Cerebral abscess, subdural empyema and spinal epidural abscess

Question 1

How is abscess differentiated from tumor on MRI?

Answer 1

The abscess usually do have a core of restricted diffusion, seen on DWI sequences. (DWI bright and ADC dark implies viscous fluid.)

Question 2

What is the most common spread route of cerebral abscesses?

Answer 2

1. Hematogenous spread,
   * pulonary infections - empyema
   * bacterial endocarditis
   * dental abscesses

Question 3

What are the 2 most common agens of bacterial abscess intracranially?

Answer 3

1. Streptococcus
2. Anaerobic or microaerophilic agens

Question 4

The agens differs if the patient has had surgery to the head previously. What are the 2 most common agens then?

Answer 4

Staff. epidermidis and Staff aureus.

Question 5

How many patients with an abscess present with hemiparesis or seizures?

Answer 5

30-50%

Question 6

What is the normal “aging/stages” of an abscess?

Answer 6

1. early cerebritis
2. late cerebritis - develope necrotic centre
3. early capsule
4. Late capsule - necrotic centre and collagen center “pop” on entrance.

Question 7

What is the use of LP in a suspected cerebral abscess?

Answer 7

None. Avoid.

Question 8

When should an abscess be drained?

Answer 8

Only those that are not responding to antibiotics alone and that are 2-6 cm. OR those that are already over 3 cm when found.

Question 9

What is the estimated size of an abcess to respond well to antibiotics?

Answer 9

0.8-2.5cm

Question 10

Indications except size over 3cm or non-responders to antibiotics:

Answer 10

• significant masseffect/ sign raised ICP
• Proximity to ventricle
• Poor neurologic condition
• traumatic abscess w foreign material
• Fungal abscess
  *difficulty diagnosing but be aware of different etiologies.

Question 11

What is the medical treatment of an abscess?

Answer 11

• Vancomycin
• Metronidazole
• 3rd generation cephalosporine
  All together. MInd the difference to meningitis treatment!

Question 12

What is the difference in treatment of meningitis and an abscess?

Answer 12

In meningitis a 4th generation cephalosporine is used.
In meningitis no metronidazole is used.
In meningitis its important to add corticosteroid treatment fast.
In meningitis vaccination is recommended

Question 13

How emergent is subdural empyema in comparison to an abscess?

Answer 13

Its more emergent. It might be complicated with *cerebral abscess, * cortical venous thrombosis, * localised cerebritis

Question 14

In a non-postoperative setting, what is the most likely cause of subdural empyema?

Answer 14

Direct extension from local infection- frontal sinuitis.

Question 15

What are the two most common pathogens of non-iatrogenic subdural empyema?

Answer 15

1. Streptococcus
2. Staphylococcus

Question 16

SIgns of spinal epidural abscess?

Answer 16

• back pain
• fever
• spine tenderness

Question 17

Risk factors for spinal epidural abscess?

Answer 17

• DM
• IV drug use
• Chronic renal failure
• Alkohol overuse
• chronic steroid use
• resent spinal procedure
• trauma - recent back trauma is common.

Question 18

How many % of pt w spinal epidural abscess are immunocompromised or have a chronic disease?

Answer 18

65%

Question 19

What is th number one finding on clinical examination of a patient with spinal epidural abscess??

Answer 19

EXCRUCIATING pain on percusion over spine.

Question 20

WHat are the two most common pathogens in epidural abscesses?

Answer 20

1. Staff. aureus
2. Streptococcus

Question 21

In chronic cases of spinal epidural abscesses, what is the most common pathogen?

Answer 21

TB!

Question 22

what is the correct treatment of an epidural abscess in the spine?

Answer 22

1. EARLY surgical evacuation and antibiotic treatment.

Question 23

What should be done in case of an infected vertebra (osteoma)

Answer 23

HIgh risk of instability with laminectomy and instrumentation is needed. Use titan.

Question 24

What is the rec. combination of antibiotics in spinal epidural abscess?

Answer 24

Ceftriaxone (rocephalin, 3rd gen cephalosporine rec for both meningitis and bone inf.)
Metronidazole
Vancomycin
+/-Rifampicin (mostly TB/mycobacterium impl)

Question 25

How often is a spinal epidural abscess fatal?

Answer 25

in 3-31%

Question 26

Is it possible to reverse a paralysis after spinal epidural abscess?

Answer 26

If it has occured for more than a few hours, reversal is very rare.

Answer 29

B