Management of brain abscess in children: review of 130 cases over a period of 21 years

Abstract

The data on 130 children with brain abscesses treated over 21 years (1970-1990) were analyzed retrospectively. The whole group included four infants. Chronic ear infection and cyanotic congenital heart disease were the most common predisposing factors. In infants, meningitis and/or ventriculitis were dominant in the etiopathogenesis. Cases were evaluated according to the treatment received and also according to time periods. More than half of the patients (n = 74) in this series were treated by primary or secondary excision. Computed tomography (CT) facilitated the diagnosis and helped the planning of treatment. Aspiration gained increasing credit after the advent of CT. Microorganisms could be identified in 54% of the cultured specimens. Staphylococci, streptococci and Proteus were the dominating microorganisms. Penicillin and chloramphenicol have long been the mainstay of antimicrobial therapy but have recently been replaced by third-generation cephalosporins and sulbactam-ampicillin combinations. Overall mortality was 15.5% but showed a decline from 30% in the pre-CT era to 6% in the last 5 years and to zero in the last three. Neither the location nor associated heart disease contributed to the mortality, but mortality among infants was as high as 50%.

Management of bacterial brain abscesses

“…The rate of mortality reduced considerably when compared with the pre-CT period. 36 Tekkok and Erbengi 39 found a reduction in mortality rate from 30% in the era before the use of CT to 6% in the last 5 years and 0% in the last 3 years of their study. Unenhanced CT of an encapsulated abscess reveals a thin ring outlined by the central area of necrosis and peripheral edema; in scans obtained after the administration of a contrast agent, this ring shows strong enhancement.…”

“…26,40,44 In the pediatric patient group, the most common predisposing factor is congenital heart disease or adjacent cranial infection. 1,2,12,39 Recently, Auvichayapat et al 2 in their series of 107 cases involving infants and children, found chronic otitis media the second most common predisposing factor after congenital heart disease, and they concluded that this was probably due to the poor socioeconomic status leading to neglect of chronic otitis media, with children going without treatment for years. Brain abscesses in patients with immunosuppression 12,40,44 and postneurosurgical nosocomial bacterial brain abscesses 45 are also increasing in incidence.…”

“…Headache, changes in level of consciousness, nausea and/or vomiting, and high fever are the most common manifestations. 6,39,40,44 Seizure is also not uncommon as an initial symptom, occurring in 25-34% of patients. 2,16 In one case series involving pediatric patients, 27% of the patients presented with seizure, and none of them had a known history of febrile seizure or epilepsy.…”

“…14,16,23,25,29,40 The choice of treatment modality depends on the patient's status, the techniques available, and the surgeon's experience; there is no significant difference in outcome between aspiration and excision. 29,39,40,44 Aspiration is the gold standard for treatment of brain abscesses; it is simple and can be easily performed via a bur hole even in critically ill patients at any stage of the abscess. 16,26,33 In recent series, aspiration is the most often selected method of surgical treatment.…”

Brain abscess in children

“…7,9,10,12,14,16 Improved imaging techniques combined with improved culturing techniques and advances in surgical and medical management of brain abscesses have contributed to the reduction in the mortality rate, which has been seen over the last century. 9,25 However, this condition remains life threatening, especially in children who are immunocompromised, who are Ͻ 1 year old, who present with significant surgery-related neurological deficits, in whom the initial diagnosis was delayed, the abscess has ruptured into the ventricle, or surgical management was complicated by hemorrhage.…”