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single photon emission CT, and proton MRS are helpful anticonvulsant should be routine in supratentorial
in differentiating abscess from tumor. [31-38] abscess, but duration is a matter of debate. [6]

Brain abscesses were singular in 77.7% of the subjects If serial CT scans show increased size of abscess at any
and multiple in 22.3%, a result similar to that reported time during conservative treatment with antibiotics or
by Landriel et al. [39] The frontal lobe was the most no decrease in size within 4 weeks, a surgical procedure
common abscess location in the patients, followed by should be performed to confirm the diagnosis, to
the temporal and occipital regions. However, in a study obtain a sample for culture of identification of specific
carried out by Cavusoglu et al., [40] the temporoparietal pathogens and sensitivity to particular antibiotics,
region was the most commonly affected location. and to remove as much purulent material as possible.
Abscesses of unknown cause accounted for 54.94% of Walled off abscess larger than 3 cm diameter and a
the subjects, higher than the values reported for other smaller deep-seated white matter abscess are unlikely
series. [12,39,41-43] In most large series of brain abscesses to respond medical treatment alone. Standard therapy
from developing countries, middle ear infection for such lesions should be surgical evacuation followed
has been reported to be the most common source of by appropriate antibiotic. [47] Instillation of antibiotics
intracranial suppuration, a result similar to the current inside the abscess cavity can be considered. A surgical
study. [44] drainage allows immediate decompression of mass
lesion and reduction of ICP that reduces the duration of
The basic principle of treatment is the prescription antibiotic therapy and hospitalization. It increases the
of appropriate antibiotics with or without aspiration, likelihood of cure. Surgery should be performed in case
treatment of sequelae that is, hydrocephalus, seizures of clinical deterioration, significant mass effect and
etc., and eradication of primary source. [26] According to neurological deficit. Many surgical techniques have
a number of authors, treatment of brain abscess involves been developed, but there is no single best method. [48]
aspiration of the pus or excision of the abscess, followed At present, aspiration and excision are two common
by parenteral antibiotic therapy. [1,5,6,12,45] Empirical procedures used. Role of aspiration versus excision
medical therapy is the best avoided and should is controversial. In choosing between aspiration and
be reserved for patients in whom a bacteriological excision, various factors including surgical morbidity,
diagnosis has been obtained from a systemic source success rate and sequelae such as recurrence and
or who are extremely ill that is, too ill to undergo any seizure disorders also must be considered. Aspiration
forms of intervention. [45] Small abscesses and lesions is a rapid and safe procedure, especially with the use of
in the cerebritis stage respond well to medical therapy stereotactic techniques, ultrasound or CT scan guidance.
alone. [14] The choice between conservative versus It can be done under local anesthesia, on bedside, even
operative treatment is influenced by age, neurological in seriously ill or high-risk patients. Aspiration can be
status, location, number, size and stage of abscess done at any stage of evolution of abscess. If no pus is
formation. Each case must be individualized and obtained, biopsy gives positive culture even in early
treated on its own merits. Conservative treatment can cerebritis stage. A large, superficial, or accessible
be tried in patients who are alert, clinically stable abscess can be aspirated via appropriately placed burr
and have a major risk for surgery and anesthesia. hole. Real time ultrasound, particularly in infants
Treatment of sequelae that is, hydrocephalus, seizures, with open fontanelle and stereotaxy provides precise
etc., and eradication of primary source should not localization. Free hand needle aspiration can be a very
be neglected. The management should be done by effective life-saving measure in the underdeveloped
neurosurgeons prepared to operate at the first sign world where stereotaxy is not available. [30] More than
of failure of medical therapy or where immediate one aspiration may be required. Repeat aspirations are
neurosurgical help is available. Medical treatment often necessary for cure.
alone should not be applied when the diagnosis is
not yet confirmed. Abscess in cerebritis stage, or With free availability of CT scan, role of aspiration
walled off but smaller than 3 cm diameter could be has increased, as abscesses can be detected easily
treated nonsurgically with antibiotics alone. [27] Serial and follow up is available immediately. Some authors
CT scans are crucial as it may enlarge despite adequate recommended stereotactic aspiration/biopsy in all
antibiotics therapy. [46] The complexity of microbial patients with suspected brain abscess regardless of
flora in brain abscess necessitates empirical antibiotic size. [49] Aspiration has a place, both as preparatory
therapy against both aerobic and anaerobic organisms. to eventual excision (secondary excision) and as a
Usually, intravenously administration of “triple high definitive procedure. [48] Multiloculated abscesses have
dose” antibiotics for 2 weeks followed by 4 weeks been treated with stereotactic aspiration of all loculi in
of oral therapy is recommended. Corticosteroid can single or staged aspiration. Encouraging results with
only be used to reduce edema and administration of endoscopic stereotactic evacuation of brain abscess has

158 Neuroimmunol Neuroinflammation | Volume 2 | Issue 3 | July 15, 2015 Neuroimmunol Neuroinflammation | Volume 2 | Issue 3 | July 15, 2015 159