Neurosurg Focus 24 (6):E6, 2008

Brain abscess in children

JASON P. SHEEHAN, M.D., PH.D.,1 JOHN A. JANE JR., M.D.,1,2 DIBYENDU K. RAY, M.D.,1 AND
HOWARD P. GOODKIN, M.D., PH.D.2,3
Departments of 1Neurosurgery, 2Pediatrics, and 3Neurology, University of Virginia Health System,
Charlottesville, Virginia

!Although it is uncommon, pediatric brain abscess remains a serious, life-threatening neurological problem. Those
with congenital heart disease, an ongoing infection, or an immunocompromised state are particularly at risk. The symp-
toms on presentation may include those associated with a space-occupying lesion in the brain, and neuroimaging has
made the diagnosis of brain abscess more reliable. Prompt diagnosis and treatment are required to lessen neurological
morbidity and the risk of death. Treatment includes medical management with appropriate and specific antimicrobials.
Although the effectiveness of medical management has improved and some children may be treated with antimicro-
bial therapy alone, surgical evaluation remains an important component of the treatment algorithm for most pediatric
patients. (DOI: 10.3171/FOC/2008/24/6/E6)

KEY WORDS brain abscess children infection

A
BRAIN abscess is an intraparenchymal infection that fracture of the skull, congenital lesions of the head and
commences as a localized area of cerebritis evolv- neck (such as dermal sinuses), and as a rare complication
ing through various stages into a collection of en- of meningitis. In addition, there have been case reports of
capsulated purulent material.3 The infection results from brain abscess in children following aspiration of foreign
the seeding of the parenchyma as the result of hematoge- bodies,21 esophageal endoscopy,18 ocular trauma,2 and
nous spread from remote sources, direct invasion from con- placement of dental braces.26 In a significant proportion of
tiguous infection of nonneural tissues, or from implantation children, however, a predisposing factor is not identified.
of pathogens following penetrating wounds or surgery. Goodkin and colleagues10 characterized the natural his-
Once formed, the abscess can result in permanent neuro- tory of brain abscess at Childrens Hospital Boston be-
logical disability by direct destruction, infarction, or com- tween the years 1981 and 2000. During that time period,
pression. Although advances in head imaging resulted in CHD and sinus/otitic infections were the most common
an initial decline in the mortality rate, children with brain predisposing factors. When compared with a similar study
abscesses do remain at risk for death.1,9,10,23,25 Early diagno- performed at the same institution for the years 19451980,9
sis combined with the prompt initiation of empirical broad- there were several interesting differences. Although CHD
spectrum antimicrobial therapy and neurosurgical interven- was the most common predisposing factor in both studies,
tion are important components in the care and treatment of there was a reduction in the number of brain abscesses in
children with brain abscesses. the setting of sinus and otitic infections (also see Carpenter
Brain abscesses in children are rare.12,15 At the University et al.5). These authors hypothesized that this decrease
of Virginia Childrens Hospital for the years 20002007
(inclusive), an average of 1.5 children per year was admit- resulted from the increased use and efficacy of antibiotics
ted to the inpatient pediatric service with a primary diagno- for the treatment of these infections during the later time
sis of brain abscess. period.19 Second, there was an increase in the number of
The most common risk factors that predispose a child to infections occurring in immunocompromised children.
the formation of a brain abscess include CHD, sinus and These abscesses were usually a severe consequence of dis-
otogenic infections, poor dental hygiene and complications seminated fungal disease, and 6 of the 9 patients identified
from dental procedures, infancy, immunosuppression, neu- as having intracerebral fungal abscesses died. Last, the
rosurgical procedures such as implantation of ventriculo- number of neonates identified as having brain abscesses
peritoneal shunts, penetrating skull injury and comminuted increased.
Abscesses may be single or multiple, and the lesions
cerebral localization is often related to the underlying, pre-
Abbreviations used in this paper: CHD = congenital heart disease; disposing factor. Abscesses that are the result of hematoge-
CSF = cerebrospinal fluid; MR = magnetic resonance. nous spread from distant sources such as the heart (endo-

Neurosurg. Focus / Volume 24 / June 2008 1

carditis) or lungs may have a distribution that reflects the scess involves the nondominant hemisphere. Cerebellar
cerebral arterial supply, most commonly that of the middle abscesses can produce appendicular and gait ataxias and
cerebral artery. Hematogenous spread can also occur by eye movement abnormalities. Brainstem abscesses are like-
way of the veins that drain into the cavernous sinus, result- ly to result in a combination of cranial nerve palsies and
ing in frontal lobe abscesses that are correlated with infec- deficits of ascending and descending pathways.
tions of the facial tissues or ethmoidal sinuses. Oral micro- As an abscess grows, intracranial pressure will increase
organisms may also spread to the frontal lobe in this and there is the potential for herniation. Therefore, the pres-
manner or enter the cranial vault through direct invasion. ence of papilledema noted on physical examination re-
Infections of the middle ear spread by direct invasion that quires prompt radiological evaluation and the initiation of
may result in abscesses in the temporal lobe or cerebellum. measures to reduce intracranial pressure, such as the ad-
The location tends to vary with a childs age; cerebellar ministration of corticosteroids and consideration of imme-
abscesses are more common in younger children and tem- diate neurosurgical intervention. In addition, abscess
poral lobe abscesses in older children. Abscesses of the growth can result in rupture of the abscess into the ventric-
brainstem are rare and can be observed in cases with either ular system. This life-threatening event will result in an
otogenic or hematogenous sources. acute decompensation and symptoms of a purulent menin-
The most commonly identified causative microorgan- gitis.
isms include the streptococci (aerobic and anaerobic) and
staphylococci (S. aureus and other staphylococcal species). Diagnosis and Management
Nevertheless, a wide range of bacteria, including other
gram-positive organisms (for example, peptostreptococci), Modern-day imaging techniques such as cranial comput-
gram-negative organisms (for example, Haemophilus spe- ed tomography scanning and MR imaging of the head
cies), fungi (Aspergillus species), and parasites have been allow the prompt confirmation of the clinical diagnosis and
recovered from brain abscesses. In the Childrens Hospital for the determination of abscess location and number (Fig.
Boston study,10 S. milleri represented the most common 1). Today, MR imaging is the study of choice.11 Diffusion-
organism in children beyond the neonatal period, and Ci- weighted MR imaging and MR spectroscopy can be help-
trobacter species were identified as the causative microor- ful in cases in which it is difficult to differentiate a brain
ganism in 3 of the 5 infections in children ! 1 month old. abscess from a tumor,6,8 (Fig. 1C and 1D) and potentially to
Because many abscesses will contain mixed flora (39% of differentiate between fungal and bacterial sources.20 If an
cases in the Childrens Hospital Boston study),10 empirical MR image cannot be obtained, a computed tomography
broad-spectrum antibiotic therapy is necessary prior to iso- scan with intravenous contrast should be performed; or, in
lation of the causative agent or agents (see below). the neonate, bedside cranial ultrasonography is another
alternative.24
Once the diagnosis is confirmed, additional studies with
the goal of identifying the predisposing factors and the
Clinical Features source of infection will be guided by the patients history
It is imperative to note that the classic triad of fever, and physical examination. Examination of the teeth is an
headache, and neurological deficit may be incomplete at important component of the physical examination of a
the time of presentation.1,9,10 Brain abscess should be a child with an intracerebral abscess. If endocarditis is sus-
strong consideration in the child who presents with the new pected, blood cultures and an echocardiogram should be
onset of acute headaches or first-time seizure, especially obtained. If there has been direct invasion from the sinuses
when focal neurological signs are present on examination. or middle ear, the imaging of the head should include these
In the neonate, a brain abscess is a potential cause of irri- regions.
tability, a bulging fontanelle, and a rapid increase in head Blood cultures are rarely positive and obtaining CSF by
circumference. lumbar puncture in the presence of a brain abscess can be
On presentation, a childs mental status can vary from life threatening. In those cases in which CSF has been ob-
mild confusion to lethargy to stupor or coma. In the Child- tained, there may be a mild mononuclear pleocytosis, slight
rens Hospital Boston studies,9,10 presentation in coma was elevation of protein, and a normal concentration of glucose;
less common during the years 19812000 compared with however, the culture tends to be sterile unless the abscess
19451980, probably due to advancements in neuroimag- has ruptured into the ventricular system.
ing techniques resulting in earlier diagnosis. Focal neuro- Although cerebritis, small solitary abscesses (! 2 cm in
logical signs are not always present. However, if sympto- diameter), or those in which the causative agent has been
matic, neurological signs will vary with abscess location. identified can be treated with antimicrobials alone,4,13,17,22
Frontal lobe abscesses may be silent until quite large, and strong consideration should be given to surgical drainage
they may result in personality change, frontal release signs, followed by the prompt initiation of empirical broad-spec-
and hemiparesis. With abscesses in the temporal lobe, dys- trum empiric antimicrobial therapy (Table 1). The regimen
phasias may be present when the abscess is located in the can be refined once the offending organism or organisms
dominant hemisphere, and visual field deficits ranging and susceptibilities have been identified in the neurologi-
from contralateral upper-quadrant field cuts to complete cally stable child in whom the abscess or abscesses are
homonymous hemianopia may be observed. With parietal accessible. The surgical management of brain abscesses in
lobe abscesses, there may be visual field cuts ranging from children is similar to that of these lesions in adults. Fre-
an inferior quadrantanopia to homonymous hemianopia; quently, especially in children in whom the abscess is the
dysphasias when the abscess is located in the dominant result of direct invasion of a contiguous infection involving
hemisphere; or dyspraxia and spatial neglect when the ab- the sinuses or middle ear, a multidisciplinary approach that

2 Neurosurg. Focus / Volume 24 / June 2008

FIG. 1. Axial MR images of a left-sided frontal pyogenic abscess in a 7-year-old boy. Axial contrast-enhanced T1-
weighted image (A) demonstrating a well-defined, relatively uniform, thin enhancing rim. On an axial T2-weighted
image (B), the rim is hypointense due to collagen, hemorrhage, or paramagnetic free radicals; this is an MR feature char-
acteristic of abscess capsules. Hyperintense vasogenic edema surrounds the abscess. Axial diffusion-weighted image (C)
and apparent diffusion coefficient map (D) show that the central pus is hyperintense and hypointense, respectively, find-
ings that help distinguish this abscess from a necrotic neoplasm.

includes both the neurosurgeon and the otolaryngologist is time of the abscess evacuation and the abscess capsule
required. Surgical drainage can often be performed using should be microsurgically removed at the time of
frameless stereotactic bur hole aspiration. Preoperative the craniotomy. Surgical complications associated with as-
stereotactic imaging allows for computation of the abscess piration and resection include hemorrhage, CSF leakage,
volume and provides an estimate of how much material can seizure, and stroke. In addition, while aspirating the ab-
reasonably be expected to be withdrawn. Use of intraoper- scess, great care should be taken to avoid a needle trajecto-
ative ultrasonography can help further to delineate pockets ry through the ventricular system.
of abscess. In our experience as well as in the Childrens Initial antimicrobial therapy is administered with broad-
Hospital Boston study,10 the majority of children only re- spectrum agents such as a third-generation cephalosporin
quire a single aspiration. However, children with new neu- and metronidazole. Therapy can be narrowed if a specific
rological signs or continued abscess growth despite antimi- organism or organisms are identified. It is difficult to iso-
crobial therapy that is deemed appropriate based on the late anaerobic bacteria even if they are part of the microbi-
causative microorganism require additional surgical proce- ological composition of the cerebral abscess, so anaerobic
dures. In children in whom the abscess remains enlarged coverage is often maintained if only one organism is iden-
despite repeated needle aspiration and medical manage- tified within the culture. There are no prospective studies in
ment, strong consideration should be given to the perfor- children to guide the duration of antimicrobial therapy;
mance of a craniotomy to allow more adequate evacuation however, in immunocompetent hosts we tend to favor in-
of the purulent material and debridement of the surround- travenous antimicrobial courses at least 46 weeks in dura-
ing parenchyma. For those abscesses associated with a for- tion (and longer in immunosuppressed patients or those
eign body such as a shunt, brain-stimulating electrode, or with tubercular brain abscess), with long-term follow-up
other device, the foreign body should be removed at the head imaging to ensure that the abscess or abscesses have

Neurosurg. Focus / Volume 24 / June 2008 3

TABLE 1 TABLE 2
Common causative organisms of brain abscess Potential empirical therapy, stratified by predisposing factor*
in children, stratified by predisposing factors
Predisposing Factor Potential Empirical Therapy
Predisposing Factor Causative Organism(s)
neonate cefotaxime plus ampicillin
neonate Proteus spp immunocompromised vancomycin plus ceftazidine plus metronidazole
Citrobacter spp host consider amphotericin & antituberculosis therapy
Enterobacter spp TMP-SMZ for Nocardia spp
immunocompromised host Nocardia spp CHD ceftriaxone plus metronidazole
fungi consider vancomycin
Mycobacterium tuberculosis infection
CHD S. viridans middle ear ceftriaxone plus metronidazole
microaerophilic streptococci sinus ceftriaxone plus metronidazole
Haemophilus spp consider therapy for MRSA
infection oral cavity penicillin plus metronidazole or ampicillin
middle ear streptococci (aerobic & anaerobic) sulbactam
Enterobacteriaceae posttraumatic vancomycin plus 3rd-generation cephalosporin
Pseudomonas spp
* MRSA = methicillin-resistant S. aureus; TMP-SMZ = trimethoprim
sinus streptococci (aerobic & anaerobic)
sulfamethoxazole.
S. aureus
Enterobacteriaceae
oral cavity mixed anaerobic flora
streptococci (aerobic & anaerobic) life-threatening intracranial entity for which prompt diag-
S. aureus nosis and treatment are required. Serial neuroimaging must
Enterobacteriaceae be performed to document an improvement in and eventu-
posttraumatic S. aureus
streptococci spp
ally a resolution of the infection. Surgical treatment with
Enterobacteriaceae either needle aspiration or excision remains an important
part of the treatment algorithm for pediatric patients afflict-
ed with brain abscesses.
resolved. Common pathogens and potential empirical anti-
microbial regimens based on these suspected organisms are Disclosure
outlined in Tables 1 and 2. Dr. Goodkin receives support from the National Institutes of
As is the case for antibiotics, there are no studies to guide Health (Grant No. NS-048413). The authors have no other financial
the prophylactic use of antiepileptic therapy in children disclosures.
with brain abscesses. Although some practitioners tend to
favor short-term prophylactic use of these drugs in all chil- Acknowledgments
dren with a brain abscess involving cortical structures, oth-
We thank J. Owen Hendley and Linda Waggoner-Fountain for
ers will start antiepileptic therapy only in patients whose their thoughtful comments and assistance in the completion of this
presentation included a seizure. If anticonvulsants are start- manuscript. We also thank Dr. Julie Matsumoto of the Department
ed, pharmacological interactions between antibiotics and of Radiology at the University of Virginia Health System for the
anticonvulsants must be considered in calculating dosages. images in Fig. 1.

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