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(gè)帶：中心壞死帶含巨噬細(xì)胞和纖維細(xì)胞的炎性增生帶膠原包膜帶新生血管和成纖維細(xì)胞炎性增生帶反應(yīng)性星形膠質(zhì)細(xì)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(wàn)古霉素+三代頭孢美洛培南、氟喹諾酮類(lèi)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(lèi)、氨曲南單核細(xì)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(wú)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(lèi)大腸桿菌三代頭孢頭孢吡肟、美洛培南、氨曲南、氟喹諾酮類(lèi)三代頭孢首選：頭孢曲松或頭孢噻肟易感因素常見(jiàn)致病菌推薦抗菌治療年齡＜1個(gè)月無(wú)乳鏈球菌、大腸桿菌、單核細(xì)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(lèi)1～23個(gè)月肺炎鏈球菌、腦膜炎奈瑟菌、無(wú)乳鏈球菌、嗜血流感桿菌、大腸桿菌萬(wàn)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(wàn)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(xì)菌增多性李斯德菌、需氧革蘭陰性桿菌萬(wàn)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(yàn)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(wàn)古霉素聯(lián)合三代頭孢開(kāi)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(wàn)古霉素聯(lián)合頭孢吡肟萬(wàn)古霉素聯(lián)合頭孢他啶萬(wàn)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(wàn)古霉素聯(lián)合頭孢吡肟萬(wàn)古霉素聯(lián)合頭孢他啶萬(wàn)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(wàn)古霉素聯(lián)合頭孢吡肟萬(wàn)古霉素聯(lián)合頭孢他啶萬(wàn)古霉素聯(lián)合美洛培南易感因素常見(jiàn)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