Case Report

Brain abscess in a non-penetrating
traumatic intracerebral hematoma:
Case report and review of literature
Santhosh George Thomas, Ranjith K. Moorthy, Vedantam Rajshekhar
Department of Neurological Sciences, Christian Medical College, Vellore, India

Abstract

Address for correspondence:
Dr. Vedantam Rajshekhar,
Department of Neurological
Sciences, Christian Medical College,
Vellore, Tamil Nadu, India.
E-mail: rajshekhar@cmcvellore.ac.in
DOI: 10.4103/0028-3886.48812

We report a 57-year-old man who presented one month after sustaining a traumatic right
temporal intracerebral hematoma with history of headache, left hemiparesis and altered
sensorium of two days duration. A diagnosis of right temporal resolving hematoma was
made on computed tomography scan. However, his sensorium progressively deteriorated
and he underwent craniotomy and partial excision of an abscess. He was treated with
appropriate antibiotics for six weeks despite of which he did not improve and died nine
months later. We conclude that there should be a high index of suspicion for brain abscess
in patients with traumatic intracerebral hemorrhage if the clinical and radiological picture
is different from the expected course of a resolving hematoma.
Key words: Brain abscess, intracerebral hemorrhage, trauma

Introduction
Brain abscess is a neurosurgical emergency that
necessitates urgent surgical evacuation and treatment
with appropriate antibiotics. Brain abscess is mostly
due to hematogenous spread from a distant focus of
infection.[1] Absence of a clear source of infection is
reported in as many as 40% of cases.[2] Brain abscess
complicating intracerebral hemorrhage is rare and to
our knowledge, only 18 cases have been reported so
far and none was post- traumatic in origin. Almost all
these patients had episodes of bacteremia, sepsis, or
local infection such as phlebitis or an infected surgical
wound.[3-9] Our patient developed the abscess in a
traumatic intracerebral hematoma with no identifiable
focus of infection.

Case Report
A 57-year-old man presented with history of headache,
left hemiparesis and altered sensorium of two days
duration. He sustained a fall one month prior to this
admission following which he developed a right
temporal intracerebral hematoma. He was managed
conservatively with antiepileptics and antiedema
Neurology India | Jan-Feb 2009 | Vol 57 | Issue 1

measures. He was a diabetic on irregular medication.
On examination, the glasgow coma scale (GCS) score
was 13/15 and pupils were equal and reacting. There
was Grade 4/5 power in the left upper and lower limbs.
There was no evidence of any external injury.
Plain computed tomography (CT) scan of the brain
done three days following the fall showed a right
temporal hematoma with mild mass effect and no
midline shift [Figure 1] Contrast CT done at the time
of this admission showed an intra-axial lesion in the
same location with mild perilesional edema which was
thought to be a resolving hematoma with an enhancing
rim [Figure 2]. There was a mild increase in the mass
effect but it did not warrant surgical evacuation. CT
angiogram was negative for an aneurysm. He was
managed conservatively with antiepileptics and
antiedema measures. On the second hospital day, the
GCS score started fluctuating between 10/15 (E3V2M5)
to 13/15 (E3V4M6). There were no seizures, fever,
meningismus or focus of any infection. The total
leucocyte count was 8300/mm3. A repeat plain CT scan
brain [Figure 3] showed increase in the perilesional
edema and mass effect. He underwent right temporal
craniotomy and partial excision of lesion on the fifth
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Thomas, et al.: Brain abscess in traumatic intracerebral hematoma

Figure 1: Axial section of a non-contrast CT of the brain three days
following trauma showing a right temporal hematoma with mild mass
effect and no midline shift

hospital day. There was a well-encapsulated collection
of pus mixed with blood in the superior temporal gyrus
with secondary adhesions to the overlying dura. The
temporal horn of the lateral ventricle was opened into
during the excision. The pus grew Escherichia coli and
he was treated with Cefotaxime and Amikacin for six
weeks based on sensitivity. Echocardiogram, chest
radiographs, otolaryngological and dental examinations
were negative for a potential source of infection.
Postoperative CT scan showed pneumocephalus with
minimal blood within the lateral ventricle. However,
the GCS persistently remained at 9/15 (E2V2M5) with
resolution of the left hemiparesis. The persistent low
GCS was thought to be due to ventriculitis as the
temporal horn was entered into during surgery. He was
discharged on the tenth postoperative day for further
management to a secondary level hospital. His GCS
score remained the same and he died after nine months.

Discussion

Figure 2: Axial section of a contrast CT of brain one month after
trauma showing an intra-axial lesion in the right temporal lobe with
mild perilesional edema thought to be a resolving hematoma with an
enhancing rim

Epidemiology and microbiological spectrum
The incidence of brain abscesses is ~8% of intracranial
masses in developing countries, whereas in the West
the incidence is ~1–2%. Mortality rates have reduced
with the advent of CT and effective antibiotics.[1,3]
About 30% of the patients who survive can be left with
neurological deficits and symptomatic seizures.[4] The
common predisposing factors for brain abscess include
synchronous infection in the middle ear or paranasal
sinuses, cyanotic heart disease, diabetes mellitus and
immunosuppression.[1,3] Several organisms (mostly
gram-positive cocci) have been reported as pathogens
in an abscess at the site of a recent spontaneous
intracerebral hematoma and the details have been
summarized in Table 1.
Pathogenesis and plausible mechanisms
An intracerebral hematoma disrupts the blood-brain
barrier, raising the susceptibility for inoculation of
bacteria through the hematogenous route.[3] Vasculitis
is also reported to be a cause of granulomatous
inflammation and fibrinoid necrosis of vessel walls that
causes disruption of leptomeningeal and parenchymal
arteries and veins leading to hemorrhages and disruption
of the blood-brain barrier. [2] Rupture of mycotic
aneurysms in patients with infective endocarditis
may lead to hematoma which can become secondarily
infected.[6] Most reported cases of abscesses at the site
of a recent spontaneous intraparenchymal hematoma
had episodes of high fever indicating bacteremia that
occurred approximately two to three weeks after the
bleed.[3-7]

Figure 3: Axial section of a non-contrast CT of the brain Þve days after
admission showing an increase in the perilesional edema and mass effect

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Our patient was a diabetic on irregular medication
and did not have any other risk factors and there was
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Thomas, et al.: Brain abscess in traumatic intracerebral hematoma

Table 1: Reported cases of brain abscess following intracerebral hematoma

Author and year

Site

Focus of infection

Pathogen

Israel et al. [3]
Biller et al. [8]
Biller et al. [8]
Kurihara et al. [5]
Mashimoto et al. [3]
Lee et al. [5]
Lida and Takemura [5]
Chen et al. [7]
Bert et al. [3]
Sumoika et al. [3]
Okami et al. [5]
Inamasu et al. [9]
Amayo et al.[6]
Nowak et al. [4]
Nakai et al. [5]

Left basal ganglia
Right frontal lobe
Right basal ganglia
Right putamen
Right basal ganglia
Right putamen
Cerebellum
Left putamen
Left temporal
Right putamen
Left thalamus
Right putamen
Left basal ganglia
Left thalamus
Left temporal
Right occipital
Left parietal
Right temporal

Unknown
Wound infection
Episiotomy
Phlebitis
Endocarditis
Sepsis
Pneumonia
Pneumonia
Phlebitis
Dental infection
Sepsis
Pneumonia
Pneumonia
Sepsis
Unknown
Bacteremia
Urinary tract Infection
No focus detected

Pneumococcus
Staphylococcus sp.
Staphylococcus sp.
Staphylococcus sp.
Enterococcus Fecalis
Streptococcus sp.
Staphylococcus sp.
Klebsiella
Staphylococcus sp.
Morgananella morgani
Staphylococcus sp.
Enterococcus faecalis
Sterile
Staphylococcus sp.
Gram-positive cocci
Sterile
Enterococcus faecalis
Escherichia coli

Siatouni et al. [3]
Present case

no discernible focus of infection. However, there was
a delay in recognizing the possibility of an abscess,
as the radiological diagnosis of a resolving hematoma
was considered. The differential diagnoses of ringenhancing lesions are abscesses (pyogenic, fungal,
parasitic), gliomas, lymphomas, metastases, resolving
hematomas and radionecrosis.[10] The delay in arriving
at a diagnosis and the iatrogenic intraventricular
rupture of the abscess that occurred at the time of
surgery were the main contributors to the poor outcome
in this patient.

Conclusion
There should be a high index of suspicion for a brain
abscess following an intracerebral hemorrhage if
the clinical and radiological picture differs from the
expected course of a resolving hematoma.

References
1.

Moorthy RK, Rajshekhar V. Management of brain abscess: An overview.
Neurosurg Focus 2008;24:3-9.

Neurology India | Jan-Feb 2009 | Vol 57 | Issue 1

2.

Dashti SR, Baharvahdat H, Sauvageau E, Chang SW, Stiefel MF,
Park MS, et al. Brain abscess formation at the site of intracerebral
hemorrhage secondary to central nervous system vasculitis. Neurosurg
Focus 2008;24:12-6.
3. Siatouni A, Mpouras T, Boviatsis EJ, Gatzonis S, Stefanatou M,
Sakas D. Brain abscess following intracerebral haemorrhage. J Clin
Neurosci 2007;14:986-9.
4. Nowak DA, Rodiek SO, Topka H. Pyogenic brain abscess following
haematogenous seeding of a thalamic haemorrhage. Neuroradiology
2003;45:157-9.
5. Nakai K, Yamamoto T, Yasuda S, Matsumura A. Brain abscess following
intracerebral haemorrhage. J Clin Neurosci 2006;13:1047-51.
6. Amayo EO, Kwasa TO, Musau CK, Mugo N, Wambani J. Primary
intracerebral haemorrhage complicated by cerebral abscess: Case report.
East Afr Med J 2002;79:163-4.
7. Chen ST, Tang LM, Ro LS. Brain abscess as a complication of stroke.
Stroke 1995;26:696-8.
8. Biller J, Adams P Jr, Godersky JC, Johnson R. Preeclampsia
complicated by cerebral hemorrhage and brain abscess. J Neurol
1985;232:378-80.
9. Inamatsu J, Kagami H, Nakamura Y, Saito R, Niimi M, Ichikizaki K.
Brain abscess developing at the site of preceding intracerebral
hemorrhage. J Neurol 2002;249:221-3.
10. Cortese I, Nath A. Case 11: A young woman with ring-enhancing brain
lesions. Med Gen Med 2006;8:3-6.
Accepted on 13-02-2009
Source of Support: Nil, Conßict of Interest: None declared.

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