The efficacies of two different surgical approaches, aspiration and excision, were investigated for the management of large solitary encapsulated pyogenic brain abscess located in superficial non-eloquent areas, and the impact on length of hospital stay, duration of postoperative antibiotic use, improvement in neurological status, and morbidity and mortality were compared. This retrospective study at Sher-i-Kashmir Institute of Medical Sciences included 47 patients with pyogenic brain abscess from a total of 114 patients evaluated in the Department of Neurosurgery over a period of 10 years from October 2001 to October 2011. Comparisons were made between aspiration and excision in terms of duration of antibiotic use, length of hospital stay, and overall treatment cost. Aspiration was performed in 29 patients (61.7%), of whom 7 patients needed second aspiration, and 18 patients underwent excision (38.3%) of the abscess capsule. The mean duration of antibiotic use in the excision group was significantly shorter at 2.7 weeks (standard deviation [SD] ± 1.1) compared to the aspiration group at 3.8 weeks (SD ± 1.3) (p = 0.006). Similarly, mean length of hospital stay was significantly shorter in the excision group at 18.1 days (SD ± 7.7) compared to the aspiration group at 24.9 days (SD ± 6.6) (p = 0.002). In addition, significantly earlier improvement in neurological function (p = 0.025) and significantly lower rate of re-surgery (p = 0.0238) were found in the excision group compared to the aspiration group. Excision is better than aspiration as far as duration of antibiotic use, length of hospital stay, and overall cost of treatment is concerned, with no significant difference in morbidity and mortality.