m NS

Child's Nerv Syst (1992) 8:411-416

9 Springer-Verlag 1992

Management of brain abscess in children:

review of 130 cases over a period of 21 years
]smail H. Tekk6k and Aykut Erbengi
Department of Neurosurgery, Hacettepe University School of Medicine, Sihhiye, Ankara 06100, Turkey
Received October 25, 1991/Revised April 26, 1992

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 c o m m o n 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been the mainstay of antimicrobial therapy but have recently been replaced by third-generation cephalosporins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%.
Key words: Brain abscess - Children - Congenital heart
disease - Infant - Infection - Mortality

The introduction of computed tomography (CT) and development of more effective antibiotic regimens have certainly contributed to the reduced mortality from brain
abscess [2, 3, 5, 8, 10, 11, 14, 17, 22]. Mortality from brain
abscess was up to 61% in the preantibiotic era [2], which
was reduced to 3 0 - 4 0 % after antibiotics came into use
[4, 13] and to about 10% after the advent o f CT [5]. A
mortality as low as 5% has been reported only recently [3,

Since the first operation for a brain abscess by

M o r a n d in 1768, methods o f surgical intervention have
also evolved [19]. Tube drainage, marsupialization, and
the migration method of K a h n are now of historical interest. Excision, aspiration, and the open evacuation
technique of Maurice-Williams [11] are the currently used
techniques, and only recently stereotactic methods have
been used for aspiration purposes [10].
Children with brain abscess appear to be an exceptional group, since the prevalence of the predisposing factors
differs from that among adults, and the regenerating capacity of the developing brain may contribute positively
to the neurological outcome of the disease. The purpose
of this paper is to analyze the epidemiology, symptomatology, bacteriology, surgical features, and the longterm outcome of patients under the age of 18 treated at
the department of Neurosurgery, Hacettepe University
Medical School, over a 21-year period, which encompasses periods before and after the availability of CT scanning.

Materials and methods

One hundred and thirty cases of brain abscess in children (aged
under 18 years) treated at our institution between January I, 1970,
and December 31, 1990, have been retrospectively studied. During
this time 80 adult patients with brain abscess appear in our records,
making a total of 210, out of which childhood abscesses constituted
62%. During the same period a total of 3278 patients of all ages
were treated for space-occupying lesions, the abscess cases making
up 6.4% of this number.
The files, X-rays or X-ray reports, treatment charts, operating
notes and laboratory reports were reviewed. CT became available at
our institution at the end of 1975, so the study period was divided
into time periods accordingly.
Inclusion/exclusion criteria were as follows:
1. All patients were admitted to or transferred to and treated in the
neurosurgery department.

101.

2. Patients with subdural empyema with infection extending intracerebrally were excluded.

Correspondence to: I.H. Tekk6k

3. In all patients the diagnosis was reached before death.

412
4. The presenting neurological state was not taken into account and
all patients with "brain abscess" on their operating notes were
included.

Table 1. Main routes of infection (n= 130)

Route

Specific origin

Direct s p r e a d
(n = 50)

Mastoiditis-otitis
Sinusitis-cellulitis
Sinus thrombosis
Meningitis
Penetrating head injuries

28
3
2
6
11

21.5
2.3
1.5
4.6
8.5

Results

Septic e m b o l i
(n = 28)

Congenitalheart disease
Lung (empyema)
Immune deficiency (IgA)

26
1
1

20.0
0.7
0.7

Epidemiology

Undetermined

52

40.0

The number of pediatric abscesses seen per year over the

entire period ranged between 2 and 14 (mean 5 per year),
with 20 cases prior to the advent of CT and 110 after.
The youngest patient was 2 months old. There were
four infants (less than 12 months of age) in the whole
series (3%). Of 130 cases, 70 were male and 60 female.
Forty-five percent overall were aged 3 - 8 years and 30%
were in the 6- to 8-year age group. The incidence of brain
abscess decreased between the ages o f 8 and 18 years.

Table 2. Congenital heart diseases in 26 cases of brain abscess

5. "Operative mortality" was defined as death while the patient was

hospitalized following surgery.
6. For the nonsurgically treated patient(s) the criterion was the CT
scan.

Predisposing factors
The most c o m m o n predisposing factor was adjacent cranial infection (mastoiditis, otitis, sinusitis, cellulitis, and
sinus thrombosis, 33 patients), followed closely by cyanotic congenital heart disease (CCHD; 26 patients) (Table
1). A m o n g the 26 patients with C C H D , tetralogy of
Fallot was the most c o m m o n pathology (Table 2). Other
predisposing factors were penetrating head injury (11 patients), meningitis (6 patients), pulmonary infection
(empyema; 1 patient). Only one patient in this series had
a documented immunodeficiency. N o predisposing factor could be identified in 52 patients.

Presenting symptoms and signs

The most c o m m o n presenting symptom was headache,
occurring in 61 patients. Hyperpyrexia occurred in 39
patients and seizures in 27 patients (Table 3).
Neurological examination was completely normal in
10, while 9 children were comatose on presentation. Papilledema was a finding in 75 children (61%). It occurred
in 55% of patients with a supratentorial and in 76% of
patients with an infratentorial abscess.

Cardiac pathology

Tetralogy of Fallot

16

Ventricular septal defect

Alone
With pulmonary stenosis
With atrial septal defect + transposition of great
arteries + tricuspid atresia
With atrial septal defect + pseudotruncus

2
1
1
1

Double outlet right ventricle

Transposition of great arteries

Alone
With pulmonary stenosis

1
1

Atrial septal defect

With single ventricle
With tricuspid insufficiency + pulmonary stenosis

1
1

Total

26

Table 3. Presenting symptoms (n = 130)

Symptoms

Headache
Nausea-vomitting
Fever
Seizures
Weakness on one side
Mental status change
Speech disturbance
Squint
Facial asymmetry
Unsteadiness

61
47
39
27
25
25
7
5
3
3

46.9
36.1
30.0
20.7
19.2
19,2
5.3
3.8
2.3
2.3

Table 4. Surgical treatment (n = 129)

Location of the abscess

The abscess was supratentorial in 113 cases out of 130.
The frontal and temporal lobes were involved in 55%. Of
28 orogenic abscesses, 13 were located in the supra- and
1 t in the infratentorial compartment, while 4 appeared in
both. In children with C C H D the parietal lobes were
most commonly involved. There was a striking left-sided
predilection (77%) in this subgroup. Seventeen children
harbored multiple abscesses (13%).

1st Operation
as

2nd Operation
as

3rd Operation
as

Aspiration 2
Aspiration 22 "~
Aspiration 71 /~
"~ Excision 3
"~ Excision 13
Excision

Aspiration
58 /~
N Excision

Total
cured by

Aspiration 55

Excision

74

413
Table 5. Cultured microorganisms. Oto., orogenic; CCHD, cyanotic congenital heart disease; Men., meningitis; Head, head injury; Sin.,
sinusitis
Bacteria

Route of infection
Oto.
(n = 28)

Staphylococcus aureus
Proteus mirabilis
Anaerobic Streptococcus
B-hemolytic Streptococcus
A-hemolytic Streptococcus
Streptococcus pneumonia
Klebsiella
Pseudomonas aeruginosa
Enterobaeter
Salmonella

19

5
5
4
1
1
1
1
1
1

5
1

Various coliform bacteria

Bacteroides fragilis

Total

80 -

9
--

"~-.~

Aspiration

//

--o-- Excision

4o

0
1970-1975
F i g . 1. E v o l u t i o n

i
1981-1985

Sin.
(n = 3)

17

60.7

19.2

33.3

36.3

100.0

T a b l e 6. M e d i c a l t r e a t m e n t (n = 1 3 0 )
/

Medication

\\

1976-1980

Head
(n = 11)

1
1

Cultivation rate (%)

,~

Men.
(n = 6)

41

100

CCHD
(n = 26)

1986-1990

Periods
of the surgical technique

Surgery

All patients but one ( n = 129) underwent one or more

surgical intervention(s). The initial surgical procedure
was aspiration in 71 and excision in 58 patients (Table 4).
The size of abscess cavity was monitored by repeated
X-rays taken after injection of a contrast material suspension (Pantopaque) during initial aspiration of the pus. CT
scanning and successive radionuclide studies were mainly
used for this purpose after 1976.
Nearly half (n = 35) of the patients initially treated by
aspiration needed a second operation, whereas only two
patients (3.4%) initially treated by excision needed further surgery. Overall, 74 patients underwent primary
(n = 58) or secondary (n = 16) excision, while in 55, aspiration alone (once or more) was the mode of treatment.
An analysis of surgical preference according to time
periods shows a trend towards aspiration from 10% during the pre-CT era to 90% during the last 5-year period
(Fig. 1).
Two patients with supra- (2/113) and 2 patients with
infratentorial (2/17) abscesses needed CSF diversion,
while mastoidectomy by the ear, nose, and throat sur-

Corticosteroids
Penicillin
Chloramphenicol
Gentamycin
Amikacin
Methicillin
Metronidazole
Sulbactam and
ampicillin
Cephalosporin
Ornidazole

Time periods and % of cases

19701975
(n=20)

19761980
(n=50)

19811985
(n=28)

19861990
(n=32)

30
75
70
40

68
82
85
10

10
-

40
78
74
22
18
-

7
7
-

72
62
53
9
19
3
40
31

6
-

11
-

25
31

geons was performed after abscess surgery in 16 out of 28

patients with mastoiditis and/or otitis.

Bacteriology

Microorganisms were identified in 41 of 76 cultured specimens (54%). In 9 patients the culture revealed growth of
more than one organism. Pus smear was the only identification method in 12. The records revealed no data in 42
patients. The most common organisms were Staphylococcus spp. (19 patients), aerobic and anaerobic Streptococcus spp. (i1 patients), and Proteus mirabilis (5 patients;
Table 5). The culture rate of otogenic pus was markedly
higher than that of C C H D (17/28 vs. 5/26). All Proteus
growing cultures were of those from the otogenic abscesses. Anaerobic streptococci, coliform bacteria, and Bacteroides grew from cardiogenic abscesses.

414
Table 7. Surgical mortality related to treatment (n= 129). Op., Operated; *, not significant (P>0.05) (Fisher's exact
Surgical technique

Before CT
Op.

Aspiration

Dead

After CT
%

Op.

)~2 test)

Overall

Dead

Op.

Dead

53

15.0

55

14.5 *

Excision

18

33.3

56

10.7

74

12

16.2"

Total

20

33.3*

109

14

12.8"

129

20

15.5

Table 8. Surgical mortality in relation to abscess location, systemic

disease, and number of abscesses. Zz test, P > 0.05, not significant
n

Mortality

112
17

17
3

15
18

Cong. heart disease

Rest

26
103

4
16

15.3
15.5

Multiple abscess
Single abscess

16
113

2
18

12.5
15.9

Location
Supratentorial
Infratentorial

Systemic pathology

Antibiotic therapy
Penicillin (97 patients, 75%) and chloramphenicol (92
patients, 71%) were the mainstay of antimicrobial therapy over the 21-year period. Methicillin gained some popularity between the years 1976 and 1980, but lost it again
soon after cephalosporins came into use. Metronidazole
and ornidazole were actively included in the regimens
after 1985. A cefotaxim and sulbactam-ampicillin combination was widely used in recent years (Table 6). Before
1980, penicillin and streptomycin were often instilled into
the abscess cavity.

Overall mortality was 15.5% (20 patients). When the

mortality rates were compared by time period, the rate
had fallen from 30% in the pre-CT era to 6% for the last
5-year period (Fig. 2). The difference between the mortality rates of the pre- and post-CT era was not statistically
significant (Fisher's exact Z2 test), but the numbers for
the pre-CT era are too small for conclusions to be drawn.
There have been no deaths (0%) among 21 patients treated over the last 3 years.
Two of four infants died (50%). Table 8 outlines the
statistical analysis of surgical mortality according to location, presence of systemic disease, and multiplicity of
cavities (all with Z2 test). The location of the abscess
did not make a statistically significant contribution
(P > 0.05) to the mortality rate (Table 8). Similarly, surgical mortality was recalculated for the congenital heart
disease group and such heart disease was not found to be
a significant contributory factor (P > 0.05). The mortality
rate for patients with multiple abscess was again comparable with that of the whole group, without a statistically significant difference (P>0.05).

Length of hospital stay

In the aspiration group the mean hospital stay was 54
days, markedly longer than in the excision group (23
days).

Use of steroids
Follow-up
Corticosteroids were given to 68 patients (52%), mainly
for the control of edema, which was reduced to nil over
5 - 8 days. The use of corticosteroids did vary significantly in the different time periods: while 37% received dexamethasone in first half of our study period (1970-1980),
the number increased to 70% during the second half
(1981-1990; Table 6). Steroids did not contribute negatively to mortality figures; 62 of the 110 survivors (56%)
were given steroids, whereas only 6 of the 20 dead (33%)
received such treatment.

Surgical mortality
Eight of 55 patients who underwent aspiration(s) as the
sole treatment died (Table 7). Two of these presented with
a Glasgow Coma Scale score (GCSS) of 3 and another
two with GCSS of 6-7. Of the remaining, three had
CCHD while another was an infant aged 2 months.

Of the 110 patients discharged, 69 patients (63%) were

available for follow-up during a period ranging between

35
3O
o~" 25
>" 20

10

1970-1975

1976-1980

1981 - 1985

1986-1990

Periods

Fig. 2. Surgical mortality according to 5-year time periods

415
6 months and 16 years. Twenty-one were followed for 3
years or more.
Long-term follow-up was evaluated according to the
sequelae and the surgical treatment received. Patients
available for long-term follow-up and treated by aspiration(s) only (n = 5) were all neurologically normal without clinical epilepsy at a mean follow-up time of 4 years,
while only 50% of the children treated by primary or
secondary excision (n = 16) appeared neurologically normal, with a 31% rate of epilepsy.

Discussion

Brain abscess, in spite of all the advances in diagnostic

procedures, surgical techniques, and antimicrobial therapeutics, is still a life-threatening condition. Considering
their susceptibility to infections and trauma as well as the
natural prevalence of C C H D in children, this age group
deserves a separate evaluation to uncover the specific
conditions of the pathogenesis and outcome.
There was a striking peak of occurrence of a brain
abscess between the ages of 4 and 8 years, and a steeper
peak between 6 and 8 years, consistent with that in the
literature [7, 12]. The mean age for different etiologies,
however, varied in our series, it was 8 for the C C H D
group and l l for children with otogenic abscess.
We, like others [2, 3, 4, 14, 22], found chronic otitis
media leading to mastoiditis to be the most common
predisposing factor (21%). The occurrence of otogenic
abscesses showed a slow but gradual decrease over a 21year period [13, 14].
CCHD as a predisposing factor appeared to occur
only in 4 - 5 % of other series [2, 3, 6, 8, 13], except for two
with 17% [9] and 26% [12], respectively, which accords
with our figure of 20%. However, C C H D seemed to
show an increase as a predisposing factor in the present
series (10% during the first half versus 34.4% during the
second half). Of 26 children with CCHD, 6 had undergone previous cardiovascular surgery but an abscess developed between 2 months and 9 years after the operation. A palliative shunt procedure like the Blalock-Taussig, which increases the life expectancy of patients with
CCHD, does not seem to affect the possibility of development of a brain abscess [7]. The fact that the left common
carotid artery arises directly from the aortic arch may be
held responsible for the left-sided predilection of abscesses in our C C H D group, since the organism from the
cardiopulmonary circulation will enter the cerebral circulation in a more direct way, avoiding a subclavian-common carotid bifurcation as in the right.
Meningitis-ventriculitis appeared as a cause unique
for the pediatric age group and this especially holds true
for three out of four infants in our series. The proportion
of children with no predisposing factor - 40% - may
reflect the child's vulnerability to subclinical infections,
leading to hematogenous dissemination without the factor being realized initially.
Headache was the major presenting symptom in approximately half of the patients, consistent with literature
data for all ages. What is striking was the fact that hyper-

pyrexia was the presenting symptom in only 30% of the

children. This may suggest a rather slow or inactive active
host reaction of the children to the infection. The occurrence of seizures in our series (21%) was in accordance
with that of the literature [14].
Relatively few children were admitted and treated in
the pre-CT era, but these were included for comparison.
There is no doubt that CT has revolutionized neurosurgical practice for brain abscesses. CT allows early diagnosis
(even the stage of the infective process), more accurate
localization than angiography or isotope scans, and it can
show multiple lesions. The detection of more cases with
multiple abscesses was only made possible by CT [9]. CT
also offers us immediate follow-up.
CT not only emerged as a diagnostic tool but also
served us as a guide for treatment. With the availability
of CT scans the role of aspiration has increased, as Kagawa et al. [7] once predicted. Certainly there are risks
involved with aspiration techniques. Rupture of the abscess into the ventricle or leakage into the subarachnoid
space should be considered [11]. A less likely risk is an
intracerebral hematoma. The advantages of excision over
aspiration are the immediate eradication of the intracranial sepsis and shortened postoperative medical treatment and length of hospital stay [11].
Though there was no statistical difference in the overall mortality associated with the two methods in our series or in others [10, 13, 22], it is necessary to mention that
the zero mortality over the last 3 years (n = 2~) is related
only to treatment by aspiration, and that long-term sequelae are significantly lower in the aspiration group.
The condition of the patient on admission was one
major factor determining the outcome: a view shared by
many [13, 14]. Five of nine children who presented in a
comatose state died, while only one of ten alert children
could not be saved. Factors like use of steroids, location,
or multiplicity of the abscess or associated CCHD that
may have contributed to mortality were investigated, but
no such contribution could be deduced. Mampalam and
Rosenblum [10] attributed four of their eight deaths to
CCHD, stating that these patients have marked and
chronic hypoxemia and are vulnerable to further alterations in oxygenation or in fluid balance. Raimondi et al.
[16] shared the same view with a mortality rate of 47.4%.
This fact partially holds true for our three patients with
CCHD, who were treated by aspiration to minimize the
general risk. This means that it is not that the aspiration
caused their death, but that their poor state allowed only
treatment by aspiration [17]. We still believe that, even in
patients with CCHD, a surgical specimen should be
sought. Another point, as suggested by Beller et al. [2]
and later by Mampalam and Rosenbhim [10], is the theoretical contribution of steroids to a higher mortality; in
actual fact its effect appeared to be the reverse of this, and
dexamethasone seemed to save more lives in our series

[15].
The only patient in this series who was treated nonsurgically was a female who had thalamic and periventricular multiple abscesses and had a favorable outcome after
12 weeks of medical treatment. Nonsurgical therapy may
be initiated in patients with a stable neurological state

416

who harbor deeply seated, multiple abscesses, especially

if the clinician has easy access to a CT scanner [9]. The
medical approach should not subrogate the role of neurosurgical management [18].
Microorganisms were identified in just over half of the
cultured specimens, which is a quite low rate for a reference centre like ours, but considering the fact that 20 out
of 35 patients with no growth received preoperative antibiotics during their initial stay in pediatric wards, a
sterile culture rate of 46% seems justifiable. With newer
microbiological techniques like selective cultivation and
prolonged anaerobic incubation, a 90% positive culture
rate can be achieved [3, 6]. Szuwart and Bennefeld concluded that the occurrence of anaerobic bacteria is
matched by a decreased occurrence of sterile suppuration
[20].
The bacteriological spectrum of this series was not
different from many of the reviews in the literature [2, 4,
6, 10, 14, 19]. Staphylococci (46%), streptococci (15%),
and Proteus (12%) were the predominant aerobic bacteria. Anaerobic organisms were usually anaerobic streptococci and rarely Bacteroides. Investigating by time period, Staphylococcus abscesses appeared to decrease, while
streptococci, especially the anaerobic subtype, have
emerged as agents over the last 5 years, a view previously
expressed by Nielsen et al. [14]. Anaerobic streptococci
were the most common agents in cardiogenic abscess in
the present series, as in the experience of Raimondi et al.
[16]. It is interesting to note that there was only one
patient identified to have a Bacteroides abscess in this
series, in spite of an increasing incidence of this species as
reported in recent reviews [3, 22]. Proteus grew solely in
specimens from otogenic abscesses, as reported earlier
[22].
The selection of antibiotics before 1980 largely depended on what was available and so penicillin
+ chloramphenicol was employed in most of the cases.
Metronidazole received popularity after 1980 and became a standard with its excellent bactericidal effect to
virtually all anaerobes [6, 8]. In recent years, new and
promising protocols are being created here at Hacettepe
and used efficiently. Cefotaxim combined with sulbactam-ampicillin (SAM) and metronidazole or ornidazole
as the standard is one such regimen that proved highly
successful in the last eight patients treated by aspiration
alone with no mortality (unpublished data). An open
prospective study at our institution was also recently carried out to evaluate the efficacy of SAM in the treatment
of brain abscess in patients of all ages (n = 19), and SAM
was found to be highly effective as a single agent for
treating brain abscesses with (n = 15) or without (n = 4)
intervention [1].

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