TY - JOUR
T1 - Non-Operative versus Neurosurgical Treatment of Brain Abscess
T2 - An Emulated Trial Nested within a Nationwide, Population-Based Cohort
AU - Eriksen, Emilie Marie
AU - Larsen, Lykke
AU - Storgaard, Merete
AU - Mens, Helene
AU - Wiese, Lothar
AU - Jepsen, Micha Phill Grønholm
AU - Hansen, Birgitte Rønde
AU - Lüttichau, Hans Rudolf
AU - Nielsen, Henrik
AU - Bodilsen, Jacob
N1 - © The Author(s) 2025. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact [email protected].
PY - 2025/6/6
Y1 - 2025/6/6
N2 - BACKGROUND: Uncertainty about the role of neurosurgery in brain abscess treatment is reflected in surveys and observational studies.METHODS: Nationwide population-based cohort study of all adults (≥18 years) diagnosed with brain abscess in Denmark from 2007 until 2023. Inverse probability weighting was applied to balance covariates according to neurosurgical treatment strategy. Outcomes included risks of mortality, rupture, and unfavourable outcome (Glasgow Outcome Scale 1-4) six months after discharge and were assessed using modified Poisson and Cox regression with 95% confidence intervals (CI). Unbalanced covariates were included in regression models for doubly robust estimations.RESULTS: The cohort comprised 558 patients (median age 59 years [interquartile range 49-69], 367/558 [66%] males). A non-operative strategy was assigned to 234/558 (42%) and neurosurgery to 324/558 (58%). Predisposing meningitis, diameter and deep location of abscess were included in doubly robust estimations.Analyses of treatment strategy showed that a non-operative approach was associated with adjusted relative risks of 2.47 (95%CI 1.50-4.04) for mortality, 2.25 (95%CI 1.26-4.01) for rupture, and 1.24 (95%CI 0.95-1-61) for unfavourable outcome compared with neurosurgery. Additionally, 85/234 (36%) patients assigned to the non-operative strategy required subsequent neurosurgery.Compared with neurosurgery at any time, maintained non-operative treatment was associated with adjusted hazard ratios of 1.53 (95%CI 0.84-2.76) for mortality, 2.00 (95%CI 1.17-3.42) for rupture, and 1.62 (95%CI 1.12-2.34) for unfavourable outcome.CONCLUSIONS: Non-operative strategy was associated with twice the risks of mortality and rupture, and one-third required subsequent neurosurgery. These results support recommendations for neurosurgical drainage of brain abscess.
AB - BACKGROUND: Uncertainty about the role of neurosurgery in brain abscess treatment is reflected in surveys and observational studies.METHODS: Nationwide population-based cohort study of all adults (≥18 years) diagnosed with brain abscess in Denmark from 2007 until 2023. Inverse probability weighting was applied to balance covariates according to neurosurgical treatment strategy. Outcomes included risks of mortality, rupture, and unfavourable outcome (Glasgow Outcome Scale 1-4) six months after discharge and were assessed using modified Poisson and Cox regression with 95% confidence intervals (CI). Unbalanced covariates were included in regression models for doubly robust estimations.RESULTS: The cohort comprised 558 patients (median age 59 years [interquartile range 49-69], 367/558 [66%] males). A non-operative strategy was assigned to 234/558 (42%) and neurosurgery to 324/558 (58%). Predisposing meningitis, diameter and deep location of abscess were included in doubly robust estimations.Analyses of treatment strategy showed that a non-operative approach was associated with adjusted relative risks of 2.47 (95%CI 1.50-4.04) for mortality, 2.25 (95%CI 1.26-4.01) for rupture, and 1.24 (95%CI 0.95-1-61) for unfavourable outcome compared with neurosurgery. Additionally, 85/234 (36%) patients assigned to the non-operative strategy required subsequent neurosurgery.Compared with neurosurgery at any time, maintained non-operative treatment was associated with adjusted hazard ratios of 1.53 (95%CI 0.84-2.76) for mortality, 2.00 (95%CI 1.17-3.42) for rupture, and 1.62 (95%CI 1.12-2.34) for unfavourable outcome.CONCLUSIONS: Non-operative strategy was associated with twice the risks of mortality and rupture, and one-third required subsequent neurosurgery. These results support recommendations for neurosurgical drainage of brain abscess.
U2 - 10.1093/cid/ciaf304
DO - 10.1093/cid/ciaf304
M3 - Journal article
C2 - 40476360
SN - 1058-4838
JO - Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
JF - Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
ER -