Journal of Infection (2006) 52, 359366

www.elsevierhealth.com/journals/jinf

Bacterial brain abscesses: An evaluation of 96 cases

l Ceranb, Ilknur Erdemb, Mehmet Zafer Berkmana,
Tayfun Hakana,*, Nurgu
ktasb
Pas
a Go
a

Neurosurgery Department, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
Department of Infectious Disease, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey

Accepted 23 July 2005

Available online 23 September 2005

KEYWORDS
Aspiration;
Brain abscess;
Computed
tomography;
Corticosteroids;
Magnetic resonance
imaging;
Stereotaxy

Summary Objectives: Although the decline of the morbidity and mortality in

recent years, brain abscess is still one of the most important problems in
Neurosurgery.
Methods: Ninety-six patients with brain abscess are analysed retrospectively, that
treated between 1988 and 2001, according to age, the clinical symptoms, etiologic
factors, infecting organisms, prognostic factors, localization, diagnostic and
treatment methods and outcome.
Results: Seventy-two patients treated with aspiration (streotactic aspiration in 12
cases), 14 patients with excision. Ten patients treated medically alone. Seven
patients in the aspiration group and one patient in the excision group were died. Cure
without any morbidity obtained in 55 patients. A significant correlation determined
with initial neurologic grade, meningismus, high fever (O38.50), leucocytosis (O
20.000/mm3) and mortality. There were no significant correlation the age groups and
outcome, treatment groups and location of abscess, period of treatment, number of
abscess, outcome according to GOS and factor, treatment period and received
antibiotic.
Conclusions: In appropriate cases, medical treatment can be successful alone but
surgery, aspiration, is gold standard for brain abscesses. In that way, definite
diagnosis is obtained and pathogen is identified and cure is obtained in a short time.
Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction
Despite the decline of the mortality from 3060 to
424% in recent years, brain abscess is still one of
* Corresponding author. Acibadem Gomec Sokak Cangar Ap. A
Blok, 27/11 Kadikoy, 34718 Istanbul, Turkey. Tel.: C90 532 324
32 84.
E-mail address: tayfunhakan@yahoo.com (T. Hakan).

the most important problems in neurosurgery.18

This ratio is achieved by the advent of diagnostic
methods, antibiotics and new surgery techniques as
stereotactic aspiration, and most of all, the usage
of computed tomographic (CT) scan and magnetic
resonance imaging (MRI).9,11 They provide more
than the monitoring of the abscess; a correct
prediction chance about the pathology and stage
of the abscess was occurred.1,12,13

0163-4453/$30.00 Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jinf.2005.07.019

360

T. Hakan et al.

The brain abscesses cause neural destruction

of different degrees, in neural tissue by the mass
effect.1,14,15 The earlier the diagnosis is done, the
higher the survive ratio is and the lower the
complication is seen.7,16
We reviewed 96 consecutive cases treated over
the past 13 year and we aimed to determine the

Table 1
patients

Clinical characteristics of brain abscess

Variable
Initial sign and symptom
Fever and leucocytosis
Headache
Nausea-vomiting
Focal neurological deficit
Mental alteration
Seizures
Meningismus
Papil edema
Cerebellar syndrome
Other
Source of infection
Meningitis
Otitis, mastoiditis
Trauma
Sinusit
Surgery
Tooth abscess
Unknown
Risk factors
Septicaemia
Congenital cardiac disease
Shut-gun injury
Pulmoner infection
Tuberculosis
Organism
Aerobic
Streptococcus sp.
Staphylococcus sp.
Proteus sp.
Pseudomonas sp
Enterobacter sp.
Klebsiella sp.
Enterococcus sp.
Moraxella
Haemophylus sp.
Citrobacter sp.
Anaerobic
Peptostreptococci
Streptococcus sp
Bacteriodes sp.
Fusobacterium
Prevotella
Tuberculosis
No. organism

Number (%)
55 (57)
52 (54)
48 (50)
40 (42)
43 (44)
24 (25)
22 (23)
11 (11)
10 (10)
8 (8)
16 (17)
16 (17)
14 (15)
5 (5)
4 (4)
2 (2)
24 (25)
6 (6)
5 (5)
2 (2)
1 (1)
1 (1)

current characteristics and the other factors that

are important for the outcome of brain abscess.

Materials and methods

This report reviews 96 consecutive patients with
brain abscess diagnosed and treated between
January 1988 and January 2001 at the Haydarpasa
Numune Education and Research Hospital. Age, sex,
symptoms and signs of the cases, the locations and
the causes of the abscesses, presenting clinical
symptoms, the results of neurological examination
and laboratory findings were recorded. CT and/or
MRI revealed in all cases as the diagnostic methods.
The abscess materials were examined microbiologically and cultured for aerobic, anaerobic bacteria, mycobacteria and fungi with use of standard
culture methods.
The results of neurological examination were
graded according to Glasgow Coma Scale (GCS) and
Glasgow Outcome Scale (GOS).17
The treatment modalities, type and duration of
antibiotic therapy and corticosteroid administration were recorded and complication and mortality rates were analysed.
The statistical data evaluated by Graph Pad
Prizma V-3 programs. Comparison of groups was
used one-way analysis of variance. Posthoc Tukey
multiple comparison tests used in subgroup comparison and comparison of qualitative data was
analysed by chi-squared test. A p value of %0.5 was
considered significant.

Results
18 (18)
17 (17)
12 (12)
3 (3)
2 (2)
2 (2)
2 (2)
1 (1)
1 (1)
1 (1)
10 (10)
4 (4)
4 (4)
2 (2)
1 (1)
2 (2)
19 (19)

Patient population
The series included 96 patients (66 males, 30
female) aged 1.580 years (mean 29.7 years).
Twenty-nine of the patients (30%) were under 15
years old.

Symptoms and signs

The duration of symptoms ranged 260 days with a
mean of 9.2 days. On admission 54% of the patients
had headache. On admission, 20% of the patients
had confusion, 4% were stupors and 10% were
comatose. The symptoms of general infections as
fever and leucocytosis were presented in 55 (57%)
of 96 patients (Table 1).

Bacterial brain abscesses: An evaluation of 96 cases

361

Etiological and predisposing factors

Laboratory findings

Seventy-five patients (78%) presented predisposing

factors; the most common predisposing factors
were localized cranial infection and head trauma.
Four children had congenital cyanotic heart disease
(CCHD); they were Fallot tetralogy, ventricular
septal defect, great vessels transposition and single
ventricle and atrium. Predisposing factor was
identified in 75% multiple abscesses.
There was a significant correlation when predisposing factors compared with age groups. While in
the 014 age group and 1545 age group focal
infections were common, in 4160 age group
unknown predisposing factors were more than
other factors and in above 60 aged group related
to trauma were lower other factors (p!0.01).

The leucocyte count was elevated (O12.000/mm3)

in 50% patients, but it was over 20.000 only in 23%
patients. The erythrocyte sedimentation rate was
elevated in 47% of the patients. Lumbar punction
performed only in three patients and all were
sterile in culture.

Location and size

There were 80 (83%) solitary and 16 (17%) multiple
abscesses. The numbers of abscesses in multiple
ones were between two and six.
As the solitary abscesses were locating mostly in
frontal and temporal lobe, multiple abscesses were
locating more than one lobe. The abscesses arose
from sinusitis and dental abscess were located in
frontal lobe, but in cases of chronic otitis and
mastoiditis, the localizations were mostly temporal
lobe and cerebellum.
The diametres of the abscesses ranged between
8 and 67 mm (median 32.8 mm). The abscess size
was 820 mm in eight cases, and 20 and 29 mm in
two cases in the non-surgically treatment group.
There was no significant correlation among the size
and prognosis.

Microbiological findings
Eighty-two micro-organisms were identified in 62
(76%) of 81 patients. No microbiological analysis
done in 15 patients (10 of them were treated
medically).
In 48 (77%) patients one type micro-organism and
in 14 (23%) patients multiple organisms were
identified. The organisms were more than two in
five patients. The most isolated micro-organisms
were Streptococcus species, Staphylococcus and
Proteus species (Table 1). Anaerobic organisms
were isolated from 12 (12%) abscesses material and
they revealed mix growth except prevotella and
Fusobacterium. Five cases were tuberculosis
abscesses. Micobacteria isolated in two cases,
micro-organisms was seen with EZN stain in one
case and pathological examination showed tuberculous granuloma in two abscesses.

Treatment modality
Surgery was performed on 86 (90%) patients; in 72
(84%) patients the lesions were aspirated and in 14
(16%) patients were excised. The aspiration was
performed stereotacticaly in 12 patients. The

Figure 1 Demonstration of an abscess case, (a) CT scanning of a huge frontal abscess with midline shift during
admission, (b) after single aspiration the abscess shrank moderately and there is a decreasing of midline shift, (c) after
second aspiration the abscess and the midline shift has disappeared.

362

T. Hakan et al.

abscesses diametres were between 30 and 69 mm

in aspiration group and 2035 mm in excision group.
In the aspirated group, 14 (19%) patients underwent reoperation. Re-aspiration applied four times
in one patient, three times in four patients and two
times in the others. Excision was performed to four
patients previously aspirated.
External ventricular drainage performed in 4 (4%)
cases, these patients underwent ventriculoperitoneal shunt operation during fallow-up.
The 10 patients (10%) were treated nonsurgically. The abscess diametre was between 8
and 20 mm in eight cases and 2029 mm in two
cases.
During the early years of this study, the
antibiotic selection was empiric as penicillin and
anti-anaerobic antibiotics (metronidazole or ornidozole) or chloramphenicol on the admission.
Recently, third generation cephalosporins such as
ceftriaxone, cefotaxim and anti-anaerobic antibiotics were used principally. Vancomisin was
used only in the cases of meticillin resistant
Staphylococcus aureus.

Table 2
Variable

In five patients, anti-tuberculous therapy was

given as combined application of isoniaside (INH),
rifampin, ethambutol and pirazinamide and continued for 24 months. Then, double regime of
INH and rifampin was given at least 1 year.

Corticosteroid
Corticosteroid (dexamethasone) was given for
diffuse cerebral edema and midline shift (Fig. 1).
It was used in 58% of the surgical treatment group
and 20% of the non-surgical treatment group (pO
0.05). There was a significant correlation between
corticosteroid usage with severe sequel and death
(Table 2).

Outcome
Clinical follow-up for 88 patients ranged from 3 to
84 month (median 9 months). Eight (8%) patients
(seven in the aspiration, one in the excision group)
were died. Three of them were comatose on

Outcome of cases compared with clinical characteristics

Recovery

No. of patient
55 (57%)
Age
Mean
28.4G20.2
Diametre of abscess
Range
865 mm
Mean
(31.5)
Solitary
49 (89%)
Multiple
6 (11%)
Duration of symptoms
Day
9.50G10.06
Predisposing factors
(C)
43 (78%)
(K)
12 (22%)
Meningismus
11 (20%)
Fever
!38.5 8C
25 (45%)
R38.5 8C
7 (13%)
Leucoytosis
R20.000
7 (13%)
Neurologic grade (GCS)
15
19 (34%)
1413
29 (53%)
129
6 (11%)
87
1 (2%)
63

Corticosteroid
22 (40%)

Moderate
sequela

Severe
sequela

Death

Total

23 (24%)

10 (10%)

8 (8%)

96

33.8G20.1

26.4G19.6

23.1G24.6

29.7G20.64

pO0.05

1867 mm
(33.8)
18 (78%)
5 (22%)

3555 mm
(44.6)
7 (70%)
3 (30%)

3052 mm
(41)
6 (75%)
2 (25%)

867 mm
(32.86)
80 (83%)
16 (17%)

p!0.05

8.4G06.39

7.00G3.09

2.87G3.10

9.22G8.35

pO0.05

16 (70%)
7 (30%)
3 (13%)

8 (80%)
2 (20%)
3 (30%)

8 (100)

5 (62%)

75 (78%)
21 (22%)
22 (23%)

pO0.05
p!0.05

11 (48%)
4 (17%)

6 (60%)
2 (20%)

8 (100%)
6 (75%)

50 (52%)
19 (20%)

pO0.05
p!0.001

5 (22%)

3 (30%)

7 (87%)

22 (23%)

p!0.0001

7 (30%)
10 (43%)
5 (22%)
1 (4%)

15 (65%)

2
3
2
2
1
8

1 (12%)
4 (50%)
2 (25%)
1 (12%)
7 (87%)

28 (29%)
43 (45%)
17 (18%)
6 (6%)
2 (2%)
52 (54%)

pO0.05
pO0.05
p!0.05
p!0.05
p!0.05
p!0.05

(20%)
(30%)
(20%)
(20%)
(10%)
(80%)

pO0.05

Bacterial brain abscesses: An evaluation of 96 cases

admission. One patients abscess was containing
gas with a bad smell. One patient was the case with
Fallot tetralogy and the intraventricular rupture of
the abscess. One patient with a posttraumatic
abscess died as a result of a trauma sequel after a
long period of hospitalization. One patient died due
to pulmonary insufficiency in the 15th postoperative day and the other for cardiac reasons in the 2nd
month; the latest two patients were improved
neurologically after surgery.
The recovery ratios were 90, 85 and 47%,
respectively, in the non-surgical, the excision and
the aspiration groups. While the ratio of recovery
was highly significant (p!0.01) in the excision
group, the ratios of disability and death was
significant (p!0.05) in the aspiration group. A
significant correlation determined between meningismus, high fever (O38.5 8C), leucocytosis (O
20.000/mm3) and poor neurological grade with
mortality ratio (Table 2).
Twenty-three patients (24%) had moderate
disability with no restriction daily activities and 10
(10%) patients had severe disability, which led to
modification daily activities.
One case had vision loss on right eye, two
patients had dysphasia and seven cases had
hemiparesis or hemiplegia. Resistant seizures
occurred in two patients.

Discussion
Brain abscesses still keep their importance with
high mortality and morbidity despite the improvement in diagnosis and treatment modalities in
recent decades.16
The most common predisposing factor for brain
abscesses are direct spread from middle ear,
meninges, mastoid infections and paranasal
sinus.1619 In the present study, the distribution of
the predisposing factors was not equal in the
different age groups and some special features
were determined in contrast with other studies.16,18
The most common cause of brain abscess in the 014
and 1540 age groups was focal infections, in the 41
60 age groups was unknown origin and in above 60
years group posttraumatic abscess was lower than
other age groups. Dental abscess, pulmonary
abscess, sepsis were the other sources of infection
in these series. The 30% of our patients were in
childhood period. Childhood period account nearly
25% cases in some series.2,19 CCHD was a significant
predisposing factor in childrens as high as 650% in
published series, but there is a decline gradually due
to advances in cardiovascular surgery nowadays.

363
In our series ratio of CCHD was 13.7%. In CCHD
diminished arterial oxygen saturation and increased
blood viscosity may cause focal cerebral ischaemia
and play as nidus for infection.1,7,20,21
Clinic symptoms and signs are non-specific
for brain abscesses; they show difference depending on the size and location, the virulence of
infecting organisms and underlying systemic conditions.1,2,15,22 The most presenting symptoms were
headache, nausea, vomiting, fever, focal neurological deficits and alteration of mental status in
this report as in recent studies.16,15,17,22
Seizures ratio were 25% in our patients and there
was no significant correlation between seizures and
abscesses located in frontal lobe in contrast to
recent reports.1 Short duration of symptoms from
the onset of symptoms to admission correlated with
a poorer outcome and characterized patients of 20
60 age groups in other series.13 In this series there
was no correlation between age groups and the
location of abscess with duration of symptoms.
Rutin laboratory tests are not helpful in diagnosis.13 However, there was a significant correlation between leucocytosis (above of 20.000) with
poor outcome and high fever (O38.5 8C) with
mortality in this study.
In patients suspected brain abscess, LP should
not be done for the risk of brain herniation.3,4,15,16
CSF findings are usually non-specific and CSF
cultures are rarely positive.1,15 LP performed only
in three of our patients after checking any mass
with CT,1,23 their CSF examination was sterile, too.
The incidence of multiple abscesses was
reported to be 150% in different series and as
high as 61% especially in the series of infants,1,5,24 it
was 16.7% in the presented study. While formerly
the mortality rate associated with multiple
abscesses has been higher than solitary abscesses,
recently results are similar for single abscesses.17
Reasons of high mortality in multiple abscesses
were delay in diagnosis and treatment. Since, these
patients often had died before receiving any
treatment. 1,5 In this study, the prognosis of
multiple abscesses were similar to solitary abscess.
CT and MRI are used for diagnosis of almost all
intracranial patogenities.13 Mamelak3 reported that
there is no difference between CT and MRI on
finding out the lesions in brain abscesses. But many
studies show that MRI scanning is more sensitive in
diagnoses of the cerebral edema and early cerebritis phase.1,2 Moreover, MRI scanning is accurate
for the diagnosis for the abscesses formation owing
to aspergillus species and the ones locating in brain
steam and posterior fossa.1,2 In three cases, we
were able to determine cerebritis with MRI that
were not detected with CT.

364
The most commonly isolated micro-organisms
were Streptococcus species, followed by Staphylococcus species and Proteus species in this study and
was not significantly different from the isolated
micro-organisms of old reports.3,8,16,18,2530 In
recent years, anaerobic micro-organisms are being
more frequently isolated from brain abscess. The
most common anaerobic bacteria are Bacteroides
(especially B. fragilis), Fusobacterium and anaerobic streptococci and their usually mixed growth is
seen in culture.4,30 We did not notice any increase in
Bacteroides species in contrast to recent reports. In
19 patients no organisms isolated, most of them had
received antibiotics at least 5 days before obtaining
culture material. The most important factor
responsible from sterile culture was the usage of
antibiotics before surgical intervention.3,9,18,20
However, in one case the culture was positive
despite to the antibiotics duration of 10 days before
from surgical intervention.
One of five patients with connection with
tuberculosis had history skin tuberculosis infection
6-month ago. In other four patients, no active focus
of tuberculosis were determined. This result is not a
surprise because tuberculosis is endemic in our
country.
Why the burr-hole aspiration is effective with
minimal risk,1 it is used mostly in our patients. It
reduces mass effect of the abscess immediately
with minimal trauma; it can provide not only the
confirmation of diagnosis but also avoid occasional
antibiotic therapy of some other lesions that can
resemble brain abscesses. Stereotactic surgery is
preferred if it can be applied and it reveals
excellent results.14,31 We used stereotactic aspiration in 12 cases. Total excision and CSF diversion is
preferred for some abscess localized in cerebellum
and for cases that cannot be cured after repeated
aspirations.14,32 It is not advised for the lesions
located in eloquent areas and for the abscesses in
cerebritis stage.
The non-surgically treatment ratio in brain
abscess has been increased since CT scanning has
been used for diagnosis.1 Dyste and Rosenblum33
considered medical treatment should be applied on
cortex localized brain abscess when their diametres
are 1017 mm. Mampalam5 suggests medical treatment when the diametre is around 20 mm and the
abscess is deeply localized. Other authors considered medical treatment when the abscess is
lesser than 30 mm and localized in brainstem.34,35
For the abscess bigger than 30 mm diametre,
surgical treatment is advised.5,11 In CCHD patients
abscesses larger than 2 cm in diametre repeatedly
aspiration is advised because of decreasing

T. Hakan et al.
intracranial pressure and avoided intraventricular
rupture of brain abscess (IVROBA).21
We successfully treated ten patients with
abscesses smaller than 30 mm diametre non-surgically. An antibiotic combination composed of a
beta-lactam and an anti-anaerobic is used.1,9 We
used formerly penicillin G and chloramphenicol
combination and recently the combination of
metronidazole with third generation cephalosporins such as cefotaxim and ceftriaxone. Metronidazole is preferred because of bactericidal activity
against strict anaerobes, reaching to high concentrations in pus and being not influenced by steroid
therapy while passing into the abscess contrast to
penicillin G, chloramphenicol.9,36,37 It was offered
to use in combination with an antibiotic active
against micro-aerophylic streptococci and aerotolerant anaerobes that are resistant to
metronidazole.1
The duration of anti-microbial therapy for brain
abscess is not clear.5,15 In many reports, parenteral
antibiotic therapy is recommended at least 36
weeks.9,10,15,35 Mamelak1 suggests minimum 6
weeks IV antibiotic therapy. In the presented
study, the duration of antibiotic treatment is 46
weeks parenterally, than 26 weeks orally. In the
surgically treated group, the duration of the oral
treatment is reduced according to the response of
the patient; this duration was as long as 1 year for
the abscess of tuberculosis.
In the literature the common causes of death are
determined as mass effect and edema with ventriculitis and thrombophlebitis. In these conditions,
steroids are recommended until the neurologic
condition stabilizes.1,4,5 They are used despite
deletion collagen deposition and decreasing antibiotic penetration.1 Steroids inhibit the migration of
leucocytes and diminish the effectiveness of host
defense mechanisms but encapsulation proceeds
and abscess wall thickness and abscess size does not
effect. In Schroeders38 experimental study on rats,
it is found that dexamethasone had little effect on
mortality rate. It is reported that corticosteroid
administration was correlated with a poorer neurological result; however the tendency of patients who
received corticosteroids to have had worse neurological grades in beginning and therefore steroids
may not have contributed to this result.3 We gave
dexamethasone to 53% of our patients and there
were significant correlation with poor outcome.
The most important factor on prognosis and
mortality in patients is the initial neurological
grade. The mortality is higher in the patient
whose symptoms are shorter, mental alterations
are serious and neurologic dysfunction is rapid.1,3,4
The size of abscess also may play a role in the

Bacterial brain abscesses: An evaluation of 96 cases

mortality.3 The ratio mortality rates of 80100% are
reported for comatose patients and for the abscess
ruptures into the ventriculus. IVROBA is the most
serious complication of purulent (especially in
CCHDs patients) brain abscesses.1,2,39 The mortality of IVROBA has been unchanged recent years
although decline in mortality associated with brain
abscess.1,20,21,39
The over all mortality (8.33%) of our series can be
accepted successful when compared with old series
with mortality rate was as high as 40%.8,15,16,18,20
With the introduction of CT and new antibiotics, the
mortality rate was reduced to 4%.3,5,15 The mortality reduced almost zero percent in some series in
that stereotaxic surgery performed.5
In conclusion brain abscesses are necessitated
multi discipline intervention. The close interaction
of neurosurgeon, specialist of infectious disease and
radiologist is very important for early diagnosis and
favorable intervention. Although, brain abscess can
be successfully treated with antibiotics alone in
appropriate cases, surgery still keeps its importance
as the main treatment modality. Aspiration either
free hand or stereotactic, is the surgical method that
first preferred. Image-guided stereotactic aspiration may achieve the objectives of management by
confirming the diagnosis, reducing the mass of the
abscess and obtaining material for accurate bacteriological diagnosis with minimal risk. It can be
therapeutic in abscesses, small or large, solitary or
multiple, superficial or deep-seated.
The initial neurological grade, meningismus, high
fever (O38.5 8C) and leucocytosis (O20.000) were
factors mostly influenced mortality and sequel. On
admission and at following when meet this signs it
should be warning for poor outcome.
When determined this sign, for patient the most
suitable treatment method should be decided and
at once should be performed. The attitudes are the
most appropriate intervention that improved prognosis of brain abscess.

365

6.

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8.
9.

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11.

12.

13.

14.

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19.

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