Brain abscess is diagnosed by imaging studies. CT with contrast infusion classically demonstrates one or several thin, smoothly contoured rings of enhancement surrounding a low-density center and surrounded by white matter edema. Early in the course, a ring may be thicker and less well defined, with the only CT finding being an area of focal hypodensity. Suspected brain abscess is one of the rare instances in the emergency department when a contrast-enhanced study is preferred over a noncontrast study. MRI usually demonstrates a ring, even without gadolinium enhancement. Both types of studies are highly sensitive, and one imaging modality has no real advantage over the other except that CT is usually more readily available in the emergency department. Other studies, such as blood analysis, EEG, and CSF examination, are too nonspecific for definitive diagnosis, and LP is contraindicated when suspicion is high and when focal neurologic signs are present. Cultures of blood or other sites of infection may guide future management and should always be obtained.
Differential diagnosis of the clinical presentation is broad because of its nonspecific and variable nature. A sudden onset with focal features may suggest cerebrovascular disease. Prominent fever, stiff neck, and confusion may suggest meningitis. A protracted course with features of increased intracranial pressure may suggest neoplasm. Brain neoplasm, subacute brain hemorrhage, other focal lesions, and other focal brain infections, such as toxoplasmosis, may mimic the imaging findings of brain abscess. Biopsy or aspiration for confirmation of diagnosis as well as for bacteriologic studies is necessary in most cases.
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