Evaluation of aspiration versus microsurgical resection for primary superficial pyogenic brain abscesses: results...

Brain abscesses are severe infections with high morbidity and mortality. Surgical drainage is essential, but the optimal technique remains unclear. The aim of this multicenter study was to compare navigated/stereotactic aspiration and microsurgical resection in terms of reoperation rates, clinical outcomes, and surgery-related complications in patients with primary pyogenic brain abscess.

A multicentric retrospective analysis was conducted across 5 university centers in Germany and Austria, and included patients who underwent surgery for primary pyogenic brain abscesses from January 2008 to December 2023. Exclusion criteria were previous head surgery or trauma, lack of preoperative MRI, multiple abscesses, concomitant subdural empyema, and infratentorial or deep-seated abscesses (> 2 cm from the cortical surface). The primary endpoint was reoperation for the abscess, while secondary endpoints included unfavorable clinical outcomes (modified Rankin Scale [mRS] score ≥ 3) at discharge, 3 months, and 6 months after surgery and surgery-related complications.

Of 148 patients (102 male, mean age 49.1 years) included in the analysis, 82 (55.4%) underwent microsurgical resection and 66 (44.6%) underwent aspiration. Reoperations were significantly more frequent in the aspiration group (39.4%) than in the resection group (20.7%) (p = 0.018). Surgical complication rates did not differ significantly. A significant improvement in clinical status (median mRS score of 1) was observed in both the aspiration and resection groups (p < 0.001 each) after surgery, with 26 patients (17.6%) still having an mRS score ≥ 3 at discharge. In the aspiration group, no further improvement was noted between hospital discharge and the 3-month follow-up (p = 0.34), but significant improvement occurred between the 3- and 6-month follow-up evaluations (p = 0.02). In contrast, patients in the resection group showed significant improvement between discharge and the 3-month follow-up (p < 0.001), with no additional improvement observed between 3 and 6 months (p = 0.49). Five in-hospital deaths occurred, all in the aspiration group, resulting in an overall mortality of 3.4% (p = 0.005).

Aspiration was linked to an increased reoperation rate and higher in-hospital mortality, although surgical complication rates were similar. Patients in both groups had comparable favorable outcomes at discharge and at 3- and 6-month follow-up evaluations. Patients who underwent open resection showed faster early recovery.