The clinical features of brain abscesses and other focal CNS suppuration are largely caused by the presence of a space occupying lesion. They are usually described as headache, fever, and focal neurological signs, but this triad is only found in half of all patients.144 Other common clinical features are focal signs pointing to the site of the lesion, convulsions, which are usually generalised but may be focal, nausea and vomiting, raised intracranial pressure even to the point of coning, and neck stiffness to suggest meningitis. There may be pyrexia and symptoms relating to the source of infection, such as otitis or sinusitis. Cerebral abscesses, therefore, must be included in the differential diagnosis of patients who present acutely with a wide range of neurological features.

Faced with a patient in whom intracranial abscess is a possible diagnosis, the priority is to confirm the diagnosis and identify the source of infection and the responsible organism or organisms. Once vital functions have been stabilised, a full examination should be made for a focus of infection, such as otitis media or pelvic sepsis, and if found, cultures should be made and steps taken to eradicate the source. Blood cultures should be set up. Contrast-enhanced CT or MRI should be done as soon as possible. In addition to visualising the intracranial contents, note should be made of the state of the paranasal sinuses and the mastoid air cells. Skull fractures and cranial defects should be looked for.

CT classically shows ring-enhancing lesions, although in the early stages ring enhancement may be absent. There may be surrounding oedema. Unfortunately, such appearances are not specific and may be seen with brain tumours, granulomas, necrotising encephalitis, and infarction. MRI is more sensitive than CT in demonstrating early cerebritis, cerebral oedema, and the contents of abscess cavities.144

Lumbar puncture should never be carried out on patients suspected of having a brain abscess.

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