Brain stem abscesses in childhood

Abstract

We report a case of a 7-year-old girl with a solitary brain stem abscess. Her neurological examination revealed involvement of the cranial nerves and pyramidal tracts. Microsurgical exposure and aspiration of the abscess resulted in rapid improvement in her neurological condition and radiological resolution of the lesion. We discuss this uncommon case to draw attention to the importance of early diagnosis and adequate treatment, and we review the relevant literature.

Management of brain abscesses in children

“…21,80 Additionally, children with brainstem abscesses typically present with fever and headache early in the infectious course, and paresis and cranial nerve palsies subsequently develop, especially involving CNs III, VI, and VII. 99 Classic brainstem syndromes are not frequently observed because the lesions are more likely to elongate into the brainstem than expand laterally. 16,78,99,106 The location of the abscess determines the focal neurological signs, which can include paresis, visual field deficits, CN palsies, nystagmus, and/or cerebellar ataxia.…”

“…99 Classic brainstem syndromes are not frequently observed because the lesions are more likely to elongate into the brainstem than expand laterally. 16,78,99,106 The location of the abscess determines the focal neurological signs, which can include paresis, visual field deficits, CN palsies, nystagmus, and/or cerebellar ataxia. Papilledema has been reported in 41-70% of cases.…”

“…7,44,78,85,99,106 Since 1974, 12 children who underwent treatment for brainstem abscesses with stereotactic aspiration, microsurgery, or antibiotic therapy alone have been reported with good outcomes. 20,34,45,47,52,66,72,78,85,99,104,105 Stereotactic drainage has been performed through the right paramedian precoronal frontal or suboccipital transcerebellar approaches. 34,71,72 Potential problems associated with the stereotactic aspiration of brain abscesses include incomplete evacuation because of thick purulent materal or multiloculations, and/or hemorrhage of the abscess capsule.…”

“…34,71,72 Potential problems associated with the stereotactic aspiration of brain abscesses include incomplete evacuation because of thick purulent materal or multiloculations, and/or hemorrhage of the abscess capsule. 87,99 Open microsurgery can reduce mass effect on the brainstem and provides direct visual control of the collapse of the abscess as an indication of complete evacuation of the pus; penetration of the abscess at the point of the highest fluctuation decreases the risk of brain stem damage. 47,99 High-risk surgical patients or neurologically stable patients with a brainstem abscess of Ͻ 2 cm diameter may be treated medically with antibiotic therapy and serial imaging follow-up.…”

“…1,19,82,91,102,108,110 Pronounced right-toleft shunting secondary to cardiac defects increases the risk of brain abscesses via paradoxical emboli. 78,99 Tetralogy of Fallot, 19,102,108 transposition of the great vessels, atrial septal defects, ventricular septal defects, and the Eisenmenger complex are other cardiac anomalies known to predispose children to brain abscesses. Although rare, a persistent left superior vena cava may also lead to a brain abscess because in patients with this abnormality, venous blood from the left arm and left side of the head drains directly into the left atrium, resulting in a right-to-left shunt.…”