Brain and Spinal Epidural Abscess

Abstract

PURPOSE OF REVIEW Brain abscesses and spinal epidural abscesses are serious, potentially life-threatening infections of the central nervous system. This article outlines the clinical presentation, evaluation, and management of brain abscesses and spinal epidural abscesses, with a specific focus on bacterial infections. RECENT FINDINGS The overall incidence of brain abscesses has declined, in part because of fewer brain abscesses associated with otogenic infections. However, emerging patient populations at high risk for brain abscess include those with a history of penetrating head trauma, neurosurgery, or immunodeficiency. Improved mortality rates for brain abscess are attributable to modern diagnostic imaging, stereotactic-guided aspiration, and newer antimicrobials that readily penetrate into the central nervous system and abscesses. Brain MRI is more sensitive than CT for brain abscess, particularly in the early stages, but CT remains more widely available and can adequately identify potential abscesses and confirm response to treatment. With the advent of minimally invasive neurosurgical techniques, surgical excision is often employed only for posterior fossa, multiloculated, or superficial well-circumscribed abscesses. In select clinical scenarios, conservative medical management may be a safe alternative to a combined surgical and medical approach. Unlike brain abscess, the incidence of spinal epidural abscess is on the rise and has been attributed to higher prevalence of predisposing factors, including spinal procedures and instrumentation. SUMMARY Successful diagnosis and management of brain abscess and spinal epidural abscess requires a collaborative approach among neurologists, neurosurgeons, radiologists, and infectious disease physicians. The foundation of management of brain abscess includes surgical intervention for diagnostic purposes if a pathogen has not been identified or for decompression of larger abscesses or those with mass effect and significant surrounding edema; appropriate dosing and adequate duration of an antimicrobial regimen tailored to the presumptive source of infection and available culture data, and eradication of the primary source of infection. For spinal epidural abscesses, neurologic status at the time of presentation is directly related to outcomes, underscoring the importance of prompt recognition and intervention.

Spinal Epidural Abscess in COVID-19 patients

“…Risk factors for SEA include diabetes, immunosuppressed state, intravenous drug abuse, chronic renal or liver failure, spinal surgery, obesity, and bacteremia [2][3][4][5][6][7][8][9]. Despite the incidence of SEA progressively increased during the last decades [3][4][5][6][7]9], indeed SEA remains uncommon ranging from 1.2 to 3 per 10,000 hospitalized patients [3,7,9], with less than 1000 cases published over a 40 years period [5,10].…”

“…The bacteria may enter the epidural space spreading from adjacent local infections (such as discitis), contaminating invasive procedures (such as spinal surgery or spinal anesthesia), or through the hematogenous route [3][4][5][6]9]. SA, usually the MSSA, is responsible for 70% of cases [3,4,6,7,9].…”

“…The classic triad of SEA consists of back pain, fever, and neurologic de cits but it is just reported in 8% of cases [3][4][5][6][7]9]. Pain is constant, fever is present in less than 50% of cases, true neurological de cits affect a minority of patients [4][5][6]9,10]. Onset of symptoms may be sudden, or slowly progressive but back pain often evolves to paraplegia within few days [7].…”

“…Onset of symptoms may be sudden, or slowly progressive but back pain often evolves to paraplegia within few days [7]. Accordingly, early diagnosis is crucial, but it is di cult, and half of cases are initially misdiagnosed [3][4][5][6][7]9]. MRI with contrast is the diagnostic method of choice: SEA is generally seen as a T1 hypointense, T2 hyperintense mass with enhancing capsule in the epidural space [4][5][6][7].…”

“…Pending the identi cation of the causative organism, empiric therapy should start using broad spectrum antibiotics [5]. Therapy usually include vancomycin, last generation cephalosporin, and sometimes aminoglycoside, and/or metronidazole [3,4,6,7]. There are no guidelines for the duration of therapy, but patients typically require 4-8 weeks of therapy [3][4][5][6][7]9] Postoperative recovery depends on age, health status, comorbidities, and history duration [13][14][15] but above all on the patient's neurologic status immediately before surgery [2,4,5,7].…”