Chapter 604  ◆  Brain Abscess  2949

Chapter 604 
Brain Abscess
Charles G. Prober and Roshni Mathew

Brain abscesses can occur in children of any age but are most
common in children between 4 and 8  yr old and in neonates.
The causes of brain abscess include embolization as a result of con-
genital heart disease with right-to-left shunts (especially tetralogy of
Fallot), endocarditis, meningitis, chronic otitis media and mastoiditis,
sinusitis, soft-tissue infection of the face or scalp, orbital cellulitis,
dental infections, severe complicated pneumonia, penetrating head
injuries, immunodeficiency states, and infection of ventriculoperito-
neal shunts.

PATHOLOGY
Cerebral abscesses are evenly distributed between the 2 hemispheres,
and 80% of cases are divided equally between the frontal, parietal, and
temporal lobes. Brain abscesses in the occipital lobe, cerebellum, and
brainstem account for approximately 20% of the cases. Most brain
abscesses are single, but 30% are multiple and may involve more than
1 lobe. The pathogenesis is undetermined in 10-15% of cases. An
abscess in the frontal lobe is often caused by extension from sinusitis
or orbital cellulitis, whereas abscesses located in the temporal lobe or Figure 604-1 CT with contrast. Note the large, wall-enhancing
cerebellum are frequently associated with chronic otitis media and abscess in the left frontal lobe causing a shift of the brain to the right.
mastoiditis. Abscesses resulting from penetrating injuries tend to be The patient had no neurologic signs until just before the CT scan
singular and caused by Staphylococcus aureus, whereas those resulting because the abscess is located in the frontal lobe, a “silent” area of
from septic emboli, congenital heart disease, or meningitis often have the brain.
several causal organisms.

ETIOLOGY
The predominant organisms causing brain abscesses in children are
aerobic and anaerobic streptococci (60-70% of the cases) with Strepto-
coccus milleri gp (Streptococcus anginosus, Streptococcus constellatus,
and Streptococcus intermedius) being increasingly isolated from surgi-
cally drained brain abscesses. Other important streptococci include
group A and B streptococci, Streptococcus pneumoniae, and Enterococ-
cus faecalis. Other bacteria isolated from brain abscesses include anaer-
obic organisms (Gram-positive cocci, Bacteroides spp., Fusobacterium
spp., Prevotella spp., Actinomyces spp.) and Gram-negative aerobic
bacilli (Haemophilus aphrophilus, Haemophilus parainfluenzae, Hae-
mophilus influenzae, Enterobacter, Escherichia coli, Proteus spp.). Citro-
bacter is most common in neonates. One organism is cultured in
70% of abscesses, 2 in 20%, and 3 or more in 10% of cases. Abscesses
associated with mucosal infections (sinusitis) frequently have anaero-
bic bacteria. Fungi (Aspergillus, Candida), Nocardia, Mycobacterium,
and Listeria spp. are more common in children with impaired host
defenses.
CLINICAL MANIFESTATIONS
The early stages of cerebritis and abscess formation are associated with
nonspecific symptoms, including low-grade fever, headache, and leth-
argy. The significance of these symptoms is generally not recognized,
and an oral antibiotic is often prescribed with resultant transient relief.
As the inflammatory process proceeds, vomiting, severe headache,
seizures, papilledema, focal neurologic signs (hemiparesis), and coma
may develop. A cerebellar abscess is characterized by nystagmus, ipsi-
lateral ataxia and dysmetria, vomiting, and headache. If the abscess
ruptures into the ventricular cavity, overwhelming shock and death
usually ensue.
DIAGNOSIS
The peripheral white blood cell count can be normal or elevated, and
the blood culture is positive in 10% of cases. Examination of the cere-
brospinal fluid shows variable results; the white blood cells and protein
may be minimally elevated or normal, and the glucose level may be
low. Cerebrospinal fluid cultures are rarely positive; culture of pus from
the neurosurgical drainage is the key to establishing a bacteriologic
diagnosis. However, the culture can be sterile in a substantial number
of cases and 16S bacterial ribosomal RNA polymerase chain reaction
amplification and sequencing may be used to identify unculturable
bacteria in brain abscesses. Because examination of the cerebrospinal
fluid is seldom useful and a lumbar puncture may cause herniation of
the cerebellar tonsils, the procedure should not be undertaken in a
child suspected of having a brain abscess. The electroencephalogram
shows corresponding focal slowing, and the radionuclide brain scan
indicates an area of enhancement caused by disruption of the blood–
brain barrier in more than 80% of cases. CT with contrast and MRI
are the most reliable methods of demonstrating cerebritis and abscess
formation (Fig. 604-1). MRI is the diagnostic test of choice. The CT
findings of cerebritis are characterized by a parenchymal low-density
lesion, and MRI T2-weighted images indicate increased signal inten-
sity. An abscess cavity shows a ring-enhancing lesion by contrast CT,
and the MRI also demonstrates an abscess capsule with gadolinium
administration.
TREATMENT
The initial management of a brain abscess includes prompt diagnosis
and institution of an antibiotic regimen that is based on the probable
pathogenesis and the most likely organism. When the cause is
unknown, the combination of vancomycin, a third-generation cepha-
losporin, and metronidazole is commonly used. The same regimen is
initiated when otitis media, sinusitis, or mastoiditis is the likely cause.
If there is a history of penetrating head injury, head trauma, or neuro-
surgery, vancomycin plus a third-generation cephalosporin is appro-
priate. When cyanotic congenital heart disease is the predisposing
factor, ampicillin-sulbactam alone or a third-generation cephalosporin
plus metronidazole may be used. Meropenem has good activity against
Gram-negative bacilli, anaerobes, staphylococci, and streptococci,

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including most antibiotic-resistant pneumococci, and may be used
alone to replace the combination of metronidazole and a β-lactam in
the previous regimens. Notably, meropenem does not provide activity
against methicillin-resistant S. aureus and may have decreased activity
against penicillin-resistant strains of S. pneumoniae, indicating that
vancomycin should remain a part of the initial regimen when these
organisms are suspected. Abscesses secondary to an infected ventricu-
loperitoneal shunt may be initially treated with vancomycin and cef-
tazidime. When Citrobacter meningitis (often in neonates) leads to
abscess formation, a third-generation cephalosporin is used, typically
in combination with an aminoglycoside. Listeria monocytogenes may
cause a brain abscess in the neonate and if suspected, ampicillin should
be added to the cephalosporin. In immunocompromised patients,
broad-spectrum antibiotic coverage is used, and amphotericin B
therapy should be considered.
A brain abscess can be treated with antibiotics without surgery if the
abscess is <2 cm in diameter, the illness is of short duration (<2 wk),
there are no signs of increased intracranial pressure, and the child is
neurologically intact. If the decision is made to treat with antibiotics
alone, the child should have follow-up neuroimaging studies to ensure
the abscess is decreasing in size. An encapsulated abscess, particularly
if the lesion is causing a mass effect or increased intracranial pressure,
should be treated with a combination of antibiotics and aspiration.
Surgical excision of an abscess is rarely required, because the procedure
may be associated with greater morbidity compared with aspiration of
a cavity. Surgery is indicated when the abscess is >2.5 cm in diameter,
gas is present in the abscess, the lesion is multiloculated, the lesion is
located in the posterior fossa, or a fungus is identified. Associated
infectious processes, such as mastoiditis, sinusitis, or a periorbital
abscess, may require surgical drainage. The duration of antibiotic
therapy depends on the organism and response to treatment but is
usually 4-6 wk.

PROGNOSIS
Mortality rates prior to 1980s ranged from 11-53%. More recent mor-
tality rates accompanying wider use of CT and MRI, improved micro-
biologic techniques and prompt antibiotic and surgical management,
range from 5-10%. Factors associated with high mortality rate at the
time of admission include age younger than 1 yr, multiple abscesses
and coma. Long-term sequelae occur in about one-third of the survi-
vors and include hemiparesis, seizures, hydrocephalus, cranial nerve
abnormalities, and behavior and learning problems.

Bibliography is available at Expert Consult.

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 Chapter 604  ◆  Brain Abscess  2950.e1

Bibliography Sáez-Llorens X, Nieto Guevara J: Parameningeal infections. In Feigin RD, Cherry

Arora P, Kalra VK, Pappas A: Multiple brain abscesses in a neonate after blood
stream infection with methicillin-resistant Staphylococcus aureus, J Pediatr
161:563, 2012.
Brouwer MC, Tunkel AR, McKhann IIGM, et al: Brain abscess, N Engl J Med
371:447–456, 2014.
Cole TS, Clark ME, et al: Pediatric focal intracranial suppuration: a UK
single-center experience, Childs Nerv Syst 28:2109–2114, 2012.
Goodkin HP, Harper MB, Pomeroy SL: Intracranial abscess in children: historical
trends at Children’s Hospital Boston, Pediatrics 113:1765–1770, 2004.
Keller PM, Rampini SK, Bloemberg GV: Detection of mixed infection in a
culture-negative brain abscess by broad-spectrum bacterial 16S rRNA gene
PCR, J Clin Microbiol 48(6):2250, 2010.
JD, Demmler-Harrison GJ, et al, editors: Feigin and Cherry’s textbook of
pediatric infectious diseases, ed 6, Ch. 38. Philadelphia, 2009, Saunders Elsevier.
Saez-Lloreus XJ, Umana NA, Odio CN, et al: Brain abscesses in infants and
children, Pediatr Infect Dis J 8:449–458, 1989.
Shachor-Meyouhas Y, Bar-Joseph G, et al: Brain abscess in children–epidemiology,
predisposing factors and management in the modern medicine era, Acta
Paediatr 99:1163–1167, 2010.
Smith RR: Neuroradiology of intracranial infection, Pediatr Neurosurg 18:92–104,
1992.
Yogev R, Bar-Meir M: Management of brain abscesses in children, Pediatr Infect
Dis J 23:157–159, 2004.

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