Outcome of Therapies for Brain Abscesses in Children

  • Multiple factors affect outcome in children: Although major advances have been made in the diagnosis and treatment of brain abscesses, the associated rates of mortality and morbidity continue to be significant. The overall outcome in children with brain abscesses is determined by a myriad of factors, such as the virulence of the pathogen, the location and number of the abscesses, the underlying source of infection, and the clinical status of the patient at the time of presentation.
  • Sequelae are function of what the abscess and associated vasculitis affect: A cerebral abscess is a destructive lesion, and therefore it is not surprising that many of the children affected will have neurological sequelae that include epilepsy, new motor deficits, persistent visual field cuts, learning disorders, and hydrocephalus requiring the placement of a ventriculoperitoneal shunt (31).
  • 0–33% mortality rate with rate increasing as LOC deteriorates: Recent studies suggest a mortality rate of 0–33% (55). The patient’s neurological status at presentation is a significant predictor of outcome with an increased mortality rate in those who present with altered mental status and rapid neurological deterioration (4, 8798). It has been reported that the single most important factor affecting outcome is the preoperative neurological examination. The mortality rate ranges from 0–21% in alert patients to 60% in patients with signs of herniation and up to 89% for those in coma (30, 98, 117).
  • Multiple abscesses and hematogenous source associated with bad outcome: Abscesses of sinusitic and otogenic origins tend to have a better prognosis than do metastatic abscesses, which are more frequently deep-seated and multiple (118). The large number of complications and deaths in children with brain abscesses may be attributable to multiple abscesses, the presence of low Glascow Coma Scale scores, and/or meningitis (30).
  • Rupture into ventricles worsens outcome – 80%+ mortality: A periventricular location carries the risk of intraventricular rupture and ventriculitis due to the relatively poorer vascularization and capsule development from the ependymal side. This event can precipitate abrupt neurological deterioration and carry a very poor prognosis, with a mortality rate reaching 80% (69, 92).
  • Organisms causing abscesses in children associated with worst outcome: Morbidity risk is higher in children, owing to the high incidence of abscesses caused by Proteus and Citrobacter, which are notorious for inducing a fulminant necrotizing reaction, with destruction of large amounts of brain parenchyma. Consequently, early aspiration is especially important in neonates and young children (118).
  • Immunocompromised patients experience larger zones of destruction: The encapsulation process is impaired in immunocompromised patients, thus delaying capsule formation and giving rise to a larger necrotic lesion with more brain damage (42).
  • Younger children have greater cognitive impairment: Many authors have reported that brain abscesses in children cause cognitive deficits. A poorer prognosis in terms of normal intellectual development is expected in younger children with brain abscesses (20, 24, 30).