entry. Thrombophlebitis originating in the mucosal veins progressively
involves the emissary veins of the skull, the dural venous sinuses, the subdural veins,
and, finally, the cerebral veins. By this mode, the subdural space may be selectively
infected without contamination of the intermediary structure; a subdural empyema
can exist without evidence of extradural infection or osteomyelitis.
Intracranial extension of the infection by the venous route is common in paranasal
sinus disease, especially in acute exacerbation of chronic inflammation. Chronic
otitis media and mastoiditis generally spread to the inferior temporal lobe and
cerebellum, causing frontal or ethmoid sinus infection and dental infection of the
frontal lobe.[8]

Trauma (10% of cases)

Trauma that causes an open skull fracture allows organisms to seed directly in the
brain. Brain abscess can also occur as a complication of intracranial surgery, and
foreign body, such as pencil tip, lawn dart, bullets, and shrapnel. Occasionally brain
abscess can develop after trauma to the face.

Hematogenous spread from a distant focus (25% of cases)

These abscesses are more commonly multiple and multiloculated and are frequently
found in the distribution of the middle cerebral artery. The most common effected
lobes (in descending frequency) are the fontal, temporal, parietal, cerebellar, and
occipital.[9]
Hematogenous spread is associated with cyanotic heart disease (mostly in children),
pulmonary arteriovenous malformations, endocarditis, chronic lung infections (eg,
abscess, empyema, bronchiectasis), skin infections, abdominal and pelvic infections,
neutropenia, transplantation,[10] esophageal dilatation, injection drug use,[11] and HIV
infection.

Epidemiology
Frequency
United States
Before the emergence of the AIDS pandemic, brain abscesses were estimated to
account for 1 per 10,000 hospital admissions, or 1500-2500 cases annually.[2] The

prevalence of brain abscess in patients with AIDS is higher, so the overall rate has
thus increased.[12] The frequency of fungal brain abscess has increased because of the
frequent administration of broad-spectrum antimicrobials, immunosuppressive
agents, and corticosteroids.
International
Brain abscesses are rare in developed countries but are a significant problem in
developing countries. The predisposing factors vary in different parts of the world.

Mortality/Morbidity
With the introduction of antimicrobics and the increasing availability of imaging
studies, such as CT scanning and MRI, the mortality rate has decreased to less than
5-15%. Rupture of a brain abscess, however, is associated with a high mortality rate
(up to 80%).
The frequency of neurological sequelae in persons who survive the infection varies
from 20-79% and is predicated on how quickly the diagnosis is reached and
antibiotics administered.[13]

Sex
Brain abscesses are more common in males than in females.

Age
Brain abscesses occur more frequently in the first 4 decades of life. Because the main
predisposing cause of subdural empyema in young children is bacterial meningitis, a
decrease in meningitis due to the Haemophilus influenzae vaccine has reduced the
prevalence in young children.