Brain Abscess PDF

Brain abscess Lecturer Yousif Y. Hassan Dip, BSc, MSc in Nursing Brain abscess A brain abscess is a localized collection of pus within the brain tissue, usually caused by a bacterial, fungal, or parasitic infection  Risk factors: Clients with compromised immune system due to...

Brain abscess Lecturer Yousif Y. Hassan Dip, BSc, MSc in Nursing Brain abscess A brain abscess is a localized collection of pus within the brain tissue, usually caused by a bacterial, fungal, or parasitic infection  Risk factors: Clients with compromised immune system due to HIV or AIDS Cancer and other chronic illnesses Congenital heart disease Meningitis Immunosuppressant drugs, such as those used in chemotherapy Chronic sinus or middle ear infections  Pathophysiology It may occur by direct invasion of the brain from intracranial trauma or surgery; by spread of infection from nearby sites, such as the sinuses, ears, and teeth (paranasal sinus infections, otitis media, dental sepsis); or by spread of infection from other.  Clinical Manifestations — Headache, usually worse in the morning, is the most prevailing symptom. — Vomiting is also common. — Focal neurologic signs (weakness of an extremity, decreasing vision, seizures) may occur, depending on the site of the abscess. — There may be a change in mental status, as reflected in lethargic, confused, irritable, or disoriented behavior. — Fever may or may not be present.  Diagnostic evaluation Neurological examination shows sings of increased intracranial pressure and problems with brain function. Blood cultures Chest x-ray Complete blood count (CBC) Head CT scan Electroencephalogram (EEG) MRI of head  Stereotactic Needle biopsy A needle biopsy is usually performed to identify the cause of the infection.  Medical Management — Antimicrobial therapy is the primary treatment for brain abscess. Antimicrobial treatment is prescribed to eliminate the causative organism or reduce its virulence. Penicillin and chloramphenicol are usually prescribed because anaerobic streptococci and Bacterioides are the most common causative organisms Corticosteroids may be prescribed to help reduce the inflammatory cerebral edema if the patient shows evidence of an increasing neurologic deficit.  Medical Management Anti seizure medications (phenytoin, phenobarbital) may be prescribed to prevent seizures. Multiple abscesses may be treated with appropriate antimicrobial therapy alone, with close monitoring by CT scans.  Surgical management Surgery is needed if: a. Increased pressure in the brain continues or gets worse b. The brain abscess does not get smaller after medication c. The brain abscess might rupture. d. CT scans can not be obtained every 1-2 weeks Craniotomy (opening the skull, exposing the brain, and draining the abscess) Needle aspiration  Complications Brain damage Meningitis that is severe and life threatening Recurrence of infection Seizures Prevention To prevent brain abscess, treat otitis media, mastoiditis, sinusitis, dental and oral infections, and systemic infections promptly. A few statistics In untreated cases the mortality rate approaches 100% Seizures occur in approximately 30 % of cases Nursing interventions Nursing interventions are similar to those for management of meningitis or increased ICP. If surgical removal is the treatment of choice, nursing interventions are similar to those described under intracranial tumors. Intracranial surgery Craniotomy Opening the skull surgically to gain access to intracranial structures Burr hole Circular opening made in the skull by a drill Craniectomy An excision of a portion of the skull Cranioplasty Repair of a cranial defect by means of a plastic or metal plate Transsphenoidal Through the nasal sinuses to gain access to the pituitary gland Increase Intracranial Pressure (ICP)  Intracranial Pressure Skull has three essential components: - Brain tissue = 78% - Blood = 12% - Cerebrospinal fluid (CSF) = 10% Any increase in any of these tissues causes increased ICP Components of the Brain Fig. 55-1 Production of Cerebrospinal Fluid Produced at constant rate 0.3 cc per minute – about 20 cc per hour, 500 cc per day – Not much different throughout childhood Most CSF produced in choroid plexus – Located within the ventricles inside the brain Circulates within the ventricles and eventually flows to the outside of the brain – Subarachnoid space  Definition Intracranial Pressure (ICP) is the pressure exerted by brain tissue, blood volume & cerebral spinal fluid (CSF) within the skull.  Monro-Kellie Hypothesis Limited space for expansion in the skull, an increase in anyone of the components causes a change in the volume of the others.  Intracranial Pressure The normal range is between 0 to 15 mmHg. ICP over 20 mm/Hg is considered elevated ICP, also known as intracranial hypertension. The management team becomes concerned whenever a patient’s ICP is over 15 mm/Hg, but is especially concerned when it reaches levels of intracranial hypertension.  Pathophysiology Increased ICP is a syndrome that affects many patients with acute neurologic conditions. Elevated ICP most commonly associated with head injury Secondary Effects – Brain tumors – Subarachnoid hemorrhage – Toxic and viral encephalities  Pathophysiology Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and shifts brain tissue through openings in the rigid dura, resulting in brain herniation (next slide), a frequently fatal event. Pathophysiology Subdural hematoma develops when blood vessels that are located between the membranes covering the brain (the meninges) leak blood after an injury to the head. This is a serious condition since the increase in intracranial pressure can cause damage to brain tissue and loss of brain function.  Why is ICP important? Raised ICP is the final common pathway that leads to death or disability in most acute cerebral conditions. It is also potentially treatable. The two major consequences of increased ICP are: brain shifts brain ischaemia.  Clinical Manifestations: The earliest sign of increasing ICP is: o Change in level of consciousness (LOC). o Slowing of speech. o Delay in response to verbal. Restlessness, confusion, increasing drowsiness. Stuporous, reacting only to loud or painful stimuli. Neurologic function deteriorates: o Comatose o Abnormal motor responses: 1. Decerebration: extreme extention of the upper and lower extremities. 2. Decortication: abnormal flexion of the upper extremities and extension of the lower extremities. If the coma is profound, with the pupils dilated and fixed, respiration absent Death is usually inevitable. Diagnostic Findings Cerebral Angiography Computed Tomography (CT) Scanning Magnetic Resonance Imaging (MRI) Positron Emission Tomography (PET) Transcranial Doppler  Cerebral Angiography The first image shows normal brain blood flow The second image shows presence of cerebral aneurysm that can cause decease cerebral blood flow may lead to increase ICP Computed Tomography Scanning The first image shows a normal view of the brain The second image shows brain with tumor and edema that may lead to increase ICP  Magnetic Resonance Imaging The first image shows normal MRI result The second image shows with brain tumor that causes increase ICP Positron Emission Tomography The first image shows normal PET result The second image shows with brain tumor that may lead to increase ICP  Transcranial Doppler The top shows a TCD of a normal artery Bottom shows a severely stenosed internal carotid artery causes decrease cerebral blood flow may lead to increase ICP Nursing Process The Patient with Increased Intracranial Pressure  Assessment o Obtain a history of events leading to the present illness o The neurologic examination : ☺ evaluation of mental status ☺ level of consciousness (LOC) - eye opening - verbal and motor responses - pupils (size, equality, reaction to light) ☺ cerebellar function (balance and coordination) ☺ reflexes ☺ motor and sensory function  Nursing Diagnosis Ineffective airway clearance related to diminished protective reflexes Ineffective breathing patterns related to neurologic dysfunction Ineffective cerebral tissue perfusion related to the effects of increased ICP  Deficient fluid volume related to fluid restriction Risk for infection related to ICP monitoring system  Planning and Goals Maintenance of patent airway Normalization of respiration Adequate cerebral tissue perfusion through reduction in ICP Restoration of fluid balance Absence of infection Absence of complication  Nursing Intervention Maintaining patent airway and adequate ventilation Monitor vital signs and neurochecks Maintain fluid balance Position client with head of the bed elevated 30 to 45 degrees and neck in neutral position Maintain a quiet environment  Prevent straining at stool Prevent excessive cough and vomiting Prevent complication of immobility Preventing infection Administer medication as ordered Evaluation  Maintained patent airway Attains optimal breathing pattern Attains desired fluid balance Infection prevented Complications prevented Intraventricular catheter ( Ventriculostomy)