Treatment

When the diagnosis of brain abscess is confirmed, the therapeutic strategy will be influenced by several factors. Most patients require surgical drainage: reasons for surgery are relief of space occupation, confirmation of the diagnosis, and obtaining specimens of pus for culture. It is seldom necessary to resort to complete surgical excision of an abscess. Simple aspiration of the contents of an abscess is the most frequently advocated technique; when carried out under stereotactic CT-guided control149 diagnostic material is obtained in more than 90% of cases. If the abscess is a consequence of head trauma, then surgery is mandatory to perform appropriate toilet, debridement, removal of fragments, and closure of dural defects. If the abscesses are small or in the cerebritis stage, then surgery may not be needed and it is appropriate to treat with antibiotics on the basis of organism identification from other sources or, if that is not possible, on a "best guess" principle governed by the likely source of infection. Close monitoring of the lesions with serial CT or MRI is necessary; if they do not diminish in size, aspiration should be undertaken. In people with immunosuppression, including those with AIDS, the threshold for aspiration of pus to identify the offending organism is substantially lowered.

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