Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Pathogenesis, clinical manifestations, and diagnosis of brain abscess

Frederick S Southwick, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Anna R Thorner, MD


Brain abscess is a focal collection within the brain parenchyma, which can arise as a complication of a variety of infections, trauma, or surgery.

The pathogenesis, clinical manifestations, and diagnosis of brain abscess will be presented here. The treatment and prognosis of this disease are discussed separately. (See "Treatment and prognosis of bacterial brain abscess".)


Bacteria can invade the brain either by direct spread or through hematogenous seeding [1]. Direct spread accounts for 20 to 60 percent of cases [2]. Bacteremic spread typically causes multiple lesions [3].

Direct spread — The direct spread of organisms from a contiguous site usually causes a single brain abscess. Primary infections that can directly spread to the cerebral cortex include [4-8]:

Subacute and chronic otitis media and mastoiditis (spread to the inferior temporal lobe and cerebellum)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Oct 26, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. Brouwer MC, Tunkel AR, McKhann GM 2nd, van de Beek D. Brain abscess. N Engl J Med 2014; 371:447.
  2. Chun CH, Johnson JD, Hofstetter M, Raff MJ. Brain abscess. A study of 45 consecutive cases. Medicine (Baltimore) 1986; 65:415.
  3. Bakshi R, Wright PD, Kinkel PR, et al. Cranial magnetic resonance imaging findings in bacterial endocarditis: the neuroimaging spectrum of septic brain embolization demonstrated in twelve patients. J Neuroimaging 1999; 9:78.
  4. Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope 1998; 108:1635.
  5. Giannoni C, Sulek M, Friedman EM. Intracranial complications of sinusitis: a pediatric series. Am J Rhinol 1998; 12:173.
  6. Giannoni CM, Stewart MG, Alford EL. Intracranial complications of sinusitis. Laryngoscope 1997; 107:863.
  7. Yen PT, Chan ST, Huang TS. Brain abscess: with special reference to otolaryngologic sources of infection. Otolaryngol Head Neck Surg 1995; 113:15.
  8. Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol 1993; 107:999.
  9. Chalstrey S, Pfleiderer AG, Moffat DA. Persisting incidence and mortality of sinogenic cerebral abscess: a continuing reflection of late clinical diagnosis. J R Soc Med 1991; 84:193.
  10. Foy P, Sharr M. Cerebral abscesses in children after pencil-tip injuries. Lancet 1980; 2:662.
  11. Lew JF, Wiedermann BL, Sneed J, et al. Aerotolerant Clostridium tertium brain abscess following a lawn dart injury. J Clin Microbiol 1990; 28:2127.
  12. Staecker H, Nadol JB Jr, Ojeman R, McKenna MJ. Delayed intracranial abscess after acoustic neuroma surgery: a report of two cases. Am J Otol 1999; 20:369.
  13. Hashmi S, Jones RA. Delayed recurrence of cerebellar abscess 20 years after excision of dermoid cyst and sinus. Br J Neurosurg 1998; 12:358.
  14. Fischer EG, Shwachman H, Wepsic JG. Brain abscess and cystic fibrosis. J Pediatr 1979; 95:385.
  15. Patel KS, Marks PV. Multiple brain abscesses secondary to bronchiectasis. A case of 34 discrete abscesses in one brain. Clin Neurol Neurosurg 1989; 91:265.
  16. Kum N, Charles D. Cerebral abscess associated with an intrauterine contraceptive device. Obstet Gynecol 1979; 54:375.
  17. Schlaeffer F, Riesenberg K, Mikolich D, et al. Serious bacterial infections after endoscopic procedures. Arch Intern Med 1996; 156:572.
  18. Takeshita M, Kagawa M, Yato S, et al. Current treatment of brain abscess in patients with congenital cyanotic heart disease. Neurosurgery 1997; 41:1270.
  19. Cahill DP, Barker FG 2nd, Davis KR, et al. Case records of the Massachusetts General Hospital. Case 10-2010. A 37-year-old woman with weakness and a mass in the brain. N Engl J Med 2010; 362:1326.
  20. Chiu HY, Lin SJ. Red papules on the tongue of a patient with hemiparesis. JAMA 2014; 312:741.
  21. Boother EJ, Brownlow S, Tighe HC, et al. Cerebral Abscess Associated With Odontogenic Bacteremias, Hypoxemia, and Iron Loading in Immunocompetent Patients With Right-to-Left Shunting Through Pulmonary Arteriovenous Malformations. Clin Infect Dis 2017; 65:595.
  22. Schliamser SE, Bäckman K, Norrby SR. Intracranial abscesses in adults: an analysis of 54 consecutive cases. Scand J Infect Dis 1988; 20:1.
  23. Ng PY, Seow WT, Ong PL. Brain abscesses: review of 30 cases treated with surgery. Aust N Z J Surg 1995; 65:664.
  24. Yang SY, Zhao CS. Review of 140 patients with brain abscess. Surg Neurol 1993; 39:290.
  25. Nielsen H, Gyldensted C, Harmsen A. Cerebral abscess. Aetiology and pathogenesis, symptoms, diagnosis and treatment. A review of 200 cases from 1935-1976. Acta Neurol Scand 1982; 65:609.
  26. Badger JL, Stins MF, Kim KS. Citrobacter freundii invades and replicates in human brain microvascular endothelial cells. Infect Immun 1999; 67:4208.
  27. Britt RH, Enzmann DR. Clinical stages of human brain abscesses on serial CT scans after contrast infusion. Computerized tomographic, neuropathological, and clinical correlations. J Neurosurg 1983; 59:972.
  28. Brouwer MC, Coutinho JM, van de Beek D. Clinical characteristics and outcome of brain abscess: systematic review and meta-analysis. Neurology 2014; 82:806.
  29. Bonvin P, Ejlertsen T, Dons-Jensen H. Brain abscess caused by Salmonella enteritidis in an immunocompetent adult patient: successful treatment with cefotaxime and ciprofloxacin. Scand J Infect Dis 1998; 30:632.
  30. Yamamoto M, Fukushima T, Ohshiro S, et al. Brain abscess caused by Streptococcus intermedius: two case reports. Surg Neurol 1999; 51:219.
  31. Grigoriadis E, Gold WL. Pyogenic brain abscess caused by Streptococcus pneumoniae: case report and review. Clin Infect Dis 1997; 25:1108.
  32. Bañuelos AF, Williams PL, Johnson RH, et al. Central nervous system abscesses due to Coccidioides species. Clin Infect Dis 1996; 22:240.
  33. Ohnishi K, Murata M, Kojima H, et al. Brain abscess due to infection with Entamoeba histolytica. Am J Trop Med Hyg 1994; 51:180.
  34. Lakshmi V, Rao RR, Dinakar I. Bacteriology of brain abscess--observations on 50 cases. J Med Microbiol 1993; 38:187.
  35. Brook I. Aerobic and anaerobic bacteriology of intracranial abscesses. Pediatr Neurol 1992; 8:210.
  36. Hagensee ME, Bauwens JE, Kjos B, Bowden RA. Brain abscess following marrow transplantation: experience at the Fred Hutchinson Cancer Research Center, 1984-1992. Clin Infect Dis 1994; 19:402.
  37. Baddley JW, Salzman D, Pappas PG. Fungal brain abscess in transplant recipients: epidemiologic, microbiologic, and clinical features. Clin Transplant 2002; 16:419.
  38. Friedlander RM, Gonzalez RG, Afridi NA, Pfannl R. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 16-2003. A 58-year-old woman with left-sided weakness and a right frontal brain mass. N Engl J Med 2003; 348:2125.
  39. Arlotti M, Grossi P, Pea F, et al. Consensus document on controversial issues for the treatment of infections of the central nervous system: bacterial brain abscesses. Int J Infect Dis 2010; 14 Suppl 4:S79.
  40. Le Moal G, Landron C, Grollier G, et al. Characteristics of brain abscess with isolation of anaerobic bacteria. Scand J Infect Dis 2003; 35:318.
  41. Drancourt M, Nkamga VD, Lakhe NA, et al. Evidence of Archaeal Methanogens in Brain Abscess. Clin Infect Dis 2017; 65:1.
  42. Sifri CD, Park J, Helm GA, et al. Fatal brain abscess due to community-associated methicillin-resistant Staphylococcus aureus strain USA300. Clin Infect Dis 2007; 45:e113.
  43. Jacobs JA, Pietersen HG, Stobberingh EE, Soeters PB. Bacteremia involving the "Streptococcus milleri" group: analysis of 19 cases. Clin Infect Dis 1994; 19:704.
  44. Corne P, Rajeebally I, Jonquet O. Rhodococcus equi brain abscess in an immunocompetent patient. Scand J Infect Dis 2002; 34:300.
  45. Brook I. Brain abscess in children: microbiology and management. J Child Neurol 1995; 10:283.
  46. Rau CS, Chang WN, Lin YC, et al. Brain abscess caused by aerobic Gram-negative bacilli: clinical features and therapeutic outcomes. Clin Neurol Neurosurg 2002; 105:60.
  47. Guppy KH, Thomas C, Thomas K, Anderson D. Cerebral fungal infections in the immunocompromised host: a literature review and a new pathogen--Chaetomium atrobrunneum: case report. Neurosurgery 1998; 43:1463.
  48. Eckburg PB, Montoya JG, Vosti KL. Brain abscess due to Listeria monocytogenes: five cases and a review of the literature. Medicine (Baltimore) 2001; 80:223.
  49. Cone LA, Leung MM, Byrd RG, et al. Multiple cerebral abscesses because of Listeria monocytogenes: three case reports and a literature review of supratentorial listerial brain abscess(es). Surg Neurol 2003; 59:320.
  50. Valarezo J, Cohen JE, Valarezo L, et al. Nocardial cerebral abscess: report of three cases and review of the current neurosurgical management. Neurol Res 2003; 25:27.
  51. Erdogan E, Beyzadeoglu M, Arpaci F, Celasun B. Cerebellar aspergillosis: case report and literature review. Neurosurgery 2002; 50:874.
  52. Garcia RR, Min Z, Narasimhan S, Bhanot N. Fusarium brain abscess: case report and literature review. Mycoses 2015; 58:22.
  53. Correa D, Sarti E, Tapia-Romero R, et al. Antigens and antibodies in sera from human cases of epilepsy or taeniasis from an area of Mexico where Taenia solium cysticercosis is endemic. Ann Trop Med Parasitol 1999; 93:69.
  54. Seydoux C, Francioli P. Bacterial brain abscesses: factors influencing mortality and sequelae. Clin Infect Dis 1992; 15:394.
  55. Heilpern KL, Lorber B. Focal intracranial infections. Infect Dis Clin North Am 1996; 10:879.
  56. Nielsen H. Cerebral abscess in children. Neuropediatrics 1983; 14:76.
  57. Patir R, Sood S, Bhatia R. Post-traumatic brain abscess: experience of 36 patients. Br J Neurosurg 1995; 9:29.
  58. Tattevin P, Bruneel F, Clair B, et al. Bacterial brain abscesses: a retrospective study of 94 patients admitted to an intensive care unit (1980 to 1999). Am J Med 2003; 115:143.
  59. Leuthardt EC, Wippold FJ 2nd, Oswood MC, Rich KM. Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses. Surg Neurol 2002; 58:395.
  60. Ferré C, Ariza J, Viladrich PF, et al. Brain abscess rupturing into the ventricles or subarachnoid space. Am J Med 1999; 106:254.
  61. Kamra P, Vatsal DK, Husain M, et al. MRI demonstration of unsuspected intraventricular rupture of pyogenic cerebral abscesses in patients being treated for meningitis. Neuroradiology 2002; 44:114.
  62. Al Masalma M, Armougom F, Scheld WM, et al. The expansion of the microbiological spectrum of brain abscesses with use of multiple 16S ribosomal DNA sequencing. Clin Infect Dis 2009; 48:1169.
  63. Keller PM, Rampini SK, Bloemberg GV. Detection of a mixed infection in a culture-negative brain abscess by broad-spectrum bacterial 16S rRNA gene PCR. J Clin Microbiol 2010; 48:2250.
  64. Al Masalma M, Lonjon M, Richet H, et al. Metagenomic analysis of brain abscesses identifies specific bacterial associations. Clin Infect Dis 2012; 54:202.
  65. DiGiulio DB, Relman DA. Majority rules? Tallying the microbial census in an abscess by means of molecular methods. Clin Infect Dis 2009; 48:1179.