Indication of Surgery in Cerebral Abcess

The goals of surgical management of brain abscess are to decompress the

space-occupying lesion, lessen intracranial pressure, and eradicate the infection as well as any
primary infectious source, if present. Surgical treatment options include (1) aspiration, which
may be performed freehand, stereotactically, or as an open procedure using ultrasound
guidance and (2) complete excision of the abscess contents and capsule. n open techni!ue
may reduce the need for additional imaging, surgical treatment, and duration of antibiotic
therapy. Therefore, in resource-limited en"ironments, excision of brain abscess may play a
more important role in patient management while maintaining fa"orable outcomes.
1
The anatomical location, number and si#e of abscesses, stage of abscess formation,
age and neurological status of the patient can influence the strategy for managing brain
abscess. $n carefully selected patients (illness duration, 2 wee%s), medical therapy alone can
be successful if the following conditions are met& 1) the causati"e agent is %nown with a
reasonably high certainty as a result of positi"e cultures from cerebrospinal fluid or drainage
from the ear or sinuses' 2) the patient is neurologically intact' () there are no signs of
increased intracranial pressure' and )) the abscess is, ( cm in diameter. n algorithm for the
treatment of brain abscess has indicated that antibiotics can be used as the sole treatment for
lesions, 1.* cm in a neurologically intact patient with a clear source of infection in a solitary
brain abscess, or for lesions, 2.* cm if initial treatment of multiple abscesses has identified
the causati"e organism. +e"ertheless, surgical drainage followed by antimicrobial therapy is
the treatment of choice for most brain abscesses.
1,2
lthough medical treatment is facilitated by the a"ailability of ,T and -. imaging,
the chance of success is maximi#ed when the causati"e agent is %nown and antimicrobial
therapy is targeted. $f abscesses were, 2.* cm in diameter or did not cause mass effect, we
prefered ,T-guided stereotactic aspiration for purposes of diagnosis and antibiotic selection.
$f another source of infection had been clearly identified, the therapy for brain lesions was
empirically based on the culture results from those other sources. $f the patient/s neurological
condition deteriorated or an increase in abscess si#e was noted at any time or if 2 wee%s of
antibiotics failed to shrin% these lesions, aspiration for diagnostic purposes was performed.
2,(
Surgical treatment can in"ol"e either aspiration or excision of the abscess. The choice
of procedure has been the sub0ect of much debate. The ad"antages of aspiration are that it is
simple, it can be used in the cerebritis stage, and it has less potential morbidity than surgical
trauma. 1n the other hand, se"eral reports ha"e ad"ocated excision as the procedure of choice
because it is often followed by a lower incidence of recurrence and shorter hospitali#ation.
2
ll abscesses 2.* cm in diameter or that caused significant mass effect were either
excised or, preferably, aspirated. 2xceptions to this included abscesses that were in an early
cerebritis phase and were therefore much more li%ely to respond to antibiotic therapy alone.
The cerebritis phase refers to abscesses in an early stage of formation in which there is
inward migration of leu%ocytes and significant secondary edema but no well-formed fibrous
capsule. These abscesses are usually seen in the first 345 days of de"elopment, and because
they are not encapsulated, antibiotic therapy is more li%ely to pro"ide ade!uate therapy
without surgery. $n such cases, the abscess would only be aspirated for diagnosis and
organism identification. The choice of surgical approach is not critical and should be dictated
by surgeon preference and the ability of the patient to tolerate each type of surgical
procedure. 6e found that stereotactic aspiration is most useful for deepseated lesions or
multiple hemispheric abscesses, whereas we preferred craniectomy with aspiration or
excision for posterior fossa abscesses. 2xcision was also reser"ed for posttraumatic and
postoperati"e abscesses or reaccumulation of fluid. -ost of the patients in this series were
treated using aspiration "ia a single bur hole and had a fa"orable outcome.
1,2,(
2"ery cerebral abscess passes through a stage of encephalitis before encapsulation. $t
is during this stage that the infection is "irulent and is most easily disseminated. Some
surgeons argue that unless the necrotic tissue is remo"ed the patient will die. This is true in
the occasional case, and cases ha"e been reported in which aspiration of necrotic material
was successful' more often than not, howe"er, the infection is disseminated by surgical
inter"ention and the patient dies from a fulminating, suppurati"e meningo-encephalitis. Some
studies belie"e that the best procedure to employ during the acute stage is supporti"e
treatment, rest in bed, high calorie diet, spinal (lrainage, ice bags to the head, fre!uent
catharsis, moderate amounts of fluids, and, if the patienit is comatose, occasional intra"enous
administration of hypertonic glucose. 2ncapsulation ta%es place in two to four wee%s. The
process is an indication that immunity is being established. $t is characteri#ed by a fall in the
leucocyte count from 23,333 or more to $2,333 or 1),333 per cubic millimetre. The
temperature li%ewise returns approximately to normal 7 or below. The cell count of the
cerebrospinal fluid, if increased, returns to normal. The cerebral symptoms gradually subside,
but seldom completely disappear until the abscess is drained. ,ho%ing of the optic (lis%s, if
present, may continue until optic atrophy results. 6hen encapsulation and immunity ha"e
been established, thorough and continuous drainage is necessary to effect a cure without
recurrence of the abscess.
2,(
.eferences &
1. 8adgil +., 9atel .:., 8opinath S.9., 231(. Open Craniotomy for Brain Abcess: A
Forgotten Experience. Surgical +eurology $nternational. ;epartment of
+eurosurgery, <aylor ,ollege =S.
2. Halit C., et al. 2008. Brain abscess: analysis of results in a series
of 51 patients with a combined surgical and medical approach
during an11-year period. ,linic of +eurosurgery, Sisli 2tfal 2ducation and
.esearch >ospital, $stanbul, Tur%ey.
(. dson .6., ,raig 6.-., The Surgical anagement of Brain Abcess. Section of
+eurologic Surgery, The -ato ,linic, .ochester, -innesota.