Brain abscess physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Physical Examination

The symptoms of brain abscess are caused by a combination of increased intracranial pressure due to a space-occupying lesion (headache, vomiting, confusion, coma), infection (fever, fatigue etc.) and focal neurologic brain tissue damage (hemiparesis, aphasia etc.).

The most frequent presenting symptoms are headache, drowsiness, confusion, seizures, hemiparesis or speech difficulties together with fever with a rapidly progressive course.

The symptoms and findings depend largely on the specific location of the abscess in the brain. An abscess in the cerebellum, for instance, may cause additional complaints as a result of brain stem compression and hydrocephalus.

Neurological examination may reveal a stiff neck in occasional cases (erroneously suggesting meningitis). The famous triad of fever, headache and focal neurologic findings are highly suggestive of brain abscess but are observed only in a minority of the patients.

As a summary the presenting signs and symptoms relate to the size and location of the abscess, the virulence of the bug and any underlying comorbidities.

• Headache is the most common complaint, seen > 75% of patients.

• There are no specific descriptors of an abscess headache accounting for one of the factors that often delays the diagnosis.
• The BA is usually not severe, unless the abscess ruptures into a ventricle, at which time meningismus and death often develop as well.
• The classic triad of BA, fever and a focal neurologic deficit are seen in < 50% of cases.

• Signs of increased ICP (N/V, lethargy etc.) can be seen in up to 50% of patients, and is usually an indication for immediate intervention.

• Papilledema, however, is seen in < 25% of cases.

• Fever is present in 40 – 50% of cases, and hence its absence should not be used to exclude the Dx.
• Approximately 30 - 50% of patients will have focal neuro deficits (most commonly hemiparesis).
• 25% of patients present with new-onset seizures.