Management of Intracranial Abscess

Diagnostic Approach

Brain MRI including diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC) and T1-weighted imaging with and without gadolinium is strongly recommended as the preferred imaging modality for patients with suspected brain abscess 1, 2, 4
If MRI is not available, contrast-enhanced CT is recommended as an alternative 1, 2, 5
Antimicrobials should be withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within a reasonable time, preferably within 24 hours of radiological diagnosis 2, 3, 5
Molecular-based diagnostics are conditionally recommended, if available, in patients with negative cultures 1, 2, 3

Neurosurgical aspiration or excision of brain abscess is strongly recommended as soon as possible in all patients whenever feasible 1, 2, 5
Surgical intervention serves both diagnostic and therapeutic purposes, allowing for pathogen identification and pressure relief 5, 6

For community-acquired brain abscess in immunocompetent individuals, a 3rd-generation cephalosporin combined with metronidazole is strongly recommended as empirical treatment 1, 2, 7
For post-neurosurgical brain abscess, a carbapenem combined with vancomycin or linezolid is conditionally recommended 6, 8
For severely immunocompromised patients, addition of trimethoprim-sulfamethoxazole and voriconazole to the empirical regimen is conditionally recommended 6, 8
The recommended duration of antimicrobial therapy is 6-8 weeks of intravenous antimicrobials for aspirated or conservatively treated brain abscesses 1, 2, 6
A shorter duration (e.g., 4 weeks) may be considered in patients treated with excision of brain abscess 2, 6

Corticosteroids (e.g., dexamethasone) are strongly recommended for management of severe symptoms due to perifocal edema or impending herniation in patients with brain abscess 1, 2, 8
Primary prophylaxis with antiepileptic drugs is conditionally not recommended in patients with brain abscess 2, 4, 9

The most common causative organisms in community-acquired brain abscess are oral cavity bacteria such as Streptococcus anginosus group, Fusobacterium spp., and Aggregatibacter spp. 8
Other pathogens include Staphylococcus aureus, Gram-negative bacilli, anaerobes, and in immunocompromised patients: Nocardia spp., fungi, and parasites 8
Predisposing conditions include sinusitis, otitis media, dental infections, mastoiditis, neurosurgery, head trauma, and immunocompromised states 8