CHRONIC

CEPHALGIA ECAUSA
BRAIN ABSCESS
Presented By
Ananda Asmara
C155201010

Supervisor
Dr. dr. Hasmawaty Basir, SpS (K)
PATIENT IDENTITIY
NAME Mrs. LY
DATE OF BIRTH 26th December 1973
AGE 48 years old
ADDRESS Lingkungan Damai, Palopo
MEDICAL RECORD 98.12.36
DATE OF ADMISSION 04th June 2022
DATE OF DISCHARGE 22nd June 2022
ABOUT THE
DISEASE
Chief Complaint : HISTORY
SEVERE TAKING
HEADACHE

Experienced since 1 year ago

and has been worsened about There was history of fever
last 5 months, The pain feels since 5 months ago, the
like a stab especially in the left temperature was fluctuative.,
side of the head,

There was history of dispneu

There was history of dental
and chest pain, There was
infection 1 year ago, but the
history of congenital heart
patient refuses to go to the
disease known since 2 years
doctor.
ago,
GENERAL STATUS
Vital signs :

Blood pressure : 100/60 mmHg

Heart rate : 98 times/minute,reguler.
Respiratory rate : 24 times/minute
Body temperature : 37,0 o Celcius
SpO2 : 98% (room air)
VAS : 4-5/10
CLINICAL EXAMINATION
HEAD : NORMOCEPHAL
Eye : anemic conjungtiva (-/-),
Icteric sclera (-/-)
Ear : normal on left and right
side
THORAX

Lung: vesicular, ronchi (-/-), wheezing (-/-)

Heart: wide fixed split sound (-), murmur -/-

ABDOMEN

flat, liver and lien were not palpable

 NEUROLOGICAL STATUS
GCS E4M6V5

HIGH CORTICAL Within Normal Limit

FUNCTION

MENINGEAL SIGN Nuchal rigidity negative ; kernig sign negative /negative

CRANIAL Pupil round, isokor, diameter OD 3.0 mm/OS 3.0 mm,

NERVE DLR positive/positive, IDLR positive/positive
OTHER
CRANIAL Within Normal Limit
NERVE
MOVEMENT STRENGTH MUSCLE
N N 5 5
TONE
N N

N N 5 5 N N

Physiologic Refleks Pathological Reflex

neg neg
N N
neg neg
N N

Sensorik : normal
Otonom : Micturition normal
Defecation normal
 WORKING DIAGNOSE
CLINICAL
DIAGNOSE
Chronic Cephalgia

ETIOLOGY
DIAGNOSE
SUSPECTED
BRAIN ABSCESS

TOPICAL
DIAGNOSE
Cerebral
Hemisphere
PROMPT TREATMENT
Intravenous Fluid Drips RL 20 drops/minute
1. Metronidazole 500 mgs/8 hours/intravenous
2. 3rd generation of Cephalosporine : Ceftriaxone 2 gr/12
hours/intravenous
3. H2 antagonist receptor : Ranitidin 50 mg /12 hours/intravenous
PROMPT EXAMINATION
• Electrocardiography
• Echocardiography
• Non Contras head CT-Scan
• Chest X-Ray
• Contrast Head MRI
• Laboratory (routine blood test, kidney and liver function,
electrolytes and HIV)
ELECTROCARDIOGRAPHY

Conclusion :
Sinus rhytm, heart rate 93 i/minutes, axis 96o (Right Axis Deviation), p wave
0,06 sec, PR Interval 0,20 sec, QRS elevation 0,08 sec, fragmanted QRS II, III
AVF, V1-V5
ECHOCARDIOGRAPHY
Atrial
Septum

RA LA

DEFECT
ASD

RV LV

Ventricle
Septum
Impression :
1. Atrial Septal Defect Sinus Venosus bidirectional shunt (defect size 24-32 mm)
2. Massive Tricuspid Regurgitation with high probability of PH
3. Moderate Pulmonal Regurgitation
4. LV and RV function within normal limit
NON CONTRAST HEAD CT SCAN (June 4th 2022)

Impression :
1. Multiple lesion on left temporoparietooccipital with perifocal edema lobe which compressing the
posterior horn of left lateral ventricle and leads to midline shift around +/-0,9 cm, suspected as a
cerebral abscess
2. Brain edema
3. Septum deviation on the left side
4. Rhinitis
CHEST X-RAY (June 14th 2022)

Impression :
- Right Pneumonia
- Cardiomegaly with pulmonal
hypertension
 HEAD MRI WITH CONTRAST (8th June 2022)

IMPRESSION :
-Peripheral enhancing lesion on the left temporoparietoocipital lobe extending to the posterior horn
of the left lateral ventricle; according to the picture of the abscess, accompanied by extensive perifocal edema
and a contralateral midline shift as far as +/- 0,98cm
- Bilateral basal ganglia calcification
- Slight Deviation of the nasal septum to the left
LABORATORY EXAMINATION (June 4th LABORATORY EXAMINATION (June 8th
2022)
COMPLETE BLOOD RESULT NORMAL RANGE
2022)
ANTI HIV NONREACTIVE NONREACTIVE
COUNT

RBC 4,38 x 106/mm3 4,5 – 6 x 106/mm3 MICROBIOLOGY

HGB 14,0 gr/dL 13 – 17 gr/dL Gram Stain
HCT 44 % 40,0 – 54,0 %
RESULT NORMAL
PLT 349 x 103/mm3 150 – 500 x 103/mm3 RANGE
WBC 9,5 x 103/mm3 4,0 – 10,0 x 103/mm3 Specimen Sputum
NEUTROFIL 79 % 52 – 75 %
Gram Afinity Gram (+) and Not found
LIMFOSIT 13,7 % 20,0 – 40,0 % gram (-)
MONOSIT 5,9 % 2,0 – 8,0 % Shape and Diplococcus Not found
EOSINOFIL 0,1 % 1,0 – 3,0 % Configuration And Bacil
BASOFIL 0,7 % 0,1 – 1,0 % Quantity Positive (2+) Not found
UREUM 35 mg/dL 10 – 50 mg/dL and positive
(1+)
KREATININ 0,90 mg/dL L(<1,3), P(<1,1) mg/dL
Localization - -
SGOT 14 U/L < 38 U/L
SGPT 11 U/L < 41 U/L Other Cells Leukocytes 4+ Not found
and Epitel 4+
SODIUM 133 mmol/l 136 – 145 mmol/l
POTASSIUM 3,2 mmol/l 3,5 – 5,1 mmol/l
Fungal Spora and Not found
Hypa
CHLORIDE 113 mmol/l 97 – 111 mmol/l
FINAL DIAGNOSE
 WORKING DIAGNOSE
CLINICAL
DIAGNOSE
Chronic Cephalgia

ETIOLOGY
DIAGNOSE
BRAIN ABSCESS

TOPICAL
DIAGNOSE
Left Cerebral
Hemisphere
FOLLOW UP
Date/Month/ 05/06/2022 10/06/2022 16/06/2022 22/06/2022
Year (2) (7) (13) (18)
Subjectives (S) -Headache -No Headache - Headache - Headache
-Chest pain -Chest pain - Chest pain - Chest pain
-Dispneu sometimes -Dispneu - Dispneu - Dispneu
- no fever - no nausea and vomit - fever - no fever
- no fever
Objectives (O)

Vital signs BP 95/60 mmHg; HR BP 94/60 mmHg; HR BP 110/70 mmHg; BP 105/80 mmHg;
90x/i, RR 28 x/i, 98x/i, RR 28 x/i, HR 88x/i, RR 28 x/i, HR 88x/i, RR 28 x/i,
Temp 37,5OC Temp 37,5OC Temp 37,5OC Temp 37,5OC
VAS : 4-5 VAS : 2-3 VAS : 6-7 VAS : 3-4
GCS E4M6V5 E4M6V5 E4M6V5 E4M6V5

High cortical function Normal Normal Normal Normal

 FOLLOW UP
Meningeal signs Negative Negative Negative Negative

Cranial nerves Normal Normal Normal Normal

Motoric

Movement N N
N N N N N N
N N N N
N N N N
Strength
5 5 5 5 5 5 5 5
5 5 5 5 5 5 5 5
Muscle Tone

N N N N N N N N
N N N N N N N N
Physiology Reflex

N N N N N N N N
Pathologic Reflex N N N N N N N N

neg neg neg neg neg neg

neg neg
neg neg neg neg neg neg
neg neg
 FOLLOW UP
Sensoric Normal Normal Normal Normal

Otonom Normal Normal Normal Normal

Assesment -Chronic Cephalgia -Chronic Cephalgia -Chronic Cephalgia -Chronic Cephalgia

ecausa Brain Abscess ecausa Brain Abscess ecausa Brain Abscess ecausa Brain Abscess
- Atrial Septal Defect - Atrial Septal Defect - Atrial Septal Defect - Atrial Septal Defect
Sinus Venosus Sinus Venosus Sinus Venosus Sinus Venosus
Bidirectional Shunt Bidirectional Shunt Bidirectional Shunt Bidirectional Shunt
-Pulmonary -Pulmonary -Pulmonary -Pulmonary
Hypertension Hypertension Hypertension Hypertension
-Community Acquired -Pneumonia Dextra -Pneumonia Dextra -Pneumonia Dextra
Pneumonia

1. Ceftriaxone 2grs/12hrs/iv (D 2)
Therapy 2. Metronidazole 500mgs/8hrs/iv (D
2)
3. Ranitidin 50mg/12hrs/iv
Cardiologist :
-IVFD NaCl 0,9% 500cc/24
hours/intravenous
-Furosemide 40mg/12hours/oral
-Slidenafil 20mg/8hrs/oral
-Paracetamol 500mg/oral/extra
Pulmonologist :
-Azitromicin
500mg/24hours/intravenous
Planning :
Sputum Induction NaCl 3%
Check Sputum gram, antibiotic
culture, and antibiotic sensitivity
Plan - Head MRI with contrast
- Lumbar puncture if conditions allow
- Consultation with Neurosurgery
1. Ceftriaxone 2grs/12hrs/iv
(D 7)
2. Metronidazole 500mgs/8hrs/iv (D
7)
Cardiologist :
-IVFD NaCl 0,9% 500cc/24
hours/intravenous
-Furosemide 40mg/12hours/oral
-Revatio 40mg/8hrs/oral
-Lansoprazole 30mg/24jam/iv
Pulmonologist :
Antibiotic therapy according to
neurologist
Waiting for Sputum gram, antibiotic
culture, and antibiotic sensitivity
Neurosurgeon :
Therapy according to neurologist,
Antibiotic, continued antibiotics for 2
weeks
Continue the therapy
FOLLOW UP
1. . Ceftriaxone 2grs/12hrs/iv
(D 13)
2. Metronidazole 500mgs/8hrs/iv (D
13)
3. Mecobalamin 50mg/24 hrs/iv
4. PDA caps/12 hrs/oral
5. Ketorolac 30mg/extra/iv
Cardiologist :
-IVFD NaCl 0,9% 500cc/24
hours/intravenous
-Furosemide 40mg/12hours/oral
-Revatio 40mg/8hrs/oral
-Lansoprazole 30mg/24jam/iv
Pulmonologist :
Antibiotik therapy according to
neurologist
Waiting for Sputum gram, antibiotic
culture, and antibiotic sensitivity
Neurosurgeon :
Therapy according to neurologist
Antibiotic, continued antibiotics for 2
weeks
Continue the therapy
1. Ceftriaxone 2grs/12hrs/iv
(D 18)
2. Metronidazole 500mgs/8hrs/iv (D
18)
3. Mecobalamin 50mg/24 hrs/iv
4. PDA caps/12 hrs/oral
5. Ketorolac 30mg/extra/iv
Cardiologist :
-IVFD NaCl 0,9% 500cc/24
hours/intravenous
-Furosemide 40mg/12hours/oral
-Revatio 40mg/8hrs/oral
-Lansoprazole 30mg/24jam/iv
Pulmonologist :
Antibiotik therapy according to
neurologist
Waiting for Thorax CT scan result
Neurosurgeon :
Therapy according to neurologist.
Head MRI control with contrast
Head MRI control with Contrast, (June, 21 st 2022)

IMPRESSION :
•Peripheral enhancing lesion on the left temporoparietoocipital lobe extending to the posterior horn
of the left lateral ventricle; according to the picture of the abscess, 1,19 cm (compared with MRI Brain results
on 8th June, 2022: the impression is progressive)
•Bilateral basal ganglia calcification
•Slight deviation of the nasal septum to the left
DISCUSSION
BRAIN ABSCESS
 A 48 years old woman, admitted to the hospital with Severe
Headache experienced since 1 year ago and has been worsened
about last 5 months.

The pain feels like a stab especially in the left side of the head,
There was history of fever since 5 months ago, the
temperature was fluctuative,

There was history of dispneu and chest pain, There was

history of congenital heart disease known since 2 years ago,
There was history of dental infection 1 year ago, but the patient
refuses to go to the doctor.
From neurological examination, we found GCS E4M6V5, normal high cortical function,
negative meningeal sign, normal motoric movement and strength, normal muscle tone
and normal physiologic reflex extremities, pathological reflex are negative

From additional examination, non contrast head CT Scan showed suspected

abscess on left temporoparietooccipital lobe with perifocal edema.

Head MRI with contrast showed Peripheral enhancing lesion on the left
temporoparietoocipital lobe extending to the posterior horn of the left lateral
ventricle; according to the picture of the abscess, accompanied by extensive
perifocal edema and a contralateral midline shift as far as +/- 0,98cm. From
laboratory examination we found Neutrofil 79%, Limfosit 13,7%,Eosinofil 0,1%,
Sodium 133mmol/l and potassium 3,2 mmol/l, antiHIV : nonreactive
 According to history taking, physical examination, and additional
examination, this patient was diagnosed as chronic cephalgia due to
cerebral abscess located on left temporoparietoocipital lobe,
 CEREBRAL ABSCESS

● Brain abscess is one of the most serious diseases of the central

nervous system. This condition is more common among men,
twice to three times, and morbidity rate is highest in fourth
decade of the life.

● Brain abscess still continues to be a significant problem in the

developing world due to large scale poverty, illiteracy, and lack of
hygiene. (1,2,7)

We reported A 48 years old woman, admitted to the hospital with Chronic Cephalgia
experienced since 1 year ago and has been worsened about last 5 months.

Jones HR, Srinivasan J, Allam GJ, Baker RA. Netter’s Neurology. 2nd ed. Philadelphia: Elsevier; 2012. 408-414 p
 DEFINITION

A brain abscess can develop from three source. First because of spread of
infection from pericranial contiguous focus in 25-50% of cases (such as
sinuses, middle ear, or dental infection).

In some of the patients with cryptogenic brain abscess, it can possible to

find a cardiac source, a congenital heart disease, like a patent foramen
ovale (PFO) or a pulmonary arteriovenous fistula, PFO is primary
contributory factor to brain abscess by permitting infected material to
bypass the lungs and enter the systemic circulation.

Brouwer MC, van de Beek D. Management of Bacterial Central Nervous System Infections. Handb Clin Neurol. 2017;140:349–64.
 EPIDEMIOLOGY

Many hematogenous-borne brain abscess are multifocal and located

in the distribution of the middle cerebral artery, especially from
cyanotic congenital heart disease, those who spread from a contigous
site generally causes a solitary brain abscess.

Miranda HA, Leones S, Awad Elzain M, Moscote-Salazar LR. Brain Abscess, Current Management. J Neurosci Rural Pract. 2015;4:67–82.
 Source of infection Location of Abscess Main Pathogen
Paranasal Sinus Frontal lobe Streptococci, Staphylococcus aureus, Haemophilus
sp, Bacteroides sp...
Otogenic infections Temporal lobe, cerebellum Streptococci, Bacteroides sp, Enterobacterial
(Proteusp), Pseudomonas sp, Haemophilus sp

Odontogenic infection Frontal lobe Streptococci, staphilococci, Bacteroides,

Actinobacillus sp
Bacterial endocarditis Usually multiple abscesses, can be anywhere in the Staphylococcus aureus, streptococcus viridans
lobe
Pulmonary infection (abscess, empyem, Usually multiple abscesses, can be anywhere in the Streptococci, staphilococci, Bacteroides,
bronchiectasis) lobe Actinobacillus sp
Right to left shunt (cyanotic heart disease, Usually multiple abscesses, any lobe can be affected Streptococcus, Staphylococcus,
pulmonary AVM) Peptostreptococcus sp
Patient or postoperative trauma Depends on location Staphylococcus aureus, Staphylococus epidermidis,
Streptococcus, Enterpbacter, Clostrium sp

Patients with immunosuppression Frequent multiple abscesses, various lobes can be Aspergillus sp, Peptosterptococcus sp, Bacteroides
affected sp, Haemophilus sp, Staphylococcus

AIDS patient Frequent multiple abscesses, various lobes can be Toxoplasma gondii, Criptococcus neoforman,
affected Listeria, Mycobacterium sp, Candida, Aspergillus

There was history of dispneu and chest pain, There was history of congenital heart disease known since 2 years
ago, There was history of dental infection 1 year ago but the patient refuses to go to the doctor, so based on the
clinical examination it can be concluded that my patient’s got the source of infection from right to the left shunt (cyanotic
heart disease)

Ropper MA, Klein JP, Samuels AH. Adams and Victor Principal of Neurology. 10th ed. Mc Graw Hil Education; 2014. 714-717 p.
 The mechanism by which germs enter the brain
Direct
Odontogenic, otogenic, sinus
(25-50%)

Hematogenous Distant Focal Infections, ex : Endocarditis, primary

lung infection. Often results in multiple cerebral
(30%) abscesses.
Spreading
Pattern
After trauma Injury, surgery

Crytogenic
(up to 30%)
No source of infection
“Multiple abscess in our patient suggested hematogenous spread rather than
direct extension of focal infection”.
 Stage Time
TIME Characteristics
& PROGRESSION OF CEREBRAL ABSCESS FORMATION
Early cerebritis 1-4 days The stage is typical by neutrophil accumulation, tissue necrosis, and
edema. This is the moment for microglial and astrocyte activation that
longs through abscess development

Late cerebritis 5-10 days This phase is associated with a predominant macrophage and lymphocyte
infiltrate

Early capsule formation 11-14 days Associated with the formation of a well-vascularized abscess wall, this
wall is crucial sequestering the lesion; maintaining the integrity of the
brain function and limiting the expansion of the infective process

Late capsule formation >14 days At 3-4 weeks, the abscess capsule becomes thick and is amenable to
excision

Miranda HA, Leones S, Awad Elzain M, Moscote-Salazar LR. Brain Abscess, Current Management. J Neurosci Rural Pract. 2015;4:67–82.
CLINICAL AND SYMPTOMS
Sign/Symptom Frequency (%)
Fever 54,5-60
Headache 72-92,8
Hemiparesis/cranial nerve 14,5
Hemiparesis 20,2
No neurological deficit 39,8
Meningism 52,2
Altered level of consciousness 10-100
Seizure 21-25,3
Nausea/vomiting 31-40
Papilledema 4,1-50
GCS, at admission
3-8 10,3
9-12 28,0
13-15 61,7

Jones HR, Srinivasan J, Allam GJ, Baker RA. Netter’s Neurology. 2nd ed. Philadelphia: Elsevier; 2012. 408-414 p.
 SUPPORTING INVESTIGATION

● Laboratory
- Increased ESR
- Positive blood culture
- Lumbal puncture is not recommended
● Imaging
- CT scan with contrast → "Ring Enhancement"
- MRI
● Other support
- EEG
Miranda HA, Leones S, Awad Elzain M, Moscote-Salazar LR. Brain Abscess, Current Management. J Neurosci Rural Pract. 2015;4:67–82.
 DIAGNOSIS
MANAGEMENT
 Surgical intervention
 Antibiotics
 Solve the cerebral edema
 Eradication of primary infected foci.
Algorithm for the management of patients suspected of brain abscess

The duration of antibiotics for

brain abscess is prolonged,
usually four to eight weeks

“We decided to give

ceftriaxone and metronidazole
in our patients based on
empirical therapy guideline.”
 INDICATIONS FOR DRAINAGE / EXCISION SURGERY

● Lesions> 2.5 cm in diameter

● There is a significant mass effect
● Lesions close to the ventricles
● Neurological conditions worsen
● After therapy 2 weeks the abscess enlarges or after 4 weeks the
size of the abscess does not shrink

Sudewi R, Sugianto P, Ritarwan K. Infeksi Pada Sistem Saraf. 1st ed. Surabaya: Airlangga University Press; 2011. 21-29 p.
 MEDICAL THERAPY WITHOUT OPERATIVE ACTION

● Single abscess, size <2 cm

● Multiple abscesses or locations that are difficult to reach
● Critical state, at the final stage

Based on the results of the CT Scan and MRI of the head, we decided to choose a conservative treatment
strategy without surgery given that the location of the abscess were multiple and difficult to access.
 COMPLICATION

● Unkal or tonsillar herniation due to an increase in ICP

● Focal neurological deficits and mental retardation are recognized
complications of brain abscess, especially when occurs during
childhood.
● Abscess rupture into the ventricles or subarachnoid layer
● Long-term neurological sequelae such as hemiparesis
● Repeated abscesses
● Seizures
Sonneville R, Ruimy R, Benzonana N, Riffaud L, Carsin A, Tadié J-M, et al. An update on bacterial brain abscess in immunocompetent patients. Clin
Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2017 Sep;23(9):614–20
 PROGNOSIS
● Mortality rate is directly related to the rate of disease progression and the
neurological condition of the patient on admission.

● Intraventricular rupture and posterior fossa location where there can be

obstruction in the flow of CSF are also associated with a poor prognosis,
and with a mortality rate near to 80%, and of 90% if the ethiological
pathogen is Aspergillus

Sonneville R, Ruimy R, Benzonana N, Riffaud L, Carsin A, Tadié J-M, et al. An update on bacterial brain abscess in immunocompetent patients. Clin
Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2017 Sep;23(9):614–20