英文課件腦膿腫

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Introduction&History

HennryII(1519-1559)OscarWilde1854~1900Epidemiology

BAismorecommonamongmen–twicetothreetimes.Morbidityrateishighestinfourthdecadeofthelife.BAstillcontinuestobeasignificantprobleminthedevelopingworldduetolargescalepoverty,illiteracy,andlackofhygiene.

Thecasesareusuallyelderorpediatricmalepatients.TheincidenceofBAis8%ofintracranialmassesindevelopingcountriesand1-2%inthewesterncountries.MortalityfromaBAhasrecentlydecreasedfromabout50%to20%,mostlyasaresultofintroductionofCTscanningthatresultedinearlierdiagnosisandaccuratelocalization.

Furtheradvancesin：

Microorganismisolationandidentification,Superiorantimicrobialswithgreatercerebrospinalfluid(CSF)penetrationStereotacticaspirationresultedinacontemporarymortalityoflessthan10%.Mortalityismainlyinfluencedby:AgeNeurologicalconditionatadmission;Delaysinhospitalization,Focalneurologicdeficitsatadmission,Impairedhostimmunity,Uncontrolleddiabetesmellitus,GlasgowComaScale(GCS)<12associatedwithdeathandpermanentneurologicdeficits.BA,fromwhereitcame?SpreadfrompericranialcontiguousfocusHematogenousspreadDirectinoculation25-50%15-30%

8-19%sinuses,middleear,dentallungabscessorempyema,bacterialendocarditis,skininfections,intra-abdominal(includingpelvic)infectionsheadtraumaneurosurgeryDentalinfections,ethmoidorfrontalsinusitisfrontallobesolitaryBA

Subacuteorchronicotitismediaormastoiditis

temporallobeandcerebellumsolitaryBA

HematogenousspreaddistributionofthemiddlecerebralarterymultifocalBAStagesofbrainabscessformation典型膿腫壁在病理上分5個帶：中心壞死帶含巨噬細胞和纖維細胞的炎性增生帶膠原包膜帶新生血管和成纖維細胞炎性增生帶反應(yīng)性星形膠質(zhì)細胞增生及腦水腫帶EtiologyOralcavityinfection

Hemathogenousspread(intra-abdominal/pelvic)infection,otorhinolaringealinfectionAnaerobicpathogensTraumaPatientswithpriorneurosurgicalproceduresGram-positivecocci

Gram-negativerods

Patientwithcardiacorigin(cyanoticheartdisease)andright-to-leftshuntsPeptostreptococcusandStreptococcusClinicalPresentation

Focalmassexpansion,Intra-cranialhypertension,Diffusedestruction,FocalneurologicaldeficitCommonpresentingsignsandsymptomsinBA

Diagnosis

CTscanwithcontrastMRIDWI1H-MRSLumbarpuncture?Suggestedexplorationprotocolwhenabrainabscessissuspected

ManagementTeam:NeurosurgeonNeurologistInfectiousdiseasespecialist,

Neuroradiologist.Approach:

Neuroradiologicalevaluation,Surgicalintervention,Useofantibiotics,Eradicationofprimaryinfectedfoci.

MedicaltreatmentSmallabscess(<2.5cm),Goodinitialclinicalcondition(GCS>12),Theetiologyiswell-knownMultipleabscesses,Aftersurgeryofabscesses>2.5cmSurgeryofabscessesthatcauseamasseffect,PatientsatseriousriskofoperationAntibioticBroadspectrumantibioticswhichcancrossblood–brainandblood–CSFbarriersinadequateconcentrations.EmpiricalantibioticsshouldincludecoverageforanaerobicpathogensPlusvancomycinifthereisahistoryofpenetratingtraumaorarecentneurosurgicalprocedure

WhathappenwiththosepatientswhohaveimmunefunctiondefectsReducedlymphocyticfunction;Nocardia

asteroidesToxoplasma

gondiisulfonamideandpyrimethanium

T-lymphocyticdefectCandidaneoforman

5flucytosineandamphotericin-BLeukemiaandlymphomaPseudomonas

aminoglycosides

RenaltransplantrecipientsPatientswithbloodcancerandthoseonsteroidtherapy,Listeria

ampicillin

AntibioticregimenThesizeofabscess,Combinationofsurgicaltreatment,Causativeorganism,ResponsetotreatmentArlotticonsider(gradeC)prudentaperiodof4-6weeksoftreatmentforsurgicallytreatedabscesses,and6-8weeksforintravenoustreatmentforBAtreatedsolelymedicallyandinthecaseofmultipleBAwhenlargeronesaretreatedsurgically.Post-traumaBAcefotaxime2gq6h+metronidazole500mgq8hPost-surgicalBAlinezolid600mgq12horVancomycin40-60mg/kg/24hsinuses,middleear,dentalinfectioncefotaxime2gq6h+metronidazole500mgq8hBAmetastaticorcryptogenic

cefotaxime2gq6h+metronidazole500mgq8h成年患者革蘭氏染色確定可能致病菌后，推薦抗菌治療方法致病菌推薦治療備選治療肺炎鏈球菌萬古霉素+三代頭孢美洛培南、氟喹諾酮類腦膜炎奈瑟菌三代頭孢青霉素、氨芐西林、氯霉素、氟喹諾酮類、氨曲南單核細菌增多性李斯德菌氨芐西林或青霉素4復(fù)方新諾明、美洛培南無乳鏈球菌氨芐西林或青霉素三代頭孢流感嗜血桿菌三代頭孢氯霉素、頭孢吡肟、美洛培南、氟喹諾酮類大腸桿菌三代頭孢頭孢吡肟、美洛培南、氨曲南、氟喹諾酮類三代頭孢首選：頭孢曲松或頭孢噻肟易感因素常見致病菌推薦抗菌治療年齡＜1個月無乳鏈球菌、大腸桿菌、單核細胞增多性李斯德菌、克雷伯菌屬氨芐西林聯(lián)合頭孢噻肟；氨芐西林聯(lián)合氨基糖苷類1～23個月肺炎鏈球菌、腦膜炎奈瑟菌、無乳鏈球菌、嗜血流感桿菌、大腸桿菌萬古霉素聯(lián)合三代頭孢2～50歲腦膜炎奈瑟菌、肺炎鏈球菌萬古霉素聯(lián)合三代頭孢＞50歲肺炎鏈球菌、腦膜炎奈瑟菌、單核細菌增多性李斯德菌、需氧革蘭陰性桿菌萬古霉素聯(lián)合氨芐西林聯(lián)合三代頭孢不同年齡和易感因素的化膿性腦膜炎經(jīng)驗抗菌治療

腦外傷顱底骨折肺炎鏈球菌、流感嗜血桿菌、A群β溶血性鏈球菌萬古霉素聯(lián)合三代頭孢開放性腦外傷金黃色葡萄球菌、凝固酶陰性葡萄球菌、需氧革蘭陰性桿菌（包括銅綠假單胞菌）萬古霉素聯(lián)合頭孢吡肟萬古霉素聯(lián)合頭孢他啶萬古霉素聯(lián)合美洛培南神經(jīng)外科術(shù)后需氧革蘭陰性桿菌（包括銅綠假單胞菌）、金黃色葡萄球菌、凝固酶陰性葡萄球菌萬古霉素聯(lián)合頭孢吡肟萬古霉素聯(lián)合頭孢他啶萬古霉素聯(lián)合美洛培南腦脊液分流術(shù)后凝固酶陰性葡萄球菌、金黃色葡萄球菌、需氧革蘭陰性桿菌（包括銅綠假單胞菌）、痤瘡丙酸桿菌萬古霉素聯(lián)合頭孢吡肟萬古霉素聯(lián)合頭孢他啶萬古霉素聯(lián)合美洛培南易感因素常見致病菌推薦抗菌治療SteroidsReducingintracranialpressureAvoidingacutebrainherniation

CytotoxicedemaSurgicalTreatmentTourgentlyreduceraisedintracranialpressurebyaspirationofthecavityusingimageguidance;Toconfirmthediagnosis;Toobtainpusformicrobiologicaldiagnosis;Toenhancetheefficacyofantibiotictherapy;Toavoidiatrogenicspreadofinfectionintotheventricles.OperativecasesNonresponseBAtoonlymedicalmanagement(i.e.,evidenceofgrowingabscesswhileonantibioticsornochangeinsizeat2-3weeks),willnecessitatesurgicaldrainage.TraumaticBAmayrequirecraniotomytoremoveforeignmaterialorbonechipsCerebellarorbrainstemabscessesareoftenindicationforposteriorfossacraniotomyduetothehighriskofbrainherniation.

PeriventricularBAoftenrequirescraniotomygiventheriskofintraventricularruptureMultipleabscessesarebesttreatedbyaspirationofthelargestonefordiagnosisandofothersiftheyarecausingmasseffect.NonoperativecasesBAswithchronicencapsulation,providedtheyarelessthan2cmindiameter,MultiplesmallabscessesPatientswhoareextremelypoorsurgicalcandidates.Complications,OutcomesandPrognosis

Delayeddiagnosis,Rapidlyprogressingdisease,Coma,Multiplelesions,

Intraventricularrupture,Fungaletiology

Before1970,overallmortalityduetoBAcouldbeashighasupto60%;fortunatelynewantibacterialapp