Brain Abscess in Emergency Medicine
- Author: Naomi George, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
Brain abscess is a focal intracranial infection that may present as a life-threatening emergency. It begins with an area of unencapsulated inflammation, known as cerebritis, and develops into a collection of necrotic pus surrounded by a vascular capsule. Brain abscess occurs as the result of a complication of variety of infections, trauma, or surgery and carries significant morbidity and mortality.[1, 2]
For centuries, brain abscess was thought of as almost certainly fatal. In 460 BCE, Hippocrates cautioned his readers of the condition, "For there is danger that the man may become delirious and die" and recommended intracranial drainage as the only cure. However, over the last half century, the epidemiology of this condition has shifted dramatically ; improvements in the detection and treatment of ear, sinus, and orofacial infections has decreased the incidence of brain abscess as a consequence of direct spread of infection. Meanwhile, the population prevalence of chronic immune suppression and immunocompromise has grown, and with it there has been a rise in opportunistic and fungal brain abscess. Management of these complex patients may require close cooperation of specialists in infectious disease, radiology, and neurosurgery.
Animal and human modeling of brain abscess has demonstrated a 4-stage process of disease progression.[5, 6] The process begins with direct inoculation of microorganisms into the brain parenchyma, resulting in focal inflammation in the 1-3 days following, which is referred to as early cerebritis.
Polymorphic neutrophils are then recruited, leading to edema. Glial cells are activated, and the area of inflammation continues to grow as the central zone develops coagulation necrosis; this is a hallmark of the second stage, called late cerebritis, which occurs at approximately 3-6 days.[8, 9]
A well-vascularized, ring-enhancing capsule forms after approximately 2 weeks and may be seen on CT. As the host defenses mount, the capsule is walled off, thus completing the development of the abscess.
The fourth stage is often marked by considerable gliosis on the cortical surface of the abscess. Tissue destruction is likely dependent on the virulence of the organism and the exuberance of the host response.
The pathogenesis of an invading organism that has inoculated the brain parenchyma is variable and dependent on the initial site of infection, host factors, and geographic location. Infection can be due to bacteria, fungi, or protozoa. Brain abscess has traditionally been classified by the primary source of the pathogen,[2, 11] with the most common etiologies being direct extension, metastatic spread, and intracranial penetrating trauma.
Brain abscess may be caused by the contiguous spread of pathogens from a primary focus of infection outside of the CNS that extends into the brain. Pathogens may originate from adjacent bone, teeth, sinus mucosa, internal auditory canal, or cochlear structures and travel into the intracranial vault via venous drainage or valveless emissary veins, thus inoculating the brain parenchyma. Abscess caused by direct extension usually leads to a solitary lesion.
Although less common, brain abscess has been described as a complication of frontal, ethmoidal, or sphenoidal sinusitis. Dental infections can lead to brain abscess via either contiguous or hematogenous routes. Meningitis rarely results in brain abscess by direct extension, particularly in adults, and therefore in most cases the finding of brain abscess should not prompt a search for meningeal infection via lumbar puncture.
In the past, chronic otitis media and mastoiditis were the most common underlying etiologies; however, complications of these infections have decreased in incidence with improvements in diagnostic modalities and antibiotic therapy. Overall, abscess caused by direct extension now comprises 12-25% of all brain abscesses ; however, where adequate healthcare infrastructure is lacking, direct extension continues to comprise approximately 50% of brain abscess collectively.[14, 15]
Hematogenous seeding of the brain from an extracranial source is the second most common etiology of brain abscess, accounting for approximately 25% of cases. While most bacteremias do not cause brain abscess, when they do, abscesses are frequently multiple and are often found in the distribution of the middle cerebral artery or watershed zones.[11, 16] When hematogenous spread is the underlying cause, there is often an additional predisposing factor; patients with comorbid conditions such as congenital heart disease with right-to-left shunt, pulmonary venous malformations, or hereditary hemorrhagic telangiectasia are at relatively high risk for brain abscess.
Among extracranial sources, chronic pulmonary infections such as lung abscess, bronchiectasis, and empyema have been frequently associated with hematogenous brain abscess. Bacteremias associated with endocardial, abdominal, pelvic, or skin infections can lead to brain abscess. Approximately 15% of cases have no identifiable source.
The formation of brain abscess after intracranial trauma or neurosurgical intervention is well described. In the case of penetrating trauma, brain abscess may form as an immediate or delayed complication; direct inoculation of pathogens can quickly lead to abscess formation, whereas a retained foreign body or focus of necrotic tissue can serve as a nidus of infection months or years after the initial insult.[18, 19] Compared with earlier series, there has been an increase in the proportion of brain abscess caused by direct trauma or neurosurgical intervention; the incidence in recent studies has ranged from 2-37%.[2, 20, 21] One factor accounting for this trend is the relative decline in otogenic brain abscess. Variability in outcome depends greatly on the age and underlying condition of the patient.
The etiology, incidence, and outcome of brain abscess vary greatly across populations. In developed countries, brain abscess is now a rare entity in the general population, with approximately 1,500-2,500 cases reported annually in the United States and an estimated incidence rate of 0.3-1.3 cases per 100,000 per year. Immunocompromised patients form a special subpopulation that sustains a higher incidence of brain abscess.
Populations in low-resource settings have a higher burden of brain abscess. It accounts for less than 1% of intracranial lesions in the developed world, as opposed to roughly 8% in developing countries.[25, 26] Without access to advancements in diagnostic imaging and antibiotic regimens, the development of brain abscess from otogenic and odontogenic infections continues unabated. Additionally, populations with increasing prevalence of HIV infection have witnessed a concomitant increase in incidence of brain abscess.
Underlying pathophysiology of brain abscess varies across locales, with mycobacterial infection (tuberculoma) being more common in parts of Asia, whereas neurocysticercosis is more prevalent in parts of Latin America and is also becoming more prevalent in the United States, particularly among immigrant communities.
In the preantibiotic era, mortality from brain abscess was nearly 100%. Despite the introduction of antibiotics and improvements in neurosurgical drainage techniques, the mortality rate remained around 30-50% through the 1970s. The introduction of enhanced neuroimaging techniques, such as CT and MRI, allowed for rapid, accurate diagnosis and localization of brain abscess. In most modern series, the mortality rate is typically less than 15%.[21, 30, 15] Rupture of a brain abscess infrequently occurs and is associated with a high mortality rate (up to 80%).
Significant morbidity, including seizures, persistent weakness, aphasia, or cognitive impairment, affects an estimated at 20-30% of survivors. In pediatric populations, outcomes have been shown to vary according to how rapidly antibiotics are initiated. Favorable outcomes have been associated with a number of factors, including initial Glasgow Coma Scale score of higher than 12, absence of underlying disease, or sepsis.
No compelling evidence exists for racial differences in the incidence of brain abscess.
Although brain abscess can affect both sexes, in multiple series of both pediatric and adult patients, the male-to-female ratio of brain abscess has been demonstrated to range from 2:1 to as great as 4:1.[15, 32, 14]
Throughout the first half of the 20th century, the age distribution of brain abscess was bimodal, with the highest rates being among children and adults older than 60 years. However, advancement in vaccination trends and antibiotic strategies, as well as a growing population of chronically immunosuppressed patients, has led to a shift in the demographics towards the middle decades. Overall, about 25% of cases of brain abscesses still occur in children, typically among those aged 4-7 years. In pediatric series, congenital heart disease remains the most common predisposing factor.
Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis. 1997 Oct. 25(4):763-79; quiz 780-1. [Medline].
Carpenter J, Stapleton S, Holliman R. Retrospective analysis of 49 cases of brain abscess and review of the literature. Eur J Clin Microbiol Infect Dis. 2007 Jan. 26(1):1-11. [Medline].
Hippocrates. The Prognostics and Prosthetics of Hippocrates. 460 B.C.
Alderson D, Strong AJ, Ingham HR, Selkon JB. Fifteen-year review of the mortality of brain abscess. Neurosurgery. 1981 Jan. 8(1):1-6. [Medline].
Baldwin AC, Kielian T. Persistent immune activation associated with a mouse model of Staphylococcus aureus-induced experimental brain abscess. J Neuroimmunol. 2004 Jun. 151(1-2):24-32. [Medline].
Lu CH, Chang WN, Lin YC, et al. Bacterial brain abscess: microbiological features, epidemiological trends and therapeutic outcomes. QJM. 2002 Aug. 95(8):501-9. [Medline].
Kao PT, Tseng HK, Liu CP, et al. Brain abscess: clinical analysis of 53 cases. J Microbiol Immunol Infect. 2003 Jun. 36(2):129-36. [Medline].
Roche M, Humphreys H, Smyth E, et al. A twelve-year review of central nervous system bacterial abscesses; presentation and aetiology. Clin Microbiol Infect. 2003 Aug. 9(8):803-9. [Medline].
Grigoriadis E, Gold WL. Pyogenic brain abscess caused by Streptococcus pneumoniae: case report and review. Clin Infect Dis. 1997 Nov. 25(5):1108-12. [Medline].
Bernardini GL. Diagnosis and management of brain abscess and subdural empyema. Curr Neurol Neurosci Rep. 2004 Nov. 4(6):448-56. [Medline].
Tonon E, Scotton PG, Gallucci M, Vaglia A. Brain abscess: clinical aspects of 100 patients. Int J Infect Dis. 2006 Mar. 10(2):103-9. [Medline].
Jim KK, Brouwer MC, van der Ende A, van de Beek D. Cerebral abscesses in patients with bacterial meningitis. J Infect. 2012 Feb. 64(2):236-8. [Medline].
Sharma R, Mohandas K, Cooke RP. Intracranial abscesses: changes in epidemiology and management over five decades in Merseyside. Infection. 2009 Feb. 37(1):39-43. [Medline].
Menon S, Bharadwaj R, Chowdhary A, Kaundinya DV, Palande DA. Current epidemiology of intracranial abscesses: a prospective 5 year study. J Med Microbiol. 2008 Oct. 57(Pt 10):1259-68. [Medline].
Bakshi R, Wright PD, Kinkel PR, et al. Cranial magnetic resonance imaging findings in bacterial endocarditis: the neuroimaging spectrum of septic brain embolization demonstrated in twelve patients. J Neuroimaging. 1999 Apr. 9(2):78-84. [Medline].
Hall WA. Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) presenting with polymicrobial brain abscess. Case report. J Neurosurg. 1994 Aug. 81(2):294-6. [Medline].
Hashmi S, Jones RA. Delayed recurrence of cerebellar abscess 20 years after excision of dermoid cyst and sinus. Br J Neurosurg. 1998 Aug. 12(4):358-60. [Medline].
Staecker H, Nadol JB Jr, Ojeman R, McKenna MJ. Delayed intracranial abscess after acoustic neuroma surgery: a report of two cases. Am J Otol. 1999 May. 20(3):369-72. [Medline].
Xiao F, Tseng MY, Teng LJ, et al. Brain abscess: clinical experience and analysis of prognostic factors. Surg Neurol. 2005 May. 63(5):442-9; discussion 449-50. [Medline].
Tseng JH, Tseng MY. Brain abscess in 142 patients: factors influencing outcome and mortality. Surg Neurol. 2006 Jun. 65(6):557-62; discussion 562. [Medline].
Kastenbauer S, Pfister HW, Wispelwey B, et al. Brain abscess. Scheld WM, Whitley RJ, Marra CM, eds. Infections of the Central Nervous System. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004. 479-507.
Farrar DJ, Flanigan TP, Gordon NM, Gold RL, Rich JD. Tuberculous brain abscess in a patient with HIV infection: case report and review. Am J Med. 1997 Mar. 102(3):297-301. [Medline].
Nathoo N, Narotam PK, Nadvi S, van Dellen JR. Taming an old enemy: a profile of intracranial suppuration. World Neurosurg. 2012 Mar-Apr. 77(3-4):484-90. [Medline].
Prasad KN, Mishra AM, Gupta D, et al. Analysis of microbial etiology and mortality in patients with brain abscess. J Infect. 2006 Oct. 53(4):221-7. [Medline].
Bhatia R, Tandon PN, Banerji AK. Brain abscess--an analysis of 55 cases. Int Surg. 1973 Aug. 58(8):565-8. [Medline].
Nathoo N, Nadvi SS, Narotam PK, van Dellen JR. Brain abscess: management and outcome analysis of a computed tomography era experience with 973 patients. World Neurosurg. 2011 May-Jun. 75(5-6):716-26; discussion 612-7. [Medline].
Sinha S, Sharma BS. Neurocysticercosis: a review of current status and management. J Clin Neurosci. 2009 Jul. 16(7):867-76. [Medline].
Sennaroglu L, Sozeri B. Otogenic brain abscess: review of 41 cases. Otolaryngol Head Neck Surg. 2000 Dec. 123(6):751-5. [Medline].
Brook I. Brain abscess in children: microbiology and management. J Child Neurol. 1995 Jul. 10(4):283-8. [Medline].
Sáez-Llorens X. Brain abscess in children. Semin Pediatr Infect Dis. 2003 Apr. 14(2):108-14. [Medline].
Heilpern KL, Lorber B. Focal intracranial infections. Infect Dis Clin North Am. 1996 Dec. 10(4):879-98. [Medline].
Shachor-Meyouhas Y, Bar-Joseph G, Guilburd JN, Lorber A, Hadash A, Kassis I. Brain abscess in children - epidemiology, predisposing factors and management in the modern medicine era. Acta Paediatr. 2010 Feb 23. [Medline].
Goodkin HP, Harper MB, Pomeroy SL. Intracerebral abscess in children: historical trends at Children's Hospital Boston. Pediatrics. 2004 Jun. 113(6):1765-70. [Medline].
Hakan T, Ceran N, Erdem I, et al. Bacterial brain abscesses: an evaluation of 96 cases. J Infect. 2006 May. 52(5):359-66. [Medline].
Zeidman SM, Geisler FH, Olivi A. Intraventricular rupture of a purulent brain abscess: case report. Neurosurgery. 1995 Jan. 36(1):189-93; discussion 193. [Medline].
Lee TH, Chang WN, Su TM, et al. Clinical features and predictive factors of intraventricular rupture in patients who have bacterial brain abscesses. J Neurol Neurosurg Psychiatry. 2007 Mar. 78(3):303-9. [Medline].
Takeshita M, Kawamata T, Izawa M, Hori T. Prodromal signs and clinical factors influencing outcome in patients with intraventricular rupture of purulent brain abscess. Neurosurgery. 2001 Feb. 48(2):310-6; discussion 316-7. [Medline].
Chun CH, Johnson JD, Hofstetter M, Raff MJ. Brain abscess. A study of 45 consecutive cases. Medicine (Baltimore). 1986 Nov. 65(6):415-31. [Medline].
Seydoux C, Francioli P. Bacterial brain abscesses: factors influencing mortality and sequelae. Clin Infect Dis. 1992 Sep. 15(3):394-401. [Medline].
Frazier JL, Ahn ES, Jallo GI. Management of brain abscesses in children. Neurosurg Focus. 2008. 24(6):E8. [Medline].
Lu CH, Chang WN, Lui CC. Strategies for the management of bacterial brain abscess. J Clin Neurosci. 2006 Dec. 13(10):979-85. [Medline].
Jacobs JA, Pietersen HG, Stobberingh EE, Soeters PB. Bacteremia involving the "Streptococcus milleri" group: analysis of 19 cases. Clin Infect Dis. 1994 Oct. 19(4):704-13. [Medline].
Horiuchi Y, Kato Y, Dembo T, Takeda H, Fukuoka T, Tanahashi N. Patent foramen ovale as a risk factor for cryptogenic brain abscess: case report and review of the literature. Intern Med. 2012. 51(9):1111-4. [Medline].
Velthuis S, Buscarini E, van Gent MW, et al. Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: a striking association. Chest. 2013 Aug. 144(2):542-8. [Medline].
Chan KS, Yu WL, Tsai CL, Cheng KC, Hou CC, Lee MC, et al. Pyogenic liver abscess caused by Klebsiella pneumoniae: analysis of the clinical characteristics and outcomes of 84 patients. Chin Med J (Engl). 2007 Jan 20. 120(2):136-9. [Medline].
Cheng DL, Liu YC, Yen MY, Liu CY, Wang RS. Septic metastatic lesions of pyogenic liver abscess. Their association with Klebsiella pneumoniae bacteremia in diabetic patients. Arch Intern Med. 1991 Aug. 151(8):1557-9. [Medline].
Saito N, Aoki K, Sakurai T, et al. Linezolid treatment for intracranial abscesses caused by methicillin-resistant Staphylococcus aureus--two case reports. Neurol Med Chir (Tokyo). 2010. 50(6):515-7. [Medline].
Martinello RA, Cooney EL. Cerebellar brain abscess associated with tongue piercing. Clin Infect Dis. 2003 Jan 15. 36(2):e32-4. [Medline].
Wolf J, Curtis N. Brain abscess secondary to dental braces. Pediatr Infect Dis J. 2008 Jan. 27(1):84-5. [Medline].
Herskovitz MY, Goldsher D, Finkelstein R, Bar-Lavi Y, Constantinescu M, Telman G. Multiple brain abscesses associated with tongue piercing. Arch Neurol. 2009 Oct. 66(10):1292. [Medline].
Roberts J, Bartlett AH, Giannoni CM, et al. Airway foreign bodies and brain abscesses: report of two cases and review of the literature. Int J Pediatr Otorhinolaryngol. 2008 Feb. 72(2):265-9. [Medline].
Gaïni S, Grand M, Michelsen J. Brain abscess after esophageal dilatation: case report. Infection. 2008 Feb. 36(1):71-3. [Medline].
Katragkou A, Dotis J, Kotsiou M, et al. Scedosporium apiospermum infection after near-drowning. Mycoses. 2007 Sep. 50(5):412-21. [Medline].
Laviv Y, Ben-Daviv U, Vated M, Rappaport ZH. Brain abscess following endoscopic ligation of esophageal varicose veins. Acta Neurochir (Wien). 2010 Apr. 152(4):733-4. [Medline].
Da Cunha S, Ferreira E, Ramos I, et al. Cerebral toxoplasmosis after renal transplantation. Case report and review. Acta Med Port. 1994 Dec. 7 Suppl 1:S61-6. [Medline].
Cone LA, Leung MM, Byrd RG, Annunziata GM, Lam RY, Herman BK. Multiple cerebral abscesses because of Listeria monocytogenes: three case reports and a literature review of supratentorial listerial brain abscess(es). Surg Neurol. 2003 Apr. 59(4):320-8. [Medline].
Ozsürekci Y, Kara A, Cengiz AB, Celik M, Ozkaya-Parlakay A, Karadag-Oncel E, et al. Brain abscess in childhood: a 28-year experience. Turk J Pediatr. 2012 Mar-Apr. 54(2):144-9. [Medline].
Chowdhry SA, Cohen AR. Citrobacter brain abscesses in neonates: early surgical intervention and review of the literature. Childs Nerv Syst. 2012 Oct. 28(10):1715-22. [Medline].
Lumbiganon P, Chaikitpinyo A. Antibiotics for brain abscesses in people with cyanotic congenital heart disease. Cochrane Database Syst Rev. 2013 Mar 28. 3:CD004469. [Medline].
Correa D, Sarti E, Tapia-Romero R, et al. Antigens and antibodies in sera from human cases of epilepsy or taeniasis from an area of Mexico where Taenia solium cysticercosis is endemic. Ann Trop Med Parasitol. 1999 Jan. 93(1):69-74. [Medline].
Ramamurthi B, Ramamurthi R, Vasudevan MC, Sridhar K. The changing face of tuberculomas. Ann Acad Med Singapore. 1993 Nov. 22(6):852-5. [Medline].
Renier D, Flandin C, Hirsch E, Hirsch JF. Brain abscesses in neonates. A study of 30 cases. J Neurosurg. 1988 Dec. 69(6):877-82. [Medline].
Kaushik KS, Kapila K, Praharaj AK. Shooting up: the interface of microbial infections and drug abuse. J Med Microbiol. 2011 Apr. 60:408-22. [Medline].
Gallitelli M, Lepore V, Pasculli G, et al. Brain abscess: a need to screen for pulmonary arteriovenous malformations. Neuroepidemiology. 2005. 24(1-2):76-8. [Medline].
Mamelak AN, Mampalam TJ, Obana WG, et al. Improved management of multiple brain abscesses: a combined surgical and medical approach. Neurosurgery. 1995. 36(1):76-85. [Medline].
Dee RR, Lorber B. Brain abscess due to Listeria monocytogenes: case report and literature review. Rev Infect Dis. 1986 Nov-Dec. 8(6):968-77. [Medline].
Luft BJ, Sivadas R. Toxoplasmosis of the central nervous system. Scheld WM, Whitley RJ, Marra CM, eds. Infections of the Central Nervous System,. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004. 755-76.
Smith SJ, Ughratdar I, MacArthur DC. Never go to sleep on undrained pus: a retrospective review of surgery for intraparenchymal cerebral abscess. Br J Neurosurg. 2009 Aug. 23(4):412-7. [Medline].
Omuro AM, Leite CC, Mokhtari K, Delattre JY. Pitfalls in the diagnosis of brain tumours. Lancet Neurol. 2006 Nov. 5(11):937-48. [Medline].
Leuthardt EC, Wippold FJ 2nd, Oswood MC, Rich KM. Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses. Surg Neurol. 2002 Dec. 58(6):395-402; discussion 402. [Medline].
Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx. 2005 Apr. 2(2):324-32. [Medline].
Lai PH, Hsu SS, Ding SW, et al. Proton magnetic resonance spectroscopy and diffusion-weighted imaging in intracranial cystic mass lesions. Surg Neurol. 2007. 68 Suppl 1:S25-36. [Medline].
Kimberly HH, Shah S, Marill K, et al. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med. 2008 Feb. 15(2):201-4. [Medline].
Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13. 345(24):1727-33. [Medline].
Song L, Guo F, Zhang W, Sun H, Long J, Wang S. Clinical features and outcome analysis of 90 cases with brain abscess in central China. Neurol Sci. 2008 Dec. 29(6):425-30. [Medline].
Brook I. The importance of lactic acid levels in body fluids in the detection of bacterial infections. Rev Infect Dis. 1981 May-Jun. 3(3):470-8. [Medline].
Erdogan E, Cansever T. Pyogenic brain abscess. Neurosurg Focus. 2008. 24(6):E2. [Medline].
Hsiao SY, Chang WN, Lin WC, Tsai NW, Huang CR, Wang HC, et al. The experiences of non-operative treatment in patients with bacterial brain abscess. Clin Microbiol Infect. 2011 Apr. 17(4):615-20. [Medline].
Cavusoglu H, Kaya RA, Türkmenoglu ON, Colak I, Aydin Y. Brain abscess: analysis of results in a series of 51 patients with a combined surgical and medical approach during an 11-year period. Neurosurg Focus. 2008. 24(6):E9. [Medline].
Sifri CD, Park J, Helm GA, et al. Fatal brain abscess due to community-associated methicillin-resistant Staphylococcus aureus strain USA300. Clin Infect Dis. 2007 Nov 1. 45(9):e113-7. [Medline].
Enany S, Higuchi W, Okubo T, et al. Brain abscess caused by Panton-Valentine leukocidin-positive community-acquired methicillin-resistant Staphylococcus aureus in Egypt, April 2007. Euro Surveill. 2007 Sep 27. 12(9):E070927.2. [Medline].
Naesens R, Ronsyn M, Druwé P, Denis O, Ieven M, Jeurissen A. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol. 2009 Sep. 58(Pt 9):1247-51. [Medline].
Schwartz S, Thiel E. Cerebral aspergillosis: tissue penetration is the key. Med Mycol. 2009. 47 Suppl 1:S387-93. [Medline].
Stiefel M, Reiss T, Staege MS, Rengelshausen J, Burhenne J, Wawer A, et al. Successful treatment with voriconazole of Aspergillus brain abscess in a boy with medulloblastoma. Pediatr Blood Cancer. 2007 Aug. 49(2):203-7. [Medline].
Boviatsis EJ, Kouyialis AT, Stranjalis G, et al. CT-guided stereotactic aspiration of brain abscesses. Neurosurg Rev. 2003 Jul. 26(3):206-9. [Medline].
Skoutelis AT, Gogos CA, Maraziotis TE, Bassaris HP. Management of brain abscesses with sequential intravenous/oral antibiotic therapy. Eur J Clin Microbiol Infect Dis. 2000 May. 19(5):332-5. [Medline].
Kutlay M, Colak A, Yildiz S, et al. Stereotactic aspiration and antibiotic treatment combined with hyperbaric oxygen therapy in the management of bacterial brain abscesses. Neurosurgery. 2005 Dec. 57(6):1140-6; discussion 1140-6. [Medline].
Ecevit IZ, Clancy CJ, Schmalfuss IM, Nguyen MH. The poor prognosis of central nervous system cryptococcosis among nonimmunosuppressed patients: a call for better disease recognition and evaluation of adjuncts to antifungal therapy. Clin Infect Dis. 2006 May 15. 42(10):1443-7. [Medline].
Landriel F, Ajler P, Hem S, et al. Supratentorial and infratentorial brain abscesses: surgical treatment, complications and outcomes--a 10-year single-center study. Acta Neurochir (Wien). 2012 May. 154(5):903-11. [Medline].
Takeshita M, Kagawa M, Izawa M, Takakura K. Current treatment strategies and factors influencing outcome in patients with bacterial brain abscess. Acta Neurochir (Wien). 1998. 140(12):1263-70. [Medline].
Demir MK, Hakan T, Kilicoglu G, et al. Bacterial brain abscesses: prognostic value of an imaging severity index. Clin Radiol. 2007 Jun. 62(6):564-72. [Medline].
Kennedy KJ, Chung KH, Bowden FJ, et al. A cluster of nocardial brain abscesses. Surg Neurol. 2007 Jul. 68(1):43-9; discussion 49. [Medline].