DOI: 10.5137/1019-5149.JTN.6591-12.2

Case Report

Brain Abscess Developing in a Non-Operated
Spontaneous Intracerebral Haemorrhage:
A Case Report and Literature Review
Ameliyat Edilmemiş Spontan İntraserebral Hemorajide Gelişen Beyin
Apsesi: Bir Olgu Sunumu ve Literatürün Gözden Geçirilmesi
Luigi Rıgante1, Tommaso Tufo1, Giancarlo Scoppettuolo2, Concetta Donato2,
Annunziato Mangıola1
1Catholic University, Faculty of Medicine, Department of Neurosurgery, Rome, Italy

2Catholic University, Faculty of Medicine, Department of Infectious Diseases, Rome, Italy

Corresponding Author: Luigi Rıgante / E-mail: [email-masked]

ABSTRACT
Brain abscesses are a rare but potentially lethal neurological lesions, generally occurring after septic episodes in immunodeficient patients or
complicating neurosurgical procedures. Even though they are known complications of surgically treated intracerebral haemorrhages (ICH),
the presence of a brain abscess at the site of an untreated ICH is a rare event. Such cases may result from haematogenous spread from distant
foci or contiguous sites and are often preceded by episodes of sepsis and local infection. Immunodeficiency, AIDS, age, diabetes mellitus
and vitamin-K deficiency are predisposing factors. Abscess formation should be considered in case of clinical deterioration, headache, and
any neurological deficit after febrile episodes. Early diagnosis with neuroradiological imaging, infection blood markers and microbiological
identification of the causative pathogen is crucial for treatment with surgical drainage or excision and specific antibiotic therapy, which
guarantee good outcome and long-term survival. In fact, while prompt diagnosis and treatment guarantee good outcome and long-term
survival, morbidity and mortality are very high in case of misdiagnosis. We report a case of a 49-year old man presenting with a brain abscess
13 weeks after a spontaneous ICH, without previous episodes of sepsis and with a suspected septic arthritis 2 weeks after abscess drainage.
Keywords: Brain abscess, Intracerebral haemorrhage, Stroke

ÖZ
Beyin apseleri genellikle immün yetmezlikli hastalarda septik episodlar sonrasında gelişen veya nöroşirürji işlemlerinin komplikasyonları olarak
görülen nadir ama ölümcül olabilen nörolojik lezyonlardır. Cerrahi olarak tedavi edilen intraserebral hemorajilerin bilinen komplikasyonları
olsalar da tedavi edilmemiş bir intraserebral hemoraji bölgesinde bir beyin apsesi bulunması nadir bir durumdur. Bu tür olgular uzak
odaklardan veya komşu bölgelerden hematojen yayılmanın sonucu olabilir ve sıklıkla öncelerinde sepsis ve yerel enfeksiyon episodları görülür.
İmmünyetmezlik, AIDS, yaş, diabetes mellitus ve K vitamini eksikliği predispozan faktörlerdir. Apse oluşumu febril episodlardan sonra herhangi
bir nörolojik defisit, başağrısı ve klinik durumda bozulma durumunda dikkate alınmalıdır. Nöroradyolojik testler, enfeksiyon kan işaretleri ve
neden olan patojenin mikrobiyolojik olarak tanımlanması uzun dönemli iyi prognoz ve uzun dönemli sağkalımı garanti edecek şekilde cerrahi
drenaj veya eksizyon ve spesifik antibiyotik tedavisiyle tedavi amacıyla erken tanı için şarttır. Hatta erken tanı ve tedavi iyi prognoz ve uzun
dönemli sağkalımı garanti ederken yanlış tanı durumunda morbidite ve mortalite çok yüksektir. Daha önce sepsis episodu olmadan, spontan
intraserebral kanamadan 13 hafta sonra beyin apsesiyle gelen ve apse drenajından 2 hafta sonra septik artrit durumundan şüphelenilen 49
yaşında bir erkek hastayı sunuyoruz.
ANAHTAR SÖZCÜKLER: Beyin apsesi, İntraserebral hemoraji, İnme

Introduction
Brain abscesses are serious infections of brain parenchyma,
requiring prompt surgical drainage and high-dose antibiotic
therapy, affecting 1/10000 patients in developed countries (1).
Mortality rate is 0-15%, although it can increase up to 80% due
to incorrect diagnosis (7,8,17). Common sources of infection
include contiguous sites (sinusitis, otitis, dental infection,
cranial trauma) or haematogenous spread from distant foci
(infectious endocarditis, right-to-left-shunt heart disease,
Turkish Neurosurgery 2013, Vol: 23, No: 6, 835-839

pneumonia, sepsis, urinary infections) (13,17). 40 % of the
cases remain cryptogenic (14), partly because of incomplete
diagnosis. Immunodeficiency, AIDS (17), vitamin K deficiency
(8), age, diabetes mellitus (7) are predisposing factors. Unlike
extra-axial empyemas, fever is not a common presenting sign.
On the other hand, signs of increased intracranial pressure
(headache, nausea and vomiting, drowsiness, confusion) are
the most frequent initial symptoms of cerebral parenchymal
abscesses followed by seizures, motor/sensory deficits, and

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Rigante L. et al: Brain Abscess Developing in a Non-Operated Spontaneous Intracerebral Haemorrhage

A

b

c

d

e

f

g

h

ı

Figure 1: A) Head-CT showing an ICH in the left parietal lobe; B) Head-CT showing an initial volume reduction of haemorrhage and
C) T1W MRI image with contrast illustrating signs suspected for an early phase of brain abscess at the site of the previous ICH at 2
weeks; D) T1W MRI image with contrast five weeks after ICH, showing cystic mass at the site of the ICH; E) and F) Head CT-angiogram
with contrast ten weeks after the ICH, showing cystic lesion with thick wall exerting mass effect on brain parenchyma and no vascular
malformation; G) Head-CT one week after surgery, showing partial reduction of the abscess and the intracavitary catheter; H) Head-CT
with contrast five weeks after surgery and I) Head CT nineteen weeks after surgery, showing progressive resolution of the abscess and
the mass effect.

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Rigante L. et al: Brain Abscess Developing in a Non-Operated Spontaneous Intracerebral Haemorrhage

speech disorders (30-50%) (9). 30% of the patients who
survive after the treatment of a brain abscess are left with
neurological deficits or seizures (15). Brain abscesses after
surgically treated intracerebral haemorrhages (ICHs) are
intuitively possible. However, brain abscesses at the site
of previously untreated ICHs are rare. We report a case and
literature review.
Case report
A 49-year-old man with mild hypertension and Hodgkin
lymphoma (Stage II) successfully treated with radio- and
chemotherapy five years before, suffered from a sudden
onset of headache, right-side weakness, and dysarthria.
After admission, head Computed Tomography (CT) showed
a left parietal spontaneous ICH (Figure 1A) with no midline
shift nor signs of increased ICP; therefore, the haematoma
was conservatively treated. The patient’s neurological
conditions gradually improved. On the 15th inpatient day,
right hemiparesis and speech disturbance worsened; he
developed fever (38.5°C). Neuroradiological imaging showed
signs of initial volume reduction of the hemorrhage (Figure
1B) and signs suspected for an early phase of brain abscess in
the same region (Figure 1C). Gram’s stain and blood cultures
were negative for microbiological pathogens. Fever was
treated with antipyretics and resolved within days. Highdose corticosteroids were given to treat neurological deficits
that improved. Five weeks later, Head Magnetic Resonance
Imaging (MRI) showed a cystic lesion at the site of the previous
ICH (Figure 1D). Ten weeks after the ICH, motor and speech
deficits worsened again; the patient was hospitalised. Clinical
examination revealed right hemiparesis and mild dysarthria.
Blood pressure was 130/80 mmHg, body temperature 37°C,
WBC 13.20x109/l, Segmented neutrophils 87.4%, Lymphocytes
8.1%, ESR 104 mm, CRP 121.0 mg/l. Head-CT displayed a 51x47
mm hypodense cystic lesion, exerting significant pressure on
brain parenchyma and causing midline shift, surrounded by a
thick contrast-enhancing capsule and mild edema. Head-CT
angiogram with contrast excluded AVM/aneurysms (Figure
1E-F). A left parietal mini-craniotomy was performed with
the evidence of a well-defined lesion with an elastic wall,
containing yellowish viscous fluid mixed with old clots. After
irrigating the cavity with 0.9% saline solution, a Codman®Bactiseal® catheter was placed inside the cyst. Methicillinsensitive Staphylococcus aureus (MMSA) was isolated and
IV Oxacillin was given for seven weeks. Blood cultures from
peripheral blood were negative, whereas subcutaneous
port central venous catheter system (for e.v. chemotherapy)
showed positivity for MMSA. Echocardiogram, chest x-ray, and
fundus oculi examination were negative, while lower limbs
color Doppler ultrasound showed deep vein thrombosis on
both legs. On this basis, subcutaneous Enoxaparin therapy
was started. Hematologic values returned within reference
range and post-operative head-CT with contrast (Figure
1G) showed partial abscess drainage. 10 days after surgery
right knee swelling appeared. Ultrasonography showed
abundant supra-patellar fluid collection with unstructured
hyperechogenic material. Arthrocentesis microbiological
Turkish Neurosurgery 2013, Vol: 23, No: 6, 835-839

exam was negative and cytochemical exam revealed fibrous
deposit of neutrophils. On the 12th post-operative day the
patient complained of lumbar pain. Spine MRI with contrast
documented an osteoporotic-traumatic vertebral collapse
with cuneiform deformation of the L1 body. A contrastenhancing lesion lateral to the spinous process of L2 and
to the left articular processes of L2 and L3, suggestive of an
inflammatory area, were also detected. Analgesic therapy and
an orthotic brace were successfully applied. Head-CT with
contrast at five weeks (Figure 1H) showed abscess absorption
and resolution of mass effect. Neurological deficits gradually
improved and the patient was eventually discharged. Oral
Levofloxacin 750 mg/day and Rifampicin 600 mg/day was
given for fifteen weeks. At nineteen weeks (Figure 1I) abscess
was completely resolved; the patient presented no dysarthria
and only mild right leg weakness.
Discussion
Only 19 cases of brain abscess at the site of previously
untreated ICHs have been reported in literature (Table I) (1-8,
10-19). Spontaneous ICHs are predominant in the basal ganglia
and cause damage to the blood-brain barrier. Since systemic
infections may easily reach such well-vascularised sites by
haematogenous spread, spontaneous cerebral abscess are
predominant in deeper areas rather than in cortical areas of
brain parenchyma (11/18 cases in which abscess location was
reported). In our case, however, ICH was in the left parietal
lobe and it was not apparently anticipated by sepsis: the
abscess etiology may have left cryptogenic (no endocarditis,
lung infection nor chorioretinitis detected). Further exams,
however, demonstrated MMSA positivity and flogistic signs in
the right knee (leukocyte sediment without microbiological
positivity in the synovial fluid, as effect of systemic antibiotic
therapy) and the lumbar spine. Our patient’s clinical history
probably started with a focal infection (septic arthritis) that
caused sepsis and eventually the brain abscess because of
BBB damage due to the ICH.
Looking at previous reports, both G+ and G- are responsible
pathogens of brain abscesses; cutaneous and respiratory
airways bacteria are predominant. Staphylococcus genus
is the most commonly responsible pathogen (found in
50% of the cases where the pathogen was identified). It
is a genus of facultative anaerobic G+ cocci commonly
found on the skin and in the upper respiratory airways.
Other common G+ or G- bacteria commonly present in
respiratory airways or the intestinal tract like Streptococci
(2 cases), Enterococcus faecalis (2 cases), Klebsiella (1 case)
and Morganella morganii (1 case) have also been reported.
Takeuchi et al. reported a case of brain abscess caused by
Stenotrophomonas maltophilia, an aerobic non-fermentative
G- bacterium common usually causing nosocomial infections
in immunocompromised patients in which prostetic devices
are used (urinary catheters, endotracheal or tracheostomy
tubes, central venous catethers) (19). In four cases it was not
possible to identify the causing pathogen.
Sepsis anticipated the occurrence of cerebral abscess in 7
cases, pneumonia in 3, while urinary infection and flebitis

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838

>70

45 dd

30/F

49/M

Takeuchi ,
2007

Eser8, 2008

Dashti7, 2008

Present case,
2012

19

79/M

L parietal

L basal ganglia

R fronto-temporoparietal

L parietal

R occipital

Siatouni17, 2007

Nakai14, 2006

L thalamus

32/M

58/M

Nowak15, 2003

R putamen

R temporo-parietal

48/M

Inamasu11,2002

L basal ganglia

L thalamus

R putamen

L temporoparietal

L putamen

Cerebellum

R putamen

R putamen

R basal ganglia

75/M

51/M

66/M

Amayo1, 2002

16

Okami , 2000

42/F

56/F

Chen6, 1995

55/M

71/M

Iida10, 1994

Sumioka18,1995

64/M

Lee13, 1994

Bert2, 1995

53/M

Kurihara12,1989

34/F

R frontal

62/M

Busse5, 1981

Biller3-4, 1985

R putamen

45/M

Author,Year

ICH site

Age /
Sex

8

4

0

1

3

4

9

4

4

12

8

8

5

3

4

20

4

>2

8

Time to
abscess
formation
after ICH
(weeks)

15

0

0

10

0

21

55

3

0

None

<14

4

4

14

7

8

10

0

9

First febrile
episode
after ICH
(days)

Table I: Reported Cases of Cerebral Abscess at the Site of Former ICHs

Unknown
Sepsis

Drainage+4 weeks
antibiotics
Excision+2 weeks
antibiotics

Staphylococcus
aureus bacteraemia
ACA and MCA
vasculitis
Unknown

Excision+VP-shunt+8
weeks antibiotics
Drainage+5 weeks IV
antibiotics+15 weeks
oral antibiotics

Cerebral amiloid
angiopathy
Excision+antibiotics

Drainage+antibiotics

Urinary infection

Staphylococcus aureus

6 weeks antibiotics

Staphylococcus aureus

Citrobacter koseri

Unidentified

Positive

Positive

Positive

Positive

Enterococcus faecalis
Stenotrophomonas maltophilia

Positive

Positive
Unidentified

G+ coccus

Enterococcus faecalis

Drainage

Partially
positive

Positive

Staphylococcus aureus
Unidentified

Positive

Staphylococcus aureus

Positive

Post-operative
extension, then
resolution

Positive

Outcome

Morganella morganii

Catheter induces
sepsis

Pneumonia

Sepsis

Unknown

Klebsiella

Staphylococcus aureus

Streptococcus

Staphylococcus

Pneumonia

Drainage

Drainage+antibiotics

Drainage

Phlebitis

Sepsis

6 weeks antibiotics,
then drainage+8 weeks
antibiotics
Drainage+excision

Pneumonia

Sepsis

3 months antibiotics
+drainage; external
ventricular drainage+
antibiotics
Drainage

Phlebitis

Staphylococcus epidermidis and
alfa-heamolitic Streptococcus

Staphylococcus aureus

Infected episiotomy

Unidentified

Infected wound of
carotid

Pathogen

Sepsis

Origin of infection

Drainage

Drainage

Excision

Drainage

Treatment

19

8

5

6

3

7

6

8

11

Resolution
time
(weeks)

Rigante L. et al: Brain Abscess Developing in a Non-Operated Spontaneous Intracerebral Haemorrhage

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Rigante L. et al: Brain Abscess Developing in a Non-Operated Spontaneous Intracerebral Haemorrhage

was the origin of infection 1 patient, respectively. Cerebral
amyloid angiopathy and vasculitis were detected in two cases
before abscess formation.

3. Biller J, Adams Jr P, Godersky JC, Johnson R: Preeclampsia
complicated by cerebral hemorrhage and brain abscess. J
Neurol 232: 378–380, 1985

Immunodeficiency definitely represents a predisposing factor
for brain abscess. Our patient had an oncologic history and
was treated with radio- and chemotherapy. Moreover, when
his neurological deficits worsened, he was initially treated
with long term high-dose corticosteroids.

4. Biller J, Baker WH, Quinn JP, Shea JF: Intracranial haematoma
with subsequent brain abscess after carotid endarterectomy.
Surg Neurol 23:605–608, 1985

Analysing the literature, a first febrile episode is generally
reported within 15 days and neurological deterioration 2590 days after ICH. Time to abscess formation after ICH is 0-20
weeks. During initial stages of infection, headache and focal
neurological deficits are not always present. Our patient
showed no signs of increased ICP, headache nor seizures.

6. Chen ST, Tang LM, Ro LS: Brain abscess as a complication of
stroke. Stroke 26:696–698, 1995

Surgical treatment with intra- and perioperative antibiotic
prophylaxis showed good results. Five cases required total
abscess excision, probably because of the thick consistence
of the cystic capsule, while Nowak et al. reported the use of
only systemic antibiotics (15). In our opinion, however, pure
medical management should be considered only for patients
with multiple brain abscesses, small lesions or poor surgical
candidates, as outlined by Greenberg (9). In fact we believe
that surgical drainage followed by systemic antibiotic therapy
(initially broad spectrum, then pathogen-targeted) has the
highest rate of success for the treatment of this condition.
Reported abscess resolution time was 3 (Nakai et al. (14)) to
19 weeks (our case), as confirmed by the laboratory tests,
neuroradiological evidences and clinical follow-up.
Systemic infections in patients with recent cerebrovascular
accidents should be scrupulously investigated and immediately treated. Broad-spectrum antibiotics prophylaxis must
be considered in patients with predisposition to infection and
brain abscess formation.
Conclusions
Brain abscesses are rare complications of previously untreated
intracerebral haemorrhages (ICHs), often anticipated by sepsis
or local infections. Abscess formation should be considered in
cases of clinical deterioration with or without febrile episodes
after an ICH. Neuroradiological imaging and laboratory tests
are crucial for early diagnosis and treatment of this potentially
life-threatening condition. Surgical drainage and antibiotic
therapy are in our opinion the best treatment option for this
pathological condition.
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intracerebral haemorrhage complicated by cerebral abscess:
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N: Staphylococcal brain abscess following haematogenous
seeding of an intracerebral haematoma. Eur J Microbiol Infect
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Turkish Neurosurgery 2013, Vol: 23, No: 6, 835-839

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