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MAJOR CATEGORIES OF NEUROLOGIC DISEASE
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Clinical Manifestations Headache is the most frequent initial symptom of intracranial abscess Other early symptoms, roughly in order of their frequency, are drowsiness and confusion; focal or generalized seizures; and focal motor, sensory, or speech disorders Fever and leukocytosis are not consistently present, depending on the phase of the development of the abscess at the time of presentation (see below) In patients who harbor chronic ear, sinus, or pulmonary infections, a recent activation of the infection frequently precedes the onset of cerebral symptoms In patients without an obvious focus of infection, headache or other cerebral symptoms may appear abruptly on a background of mild general ill health or congenital heart disease In some patients, bacterial invasion of the brain may be asymptomatic or may be attended only by a transitory focal neurologic disorder, as might happen when a septic embolus lodges in a brain artery Sometimes stiff neck accompanies generalized headache, suggesting the diagnosis of meningitis (especially a partially treated one) These early symptoms may improve in response to antimicrobial agents, but within a few days or weeks, recurrent headache, slowness in mentation, focal or generalized convulsions, and obvious signs of increased intracranial pressure provide evidence of an in ammatory mass in the brain Localizing neurologic signs become evident sooner or later, but, like papilledema, they occur relatively late in the course of the illness However, as stated above, some patients present only with focal neurologic signs The nature of the focal neurologic defect will, of course, depend on the location of the abscess In temporal lobe abscess, headache in the early stages is usually on the same side as the abscess and is localized to the frontotemporal region If the abscess lies in the dominant temporal lobe, there is characteristically an anomic aphasia An upper homonymous quadrantanopia may be demonstrable owing to interruption of the inferior portion of the optic radiation This may be the only sign of abscess of the right temporal lobe; contralateral motor or sensory defects in the limbs tend to be minimal, though weakness of the lower face is often observed In frontal lobe abscess, headache, drowsiness, inattention, and general impairment of mental function are prominent Contralateral hemiparesis with motor seizures and a motor disorder of speech (with dominant hemisphere lesions) are the most frequent neurologic signs An abscess of the parietal lobe will give rise to a series of characteristic but sometimes subtle focal disturbances (page 400) The main manifestation of an occipital lobe lesion is a homonymous hemianopia All of the aforementioned focal signs may be obscured by inattentiveness, drowsiness, and stupor, and one must be persistent in searching for them When abscesses are multiple and widely distributed in the cerebral and cerebellar hemispheres, the ultimate syndrome is unpredictable; but most often, in our experience, it has taken the form of a global encephalopathy, like that of a metabolic confusional state, with a subtle hemiparesis or seizure In cerebellar abscess, headache in the postauricular or suboccipital region is usually the initial symptom and may at rst be ascribed to infection in the mastoid cells Coarse nystagmus, weakness of conjugate gaze to the side of the lesion, cerebellar ataxia of the ipsilateral arm and leg, and ataxia of gait are the usual signs The ataxia may be dif cult to demonstrate if the patient is very ill and cannot sit up or walk As a general rule, the signs of increased intracranial pressure are more prominent with cerebellar abscesses than with cerebral ones Mild contralateral or bilateral corticospinal tract signs are often misleading, being evidence of brainstem compression or hydrocephalus rather than a frontal lobe lesion In the
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late stages, consciousness becomes impaired as a result of direct compression of the upper brainstem or from hydrocephalus; both are ominous signs Although slight fever is characteristic of the early invasive phase of cerebral abscess, the temperature may return to normal as the abscess becomes encapsulated The same is true of leukocytosis The sedimentation rate is usually elevated In the early stages of abscess formation, the CSF pressure is moderately increased; the cell count ranges from 20 to 300 per cubic millimeter, occasionally higher or lower, with 10 to 80 percent neutrophils; and the protein content is modestly elevated, rarely more than 100 mg/dL Glucose values are not lowered and the CSF is sterile unless there is a concomitant bacterial meningitis As already mentioned, the combination of brain abscess and acute bacterial meningitis occurs only rarely However, in some patients abscess is combined with subdural empyema; in these instances the clinical picture can be very complicated, although headache, fever, and focal signs again predominate In a small number of cases, especially partially treated ones, there are no spinal uid abnormalities and the sedimentation rate may be normal It is apparent from this overview that the clinical picture of brain abscess is far from stereotyped Whereas headache is the most prominent feature in most patients, seizures or certain focal signs may predominate in others, and a considerable number of patients will present with only signs of increased intracranial pressure In some instances the symptoms evolve swiftly over a week, new ones being added day by day In others, the invasive stage of cerebral infection is inconspicuous, and the course is so indolent that the entire clinical picture does not differ from that of malignant brain tumor In such cases the abscess may become apparent only when cerebral imaging performed for the evaluation of headache or other symptoms discloses a ring-enhancing mass Even then, the radiologic distinction between tumor and abscess is not straightforward, depending often on the presence of a uniform, enhancing capsule that is typical of a mature abscess (see below) Another impressive feature of cerebral abscess is the unpredictability with which the symptoms may evolve, particularly in children Thus, a patient whose clinical condition seems to have stabilized may, in a matter of hours or a day or two, advance to an irreversible state of coma Often this is due to rupture of the abscess into the subarachnoid or ventricular CSF Diagnosis CT and MRI are the most important diagnostic procedures In the CT scan, the capsule of the abscess enhances and the center of the abscess and surrounding edematous white matter are hypodense (Fig 32-1) With MRI, in T1-weighted images, the capsule enhances and the interior of the abscess is hypointense; in T2-weighted images, the surrounding edema is apparent and the capsule is hypointense Suppurative encephalitis (cerebritis) appears as dot-sized areas of decreased density that enhance with gadolinium Practically all abscesses larger than 1 cm produce positive scans There is almost no likelihood of cerebral abscess if enhanced CT and MRI studies are negative Blood cultures, sedimentation rate and chest x-ray are indispensable in the complete diagnosis of brain abscess, although it must be acknowledged that blood cultures are likely to be unrevealing except in cases of acute endocarditis If there is no apparent source of infection and there are only signs and symptoms of a mass lesion, the differential diagnosis includes tuberculous or fungal abscess, glioma, metastatic carcinoma, toxoplasmosis, subdural hematoma, subacute infarction of
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