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of Child Neurology

Brain Abscesses in Children: Results of 24 Children From a Reference Center in Central Anatolia,
Turkey
Mehmet Canpolat, Ozgur Ceylan, Huseyin Per, Gonca Koc, Abdulfettah Tumturk, Sefer Kumandas, Turkan Patiroglu,
Selim Doganay, Hakan Gumus, Ekrem Unal, Mehmet Kose, Sureyya Burcu Gorkem, Ali Kurtsoy and Mustafa Kursat
Ozturk
J Child Neurol published online 15 September 2014
DOI: 10.1177/0883073814549247

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Original Article
Journal of Child Neurology
1-10
Brain Abscesses in Children: Results of ª The Author(s) 2014
Reprints and permission:
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24 Children From a Reference Center DOI: 10.1177/0883073814549247
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in Central Anatolia, Turkey

Mehmet Canpolat, MD1, Ozgur Ceylan, MD2, Huseyin Per, MD1,

Gonca Koc, MD3, Abdulfettah Tumturk, MD4, Sefer Kumandas, MD1,
Turkan Patiroglu, MD5,6, Selim Doganay, MD3, Hakan Gumus, MD1,
Ekrem Unal, MD5, Mehmet Kose, MD7, Sureyya Burcu Gorkem, MD3,
Ali Kurtsoy, MD4, and Mustafa Kursat Ozturk, MD2

Abstract
Childhood brain abscesses are a rare and potentially life-threatening condition requiring urgent diagnosis and treatment. This retro-
spective study analyzed the clinical and radiologic findings of 24 (7 girl, 17 boys) cases with brain abscess. Mean age was 92.98 + 68.04
months. The most common presenting symptoms were nausea-vomiting (45.8%) and headache (41.7%). Brain abscess was most com-
monly located in the frontal region. Diffusion restriction was determined in 78.4% of lesions. The mean apparent diffusion coefficient
value in these lesions was 0.511 + 0.23  10–3 mm2/s. Cultures were sterile in 40% of cases. Antimicrobial therapy was given to only
16.7% of cases. Predisposing factors were identified in 91.6% of cases (congenital heart disease in 20.8% and immunosuppression in
20.8%). Mortality level was 12.5%. In conclusion, immunocompromised states, and congenital heart disease have become an important
predisposing factor for brain abscesses. Effective and prompt management should ensure better outcome in childhood.

Keywords
brain abscess, child, clinical and radiologic features

Received June 10, 2014. Received revised July 02, 2014. Accepted for publication August 02, 2014.

Brain abscesses in childhood are rare but serious infectious dis-
ease.1 It is difficult to assess the incidence of brain abscesses, but
it is probably 2 to 3 cases of every 10 000 hospital admissions.2
Approximately 25% of all brain abscesses are seen in childhood,
most commonly between the ages of 4 and 7.3-5 There is gener-
ally an underlying predisposing condition. The majority of brain
abscesses are associated with congenital heart defects and infec-
tions in the face, head, and brain. There is also a risk of brain
abscess in immunosuppressed children.3-7 Brain abscess may not
produce symptoms for weeks. Clinical findings may be mild and
may be affected by various factors such as age and location of
abscess. A classic triad characterized by headache, fever, and
focal neurologic deficit is seen in 9% to 28% of children.4,5 The
main micro-organisms responsible for brain abscess are
aerobic and anaerobic streptococci and staphylococci. The most
prevalent species in the viridans group are streptococci, espe-
cially Streptococcus milleri. Staphylococcus aureus generally
grows in cultures of abscesses developing after trauma. Other
microorganisms that cause brain abscesses are Bacteroides spe-
cies, Proteus species, Haemophilus influenzae, Escherichia coli,
Citrobacter group, Nocardia, Aspergillus, and Corynebacterium
species and Mycobacterium tuberculosis. No growth is
determined in more than 10% of cases, despite the latest culture
techniques.1-8
Management of brain abscesses is both medical and surgi-
cal, although medical treatment alone may be sufficient in
1
Division of Pediatric Neurology, Department of Pediatrics, Faculty of
Medicine, Erciyes University, Kayseri, Turkey
2
Division of Pediatric Infectious diseases, Department of Pediatrics, Faculty of
Medicine, Erciyes University, Kayseri, Turkey
3
Department of Pediatric Radiology, Faculty of Medicine, Erciyes University,
Kayseri, Turkey
4
Department of Neurosurgery, Erciyes University, Faculty of Medicine,
5
Kayseri, Turkey
Division of Hematology and Oncology, Department of Pediatrics, Faculty of
Medicine, Erciyes University, Kayseri, Turkey
6
Division of Allergy and Immunology, Department of Pediatrics, Faculty of
Medicine, Erciyes University, Kayseri, Turkey
7
Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of
Medicine, Erciyes University, Kayseri, Turkey
Corresponding Author:
Huseyin Per, MD, Division of Pediatric Neurology, Department of Pediatrics,
Faculty of Medicine, Erciyes University, Talas, Kayseri 38039, Turkey.
Email: huseyinper@yahoo.com

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2 Journal of Child Neurology

Figure 1. Abscess lesion in the right occipital lobe of an 11-year-old boy (case 21). The lesion was multilobulated on T2-weighted image (A) and
had a hypointense rim. Pronounced perilesional edema and shift to the left in midline structures can be seen. T1-weighted image after use of
contrast (B) shows ring enhancement around the lesion. Note that the lesion exhibits pronounced diffusion restriction (C). T1-weighted image
(D) at magnetic resonance imaging (MRI) obtained approximately 1 month after lesion drainage shows a smaller collection area showing ring
enhancement in the operation localization. Because of the absence of a hypointense rim (E) and of diffusion restriction (not shown), this was
interpreted as an operation cavity.

some selected cases. Surgical drainage and antimicrobial ther-
apy are the preferred options in most cases of brain tumor. Sur-
gical drainage (aspiration) or excision is advised if the lesion
diameter is >2.5 cm or if it causes a mass effect.2-5,9-11
The death rate in brain abscesses used to be around 30% to
60%, although there has been a significant decrease in recent
years, to below 10%. Early diagnosis with neuroradiologic
imaging, rapid neurosurgical intervention, and broad spectrum
antimicrobial therapy including both aerobic and anaerobic
bacteria has led to positive outcomes.3-5
The purpose of this study was to analyze the clinical findings,
radiologic characteristics, risk factors, and prognoses of 24 cases
under observation in our clinic with a diagnosis of brain abscess.
Methods
Cases diagnosed with brain abscess between September 2003 and May
2014, and monitored by the Erciyes University Faculty of Medicine
Pediatric Neurology and Pediatric Infectious Diseases, Turkey, were
evaluated retrospectively. The demographic findings, presenting
symptoms, underlying medical conditions, predisposing risk factors,
abscess sites, radiologic findings, micro-organisms isolated, treatment
regimes, prognoses, and outcomes were recorded of 24 patients aged
between 1 month and 17 years diagnosed with brain abscess and for
which records were available.
Brain abscess cranial computed tomography (CT) or magnetic
resonance imaging (MRI) findings were assessed retrospectively.
These consisted of lesion number and site, perilesional edema, post-
contrast ring sign, shift, presence of hypointense rim on T2-
weighted MRI, and presence or not of diffusion restriction on
diffusion-weighted MRIs. Apparent diffusion coefficient (ADC) val-
ues from lesions were analyzed quantitatively.
Aspirate material collected during surgery was processed in the
microbiology laboratory for urgent aerobic and anaerobic culture. In
nonsurgical cases, diagnosis was confirmed with typical clinical
symptoms and response to treatment.
Results
Twenty-four cases, 7 (29.2%) female and 17 (71.8%) male,
were diagnosed with brain abscess in the 10-year study period.

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Canpolat et al
Mean age of patients was 92.98 + 68.04 months (minimum 1
month to maximum 204 months). Four cases were referred to
our clinic from other hospitals. General characteristics of cases
are shown in Table 1.
Clinical Features
The most common presenting symptoms were nausea-vomiting
in 11/24 (45.8%) cases, headache in 10/24 (41.7%), convulsion
in 9/24 (37.5%), fever in 7/24 (29.2%), and altered state of con-
sciousness in 7/24 (29.2%) (Table 1).
The most common findings at neurologic examination
were a normal neurologic appearance in 9/24 (37.5%) cases,
altered state of consciousness in 9/24 (37.5%) (stupor in 3 and
somnolence in 6), focal neurologic deficit in 6/24 (25.0%)
(aphasia in 1 case, facial paralysis in 1 case, hemiparesis in
2 cases, and anisocoria in 2 cases), bilateral positive Babinski
reflex in 3/24 (12.5%), papilledema in 1/24 (4.2%), and pos-
itive meningeal irritation findings in 1/24 (4.2%) (Table 1).
The classic triad of fever, headache, and focal neurologic
deficit was determined in 2/24 (8.4%) cases.
Predisposing Factors
Predisposing factors were identified in 22/24 (91.6%) cases.
The most common were congenital heart disease in 5/24
(20.8%) cases and immunosuppression in 5/24 (20.8%). Addi-
tionally, sinusitis was determined in 2/24 (8.3%) cases, dental
procedure in 2/24 (8.3%), autogenic factors in 2/24 (8.3%),
sepsis in 2/24 (8.3%), and trauma in 2/24 (8.3%), whereas the
condition developed postoperatively in 2/24 (8.3%). Pneumo-
nia was a predisposing factor in 1/24 (4.2%) cases and menin-
gitis in 1/24 (4.2%) cases. No predisposing factor was
determined in 2/24 (8.3%) cases (Table 1).
Dissemination
Postoperative spread was determined in 2/24 (8.3%) cases,
contiguous spread in 5/24 (20.8), and hematogenous spread
in 15/24 (62.5%). The 2 cases (8.3%) in which predisposing
factors were not identified were assessed as hematogenous
spread (Table 1).
Radiologic Findings
All cases underwent CT or MRI. Because preoperative images
for 4 cases referred to our clinic were not available from the
hospital records, these cases were evaluated from the records
in the files, and the other 20 cases were evaluated retrospec-
tively using the available images by 2 pediatric radiologists,
GK and SD. All cases were diagnosed radiologically with
brain abscess before surgery. Radiologic findings are given
in Table 2, and sample case images are given in Figure 1.
Abscesses ranged between 3.4 and 54 mm in size (mean +
standard deviation ¼ 32 + 14.7 mm). The most common
abscess locations were supratentorial, in 16/20 (80%) cases.
Abscesses were located infratentorially in 1/20 (5%) cases and
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3
were located in both supra- and infratentorial regions in 3/20
(15%) cases. Abscesses were single in 15/20 (75%) cases and
multiple in 5/20 (25%). Abscesses were frontal in 8/20 (40%)
cases, parietal in 1/20 (5%), occipital in 2/20 (10%), fronto-
parietal in 1/20 (5%), parieto-occipital in 1/20 (5%), tempor-
oparietal in 1/20 (5%), temporooccipital in 1/20 (5%),
cerebellar in 2/20 (10%), in the brain stem in 1/20 (5%), and
in the basal ganglia in 3/20 (15%) cases. Lesions were intra-
parenchymal in 16/20 (80%) cases, subdural in 3/20 (15%), and
epidural in 1/20 (5%).
Total number of abscesses determined in the 20 cases was
38. Only CT images were available for 1 patient. T2 hypoin-
tense rim was determined in 21/37 (56.8%) lesions (2 lesions
had 2-layer hypointense rims), capsular enhancement in 22/
37 (59.5%) lesions, perilesional edema in 30/37 (81.1%)
lesions, and shift in 8/20 (40%) cases, and diffusion restriction
was determined qualitatively in 29/37 (78.4%). Mean apparent
diffusion coefficient value in these 29 abscesses was 0.511 +
0.23  10–3 mm2/s. Mean apparent diffusion coefficient value
in the 8 lesions not exhibiting qualitative diffusion restriction
was 1.274 + 0.12  10–3 mm2/s.
Microbiology
No growth occurred in blood cultures of the 4/24 (16.7%)
nonsurgical cases. Bacteriological investigation was positive
in 13/20 (65.0%) of cases receiving surgery and from which
abscess specimens were taken.
Positive results were obtained in 3/20 (15.0%) cases at gram
staining. Gram-negative bacillus was observed in 1 case at
Gram staining, but culture was sterile. Gram-positive chain
coke was observed in 2 cases at Gram staining, and Peptostrep-
tococcus grew in culture.
Growth was determined in abscess culture in 12/20 (60.0%)
cases. Peptostreptococcus grew in abscess culture in 4 cases
and Aspergillus in 2 cases. Proteus, Pseudomonas, Bacter-
oides, Streptococcus pneumoniae, S aureus, and E coli grew
in abscess culture in 1 case each (Table 1).
Treatment
Antimicrobial therapy alone was administered in 4/24 (16.7%)
cases, and both surgical and antimicrobial therapy in 20/24
(83.3%). In surgical treatment, excision with craniotomy was
performed in 4/20 (20.0%) cases and drainage surgery with burr
hole in 16/20 (80.0%). Shunt removal surgery and extraventricu-
lar drainage surgery were performed in the same session in 1
case in which drainage was applied. Medical treatment was
administered as antibiotic therapy for 6 weeks. Empiric antimi-
crobial therapy was given in 4/24 (16.7%) cases in which sur-
gery could not be performed and abscess specimens could not
be obtained, on the basis of predisposing risk factor, assumed
origin of infection, or hospital- or community-acquired infection
status. Empiric antimicrobial therapy initiated in 20/24 (83.3%)
cases undergoing surgery was adjusted on the basis of microbio-
logical investigation (Table 1).
 4
Table 1. Patients’ Clinical Characteristics.
Presenting Predisposing Microbiology Antibiotic
Patient Age Gender symptoms condition Dissemination Neurologic examination Surgery (culture) treatment Outcome

1 17 y Male F, NV, AC CRF (renal Hematogenous Stupor, Babinski þ/þ No Negative Meropenem þ Died
transplant), DTR hyperactive amikacin þ
secondary fluconazole þ
immunodeficiency, amphotericin B
pancytopenia,
hemophagocytosis
2 13 y Male H, NV No Hematogenous Papilledema Drainage Negative Ceftriaxone þ Good
metronidazole
3 1.5 y Male F, NV, S Pneumonia Hematogenous Somnolence Drainage Negative Ceftriaxone þ Good
metronidazole
þ vancomycin
4 4.5 y Female F, S ALL Hematogenous Normal Drainage Aspergillus niger Amphotericin B þ Epilepsy
voriconazole
5 2.5 mo Male F, Ps, somnolence Urosepsis Hematogenous Somnolence and bulging Drainage Proteus Cefotaxime þ Epilepsy, hemiparesis
fontanelle, eyes deviated to amikacin þ
the left, right hemiparesis meropenem
6 7.5 y Male H, NV, S Maxillary and frontal Contiguous Normal No Negative Ceftriaxone þ Epilepsy
sinusitis metronidazole
þ vancomycin
7 14 y Female F, H, NV, left No Hematogenous Facial paralysis Drainage Negative Meropenem þ Good
central facial metronidazole
paralysis þ rifampin
8 7y Male F, H, somnolence TGA þ PS Hematogenous Somnolence Drainage GrS ! Gr (–) bacillus Ceftriaxone þ Epilepsy
Negative vancomycin þ
metronidazole
9 9y Male H Trauma: frontal bone Contiguous Normal Drainage Negative Ceftriaxone þ Good
fracture vancomycin þ
metronidazole
10 4y Male S Arachnoid cysts Postoperative Normal Excision Pseudomonas Ceftriaxone þ Epilepsy
operated vancomycin þ
metronidazole
11 16 y Male S, paresthesia in CGD Hematogenous Unremarkable except for oral Drainage Aspergillus fumigatus Amphotericin B þ Good
the left leg moniliasis and skin scars at voriconazole
axillary and perianal region

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12 14 y Male Speech disorders, Sinusitis Contiguous Aphasia, somnolence Drainage GrS ! Gr (þ) chain coke Ceftriaxone þ Epilepsy
S Peptostreptococcus vancomycin þ
metronidazole
13 12 y Female H, NV Otitis media, Contiguous Meningeal irritation signs Drainage Negative Ceftriaxone þ Epilepsy
mastoiditis, positive meropenem þ
meningitis metronidazole
14 12 y Male S, cough WAS, mucositis, lung Hematogenous Normal Drainage Peptostreptococcus Ceftriaxone þ Epilepsy
abscess vancomycin
15 3y Female S, somnolence ALL, febrile Hematogenous Somnolence anisocoria, Drainage Negative Ceftriaxone þ Good
neutropenia Babinski reflex þ/þ vancomycin þ
metronidazole
þ amphotericin
B
16 3y Female NV Foramen ovale Hematogenous Normal Drainage Bacteroides Ceftriaxone þ Good
vancomycin þ
metronidazole
17 4.5 y Male R, NV Dental procedure Hematogenous Left hemiparesis Excision Peptostreptococcus Ampicillin/ Epilepsy, hemiparesis
sulbactam þ
amikacin þ
metronidazole

(continued)
 Table 1. (continued)

Presenting Predisposing Microbiology Antibiotic

Patient Age Gender symptoms condition Dissemination Neurologic examination Surgery (culture) treatment Outcome

18 5 mo Male Swelling behind Trauma þ mastoiditis Contiguous Normal Excision Streptococcus pneumoniaeAmpicillin/ Good
the right ear sulbactam þ
clindamycin
19 16 y Female F, NV, H, AC TGA þ VSD þ Hematogenous Stupor, anisocoria, bilateral No Negative Ceftriaxone þ Died
pulmonary Babinski reflex þ/þ vancomycin þ
hypertension metronidazole
20 3 mo Male R, NV, S, AC, head Hydrocephalus þ Postoperative Stupor and bulging fontanelle Drainage þ shunt Staphylococcus aureus Ceftriaxone þ Died
growth DWA þ VPS removing and EVD vancomycin
21 11 y Male H, NV Truncus arteriosus Hematogenous Normal Excision Negative Ceftriaxone þ Epilepsy
type 4 vancomycin þ
metronidazole
22 5y Female H TGA Hematogenous Normal Drainage GrS ! Gr (þ) chain coke Ceftriaxone þ Good
Peptostreptococcus vancomycin þ
metronidazole
23 11 y Male H Dental procedure Hematogenous Normal No Negative Ceftriaxone þ Good
vancomycinþ
metronidazole
þ rifampin

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24 1 mo Male Ps, somnolence Sepsis Hematogenous Somnolence and bulging Drainage E coli Cefotaxime þ Good
fontanelle rifampin þ
vancomycin

Abbreviations: AC, altered consciousness; ALL, acute lymphoblastic leukemia; CGD, chronic granulomatous disease; CRF, chronic renal failure; DTR, deep tendon reflexes; DWA, Dandy-Walker Anomaly; EVD, extra-
ventricular drainage; F, fever; Gr (þ), gram-positive; Gr (–), gram-negative; GrS, gram staining; H, headache; NV, nausea-vomiting; Ps, poor sucking; PS, pulmonary stenosis; R, restlessness; S, seizures; TGA, transposition of
the great arteries; VPS, ventriculoperitoneal shunting; VSD, ventricular septal defect; WAS, Wiskott-Aldrich syndrome.

5
 6
Table 2. Patients’ Radiologic Findings.

Number of Mean T2 hypointense Capsular Perilesional Diffusion Mean ADC

Patient Location abscesses diameter rim enhancement edema Shift restriction value

1 Frontoparietal 8 13.1 + 8.2 (þ), 2 of lesions localized in (þ), 2 of lesions localized in (þ), 5 of lesions (–) (þ) 386.9+114.4
periventricular WM, pons mm right frontal and left right frontal and left
parietal WM parietal WM
2 Right frontal lobe 1 50 mm X X X X X X
3 Bilateral frontal lobe 3 25 + 8.7 X X X X X X
mm
4 Left frontal WM, right frontal 3 7.8 + 5.0 (þ), only 1, localized in left (þ), only 1, localized in left (þ), 2 of the lesions, (–) (þ) 266 + 133
parasagittal, left cerebellar mm frontal lobe frontal lobe cerebellar and left
WM frontal,
5 Left cerebral hemisphere multiple X X X X X X X
6 Left frontal subdural space 1 11 mm (þ) (þ) (þ) (þ) (þ) 360
7 Right lentiform nucleus 1 37 mm (þ), double layered capsule (þ) (þ) (þ) (þ) 269
8 Right thalamus 1 30 mm (þ) (þ) (þ) (þ) (þ) 600
9 Left frontal WM 1 30 mm (þ) (þ) (þ) (–) (þ) 215
10 Left occipital WM 2 20 + 5.7 (þ), both (þ), both (þ) (–) (þ) 931
mm
11 Right frontal WM 1 24 mm (þ) (þ) (þ) (þ) (þ) 337
12 Left frontal WM 1 37 mm X X (þ) (þ) X X
13 Left temporal lobe 1 X X X X (þ) X X
14 Left frontal, thalami and right 8 7.9 + 4.8 (þ), lesions localized in left (þ), lesions localized in left (þ) (–) (þ), localized in left 754 + 54
occipital WM, left mm frontal lobe, cerebellum frontal lobe, cerebellum frontal lobe and
cerebellar WM thalami

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15 Left parietal WM 1 14 mm (þ) (þ) (þ) (–) (þ) 853
16 Right frontal lobe 1 28 mm (þ), double layered (þ) (þ) (–) (þ) 802
17 Right temporoparietal WM 1 59 mm (þ) (þ) (þ) (þ) (þ) 348
18 Right temporooccipital 1 37 mm (–) (–) (–) (–) (þ) 590
epidural space
19 Right frontal lobe 1 19 mm (þ) (þ) (þ) (–) (þ) 375
20 Retrocerebellar 1 54 mm (þ) (þ) (–) (–) (þ) 445
21 Right occipital 1 37 mm (þ) (þ) (þ) (þ) (þ) 331
22 Right frontal lobe 2 46 + 17 (þ) (þ) (þ) (þ) (þ) 296 + 50.9
23 Left frontal lobe 1 8 mm (–) (þ) (þ) (–) (–) 1238
24 Bilateral parietooccipital- 1 37 mm (þ) (þ) (–) (–) (þ) 698
subdural space
Abbreviations: ADC, apparent diffusion coefficient; (–), negative; (þ), positive; WM, white matter; X, not evaluated.
Canpolat et al
Outcomes
Three of the 24 patients (12.5%) died during treatment. No neu-
rologic sequelae were observed in 11/24 (45.8%) cases in the
first year of monitoring. Epilepsy was diagnosed in 8/24
(33.3%) cases and epilepsy and hemiparesis in 2/24 (8.3%) in
the first year of monitoring (Table 1).
Discussion
Brain abscess in children is rare. Clinical presentation is asso-
ciated with a large number of factors, including site of abscess,
number of abscesses, pathogen, presence or absence of accom-
panying meningitis or ventriculitis, the patient’s immune status
and stage of disease. Although fever, headache and vomiting
are seen in 60% to 70% of adults, clinical findings in children
may be nonspecific, especially as age decreases.2-5,9,12 Fever is
a nonspecific finding that may be generally seen at a level of
30% to 70% in various phases of the disease. Headache is seen
in 42% to 80% of adults, although this level may be lower in
children, at 30% to 50%. Nausea-vomiting is a finding of
increased intracranial pressure and is seen in approximately
25% to 50% of patients. Altered state of consciousness is seen
in approximately 2/3 of cases and may vary in degree from a
mild state of sleep to coma.1-7 Brain abscess in children may
lead to increased head circumference, bulging fontanel, and
separation of cranial sutures.1 Presenting symptoms in our
study were nausea-vomiting in 45.8% of cases, headache in
41.7%, convulsion in 37.5%, fever in 29.2%, and altered con-
sciousness in 29.2%. Our clinical findings were similar to those
of other studies involving the same age group.4,5,9,11-17
Focal neurologic deficit may be seen in 20% to 60% of
cases.4,5,9 Location of the abscess determined focal neurologic
deficits. If the abscess is in the parietal lobe, it leads to hemi-
paresis, to dysphagia if it is in the temporal lobe, and to vision
defects if it is in the occipital lobe.9 Cranial nerve paralysis,
nystagmus, and ataxia may also be seen, depending on the loca-
tion of the abscess.1 Papilledema is seen in 41% to 70% of
adults.9,16,18 However, that level decreases in childhood since
the fontanels are still open. In agreement with the literature,
in this study neurologic appearance was normal in 37.5% of
cases, altered consciousness was present in 37.5%, and focal
neurologic deficit in 25.0%, and bilateral Babinski reflex posi-
tivity was determined in 12.5%. The classic triad characterized
by headache, fever, and focal neurologic deficit was deter-
mined in 8.4% of children.4,5
No underlying predisposing factor is determined in 15% to
30% of brain abscesses.1 In this study, no predisposing factor
was identified in 8.4% of children. Predisposing factors in brain
abscesses are contiguous infections, hematogenous dissemina-
tion, and penetrating head injuries, including surgical interven-
tions.9 Neurosurgical procedures are responsible for some 8%
to 10% of cases.16,18 In this study, postoperative spread was
present in 8.3% of cases, contiguous spread in 20.8%, and
hematogenous spread in 62.5%. Shachor-Meyouhas et al5
determined predisposing factors at a level of 81% in their
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7
27-case series; sinusitis-mastoiditis-otitis at a level of 30%,
trauma at 15%, meningitis at 15%, anatomic brain cyst at
7%, pulmonary origin at 4%, congenital heart disease at 7%,
and other causes at 4%, whereas no predisposing factor was
identified in 18% of cases. Goodkin et al14 determined conge-
nital heart disease at a level of 51% and sinusitis-mastoiditis-
otitis at a level of 11% and identified no predisposing factor
in 7% of cases. Auvichayapat et al7 identified congenital heart
disease at a level of 35% and sinusitis-mastoiditis-otitis at a
level of 20%. In a 75-case series from Turkey, Ozsürekci
et al4 determined congenital heart disease at a level of
33.3%, sinusitis at 5.3%, mastoiditis-otitis at 16%, pulmonary
origin at 2.6%, trauma at 2.6%, and immunosuppression at
3.9%. Landriel et al19 determined an immunosuppression level
of 18% in their 59-case series. The most common predisposing
factors in this study were congenital heart disease in 20.8% of
cases, immunosuppression in 20.8%, sinusitis in 8.3%, dental
procedure in 8.3%, autogenic in 8.3%, sepsis in 8.3%, trauma
in 8.3%, neurosurgical procedures in 8.3%, pneumonia in
4.2%, and meningitis in 4.2%. Two cases identified as immu-
nosuppression were associated with acute lymphoblastic leuke-
mia and 1 with chronic renal failure and renal transplantation.
Wiskott-Aldrich syndrome was present in one case, and
chronic granulomatous disease–related immune deficiency in
the other. Brain abscess associated with immunosuppression/
immune deficiency has been increasingly frequently reported
in recent years.4,19-21 This may be related to the development
of diagnostic tests in rare immune deficiencies and the easy
availability of such tests.
Imaging techniques help determine abscess location, edema,
and mass effect.1 Cranial CT used to be widely employed in the
diagnosis of brain abscesses. Significant delays in diagnosis
occurred in the pre–CT scan era, leading to high morbidity and
mortality. Today, MRI may be regarded as the primary imaging
technique for intracranial lesions. Abscess lesions appear
hypointense on T1-weighted images and hyperintense on T2-
weighted images. Vasogenic edema is often determined around
the lesion and occupying a broader space than it. A hypointense
capsule may be observed around the abscess on T2-weighted
images, and an iso-hyperintense capsule on T1-weighted
images. Nathoo et al11 reported that 89.6% of abscesses were
supratentorial, 9.4% infratentorial, and 1% both supra- and
infratentorial. In a study of 75 cases, Ozsürekci et al4 deter-
mined single abscesses in 66.6% of cases and multiple
abscesses in 33.3%. The most frequent abscess locations were
25.3% frontal, 22.6% parietal, 14.6% temporal, 5.3% occipital,
14.6% frontoparietal, 6.6% parieto-occipital, 4% temporopar-
ietal, 4% temporoparieto-occipital, 13.3% cerebellum, and
8% brain stem. Other studies have reported that the most com-
mon abscess locations are parietal and/or frontal lobe.4,5,9 In
our study, and in agreement with the literature, 80% of
abscesses were supratentorial, 5% infratentorial, and 15% in
both supra- and infratentorial regions. Single abscess was pres-
ent in 75% of cases and multiple in 25%. The most common
location for abscesses was the frontal region. Underlying
immune deficiency, congenital heart diseases, sinusitis, and
8 Journal of Child Neurology
facial infections such as dental infection in cases of frontally
located brain abscess (Tables 1 and 2) were noteworthy as
being compatible with the literature and the general study pop-
ulation as etiologic risk factors. Abscess usually appears in a
pronounced hyperintense form on diffusion-weighted images
and possesses low ADC values, indicating diffusion restriction.
Presence of diffusion restriction helps differentiate abscess
from other cystic lesions (e.g., cystic brain tumors).1,9,22-24
Fanning et al25 showed significantly low ADC signal values
in abscesses. Several studies have reported that diffusion-
weighted images are reliable in differentiating abscesses from
malign cystic tumors in particular. Generally, ADC values
decrease because of intense viscosity appearing because of
their high necrotic living cells, bacteria, and protein content,
whereas cystic-necrotic brain tumors have higher ADC values
because of their more serous structure than that of abscesses.
ADC values defined for abscesses in the literature range
between 0.28 and 0.7 (10–3 mm2/s).25-28 However, diffusion
restriction may not be determined in pyogenic abscess lesions
as presented in our study and relevant literature. There may
therefore be a need for advanced radiologic imaging tech-
niques in the differential diagnosis of cystic tumors.29,30 Dif-
fusion restriction may not appear in fungal abscesses and
abscess lesions containing sterile pus.
In agreement with the literature, T2 hypointense rim was
determined in 56.8% of lesions in this study, capsular enhance-
ment in 59.5%, perilesional edema in 81.1%, and shift in 40%.
Qualitative diffusion restriction was determined in 29 (78.4%)
lesions. Mean apparent diffusion coefficient value in these 29
abscesses was 0.511 + 0.23  10–3 mm2/s.
Sterile pus cultures were found in 40% of cases. The level of
sterile pus cultures in the literature ranges between 10% and
56%.3-9,12 Growth was determined in 60.0% of pus cultures
in this study. Peptostreptococcus grew in 4 abscess cultures
(20%) and Aspergillus in 2 (10%). Proteus, Pseudomonas, Bac-
teroides, S pneumoniae, S aureus, and E coli grew in 1 (5%)
abscess culture each. Aspergillus growth was present in 2 of our
immunosuppressed cases and Peptostreptococcus growth in 1.
This was compatible with the literature.1,14,20,21 Gram-negative
organisms such as Klebsiella, E coli, Proteus, and Citrobacter
have been reported to be capable of causing abscesses in new-
borns.1,14,31,32 E coli was determined in pus cultures as an agent
in a 1-month-old case in our study.
Although treatment of brain abscesses is still a subject of
debate in the literature, contemporary treatment is a combina-
tion of antimicrobial therapy and surgical intervention.9 Ther-
apeutic approach depends on several factors, such as stage of
the abscess, its location and origin, virulence of the pathogen
micro-organism, number of abscesses, patient response, and
degree of edema.9,12 Antimicrobial therapy alone is preferred
in abscesses <2 cm in size, in high-density lesions, in multiple
abscesses, in patients whose condition is too poor for surgery,
and if the abscess is located in a position inaccessible to sur-
gery.9 Auvichayapat et al7 used antimicrobial therapy alone in
14.7% of cases, Goodkin et al14 in 12.5%, and Ozsürekci et al4
in 24%. In our study, again in agreement with the literature,
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16.7% of cases received antimicrobial therapy alone. There
are no randomized controlled trials about the effectiveness
of antibiotic regimens for treating children with brain
abscess.33 Empiric antimicrobial therapy is dictated by pre-
sumed source, but often includes nafcillin or vancomycin,
cefotaxime or ceftriaxone, and metronidazole. Therapy is
adjusted when the culture results are available. Patients usu-
ally receive a minimum 6- to 8-week course of intravenous
antibiotics, which may be prolonged depending on the clinical
context, such as in immunocompromised patients.1-3,15 In our
study, in agreement with the literature, the most preferred
drugs for combination treatment were vancomycin, third-
generation cephalosporin, and metronidazole (Table 1). There
is a need for a well-designed randomized controlled trial to
evaluate the effects of different antibiotic regimens on brain
abscess.
Generally, combination therapy is preferred. In this study,
83.3% of cases received both surgery and antimicrobial ther-
apy. The most common surgical approach is drainage.1,34 This
is particularly advised if the abscess is >2.5 cm in size.1 In
agreement with previous studies,4-12,14,15,19 craniotomy and
excision were performed in 20.0% of the cases in this study,
and drainage surgery in 80.0%.
Until the 1980s, brain abscess–related mortality rates in
children were 11% to 53%. Although some studies have
reported that mortality rates have decreased to 3.7% to 10%
thanks to the use of CT and MRI, rapid advances in microbio-
logical tests, fast and effective antibiotherapy, and advances in
neurosurgery, the general mortality rate today is still approxi-
mately 15%.1-18 The mortality rate in our series was 12.5%.
Although our mortality rate was compatible with the literature,
it was higher than that in some recently published case
series.4,5,7,11,12 We attribute this to the predisposing factors in
fatal cases 1 and 19 and their general condition being too poor
for surgery.
The main limitation of this study is that preoperative radi-
ologic images for 4 cases were unavailable since the analysis
was retrospective.
In conclusion, despite advances in diagnosis and treatment,
brain abscesses in children are still associated with high
neurologic morbidity and mortality. Clinical findings may
sometimes be highly indistinct and diagnosis requires a high
index of suspicion. Diagnosis is made on the basis of a com-
bination of clinical and radiologic tests. In recent years,
immunocompromised states have become an important pre-
disposing factor for the development of brain abscesses.
Surgical drainage combined with specific antibiotic therapy
is recommended in these patients. Effective and prompt
management should ensure a much better outcome of brain
abscess in childhood.
Acknowledgments
We are most grateful to Prof Dr Ibrahim Suat Oktem, Prof Dr Abdul-
hakim Coskun, Dr Alper Ozcan, and Dr Huseyin Baz for their support
for this study. We also extend our grateful thanks to all the patients in
this study and their long-suffering families.
Canpolat et al
Author Contributions
MC, HP, MKO, SD, MK, AK, TP, SK, and HG planned the study and
prepared the first draft. MC, HP, OC, and GK collected the patient
data. MC, OC, AT, GK, SBG, and EU prepared the manuscript for
publication and reviewed the literature. All the authors were involved
in and contributed to patient monitoring and treatment.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
Ethical Approval
This study was approved by Erciyes University Scientific Research
Committee (2014/354).
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