Contemporary surgical management of brain abscess consists of stereotactic aspiration or craniotomy and excision of the capsule. Each has its advantages, proponents and specific indications, and excellent outcomes have been achieved with both methods. Aside from personal bias, several factors may influence the choice of procedure, including age, neurological condition, location and stage of the abscess, type of abscess (fungal vs bacterial), the presence of multiple lesions and co-morbidity.
Aspiration using stereotactic image-guided techniques can be performed with precise localization, with minimal tissue damage. This is especially important for deep-seated abscesses, those located in eloquent areas and for drainage of multiple abscesses. Stereotactic aspiration can be performed under local anesthesia, even in very ill patients. Additionally, cultures can be obtained, even during the cerebritis stage, at a time when antibiotics are likely to be curative.
There are some circumstances where cran-iotomy and resection of the abscess may be more appropriate. Post-traumatic abscesses with a retained foreign body generally cannot be cured with aspiration. Abscesses that occur as a result of a CSF leak often require excision, along with repair of the CSF fistula. Air within the abscess may indicate the presence of a CSF leak and dictate the need for excision. Multiloculated abscesses may be appropriate for excision, due to difficulty in completely aspirating these lesions. Fungal abscesses often can only be cured by complete excision, since organisms
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