Pathophysiology

Brain abscess is caused by intracranial inflammation with subsequent abscess formation. The
most frequent intracranial locations (in descending order of frequency) are frontal-temporal,
frontal-parietal, partial, cerebellar, and occipital lobes. [3] In at least 15% of cases, the source
of the infection is unknown (cryptogenic). [4]

Infection may enter the intracranial compartment directly or indirectly via 3 routes.

Contiguous suppurative focus (45-50% of cases)

Direct extension usually causes a single brain abscess and may occur from necrotic areas of
osteomyelitis in the posterior wall of the frontal sinus, the sphenoid and ethmoid sinuses,
mandibular dental infections, as well as from subacute and chronic otitis media and
mastoiditis. [5] This direct route of intracranial extension is more commonly associated with
subacute and chronic otitic infection and mastoiditis than with sinusitis. [6]

Subacute and chronic otitis media and mastoiditis generally spread to the inferior temporal
lobe and cerebellum. Frontal or ethmoid sinus spread to the frontal lobes. Odontogenic
infections can spread to the intracranial space via direct extension or a hematogenous route.
Mandibular odontogenic infections also generally spread to the frontal lobe.

The frequency of brain abscesses resulting from ear infections has declined in developed
countries. However, abscesses complicating sinusitis has not decreased in frequency. [7]
Contiguous spread could extend to various sites in the central nervous system, causing
cavernous sinus thrombosis; retrograde meningitis; and epidural, subdural, and brain abscess.

The valveless venous network that interconnects the intracranial venous system and the
vasculature of the sinus mucosa provides an alternative route of intracranial bacterial entry.
Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins
of the skull, the dural venous sinuses, the subdural veins, and, finally, the cerebral veins. By
this mode, the subdural space may be selectively infected without contamination of the
intermediary structure; a subdural empyema can exist without evidence of extradural
infection or osteomyelitis.

Intracranial extension of the infection by the venous route is common in paranasal sinus
disease, especially in acute exacerbation of chronic inflammation. Chronic otitis media and
mastoiditis generally spread to the inferior temporal lobe and cerebellum, causing frontal or
ethmoid sinus infection and dental infection of the frontal lobe. [8]

Trauma (10% of cases)

Trauma that causes an open skull fracture allows organisms to seed directly in the brain.
Brain abscess can also occur as a complication of intracranial surgery, and foreign body, such
as pencil tip, lawn dart, bullets, and shrapnel. Occasionally brain abscess can develop after
trauma to the face.

Hematogenous spread from a distant focus (25% of cases)

These abscesses are more commonly multiple and multiloculated and are frequently found in
the distribution of the middle cerebral artery. The most common effected lobes (in
descending frequency) are the fontal, temporal, parietal, cerebellar, and occipital. [9]

Hematogenous spread is associated with cyanotic heart disease (mostly in children),

pulmonary arteriovenous malformations, endocarditis, chronic lung infections (eg, abscess,
empyema, bronchiectasis), skin infections, abdominal and pelvic infections, neutropenia,
transplantation, [10] esophageal dilatation, injection drug use, [11] and HIV infection.