|
 
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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 9
| Issue : 1 | Page : 7-11 |
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Brain abscesses in children with cyanotic congenital heart disease
Ke Liu, Ming Zhu, Suzhen Dong
Department of Radiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| Date of Submission | 05-Jan-2022 |
| Date of Decision | 05-Mar-2022 |
| Date of Acceptance | 13-Mar-2022 |
| Date of Web Publication | 13-Oct-2022 |
Correspondence Address:
Suzhen Dong
Department of Radiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai
China
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/RID.RID_2_22
Brain abscess is a serious infection of the brain parenchyma that can occur in children with cyanotic congenital heart disease (CCHD). In children with CCHD, brain abscesses are often caused by the direct extension of an adjacent infection, or by distant hematogenous dissemination. In the present review, we discuss the epidemiology, etiology, clinical features, radiologic features, current treatments, and outcomes of brain abscesses associated with CCHD in children. Common clinical presentations of brain abscesses with CCHD include a fever, vomiting, headache, hemiparesis, and focal seizures. The most common causative microorganisms of brain abscesses are Streptococcus and Staphylococcus species. The radiologic features of brain abscesses in children with CCHD are a ring enhancing, well-defined lesion with a hypodense center; this is usually accompanied by surrounding cerebral edema. Appropriate surgery and antibiotic treatment are the gold standard for treating brain abscesses in children with CCHD. In addition, the early recognition of such brain abscesses is very important for their timely clinical treatment. Brain imaging techniques, including magnetic resonance imaging and computed tomography, are crucial for the early recognition of brain abscesses in CCHD.
Keywords: Brain abscesses, computed tomography, cyanotic congenital heart disease, magnetic resonance imaging, pediatric
How to cite this article:
Liu K, Zhu M, Dong S. Brain abscesses in children with cyanotic congenital heart disease. Radiol Infect Dis 2022;9:7-11 |
| Introduction | |  |
Brain abscess is a focal brain infection that begins as a local area of brain infection and then turns into a collection of pus surrounded by a well-vascularized capsule.[1] Children with cyanotic congenital heart disease (CCHD) are at risk of developing brain abscesses.[2] In the setting of abnormal cardiovascular circulation, children with serious congenital heart disease (CHD) present with cyanosis and decreased mobility, which can then lead to death because the abscesses cause abnormal brain function.[3] Brain abscesses can be caused by bacteria, mycobacteria, fungi, or parasites, and have a high morbidity.[4] The treatment of brain abscesses includes antibiotics alone or combined with surgical interventions, such as aspiration of the abscesses and/or abscesses excision.[5] Despite the reduced mortality of brain abscess,[6] It remain a challenging clinical problem with severe sequelae.[7] In the present review, we will summarize the epidemiology, etiology, clinical features, radiologic features, current treatments, and outcomes of brain abscesses in children with CCHD; this information can be used to guide clinical diagnosis and treatment.
| Epidemiology | | |
Brain abscesses are serious infections in the parenchyma of the brain. It has been reported that 42% of brain abscesses occur in the pediatric population.[8] The average age of onset of brain abscesses ranges from 4 to 7 years.[9] The incidence of CHD is approximately 5–8/1000 live births,[10] and CCHD represents around 25% of all CHD cases. Surgical intervention has been reported to improve the outcomes of patients with CCHD.[11] However, children with CCHD are at risk of developing brain abscesses. The total incidence of brain abscesses in patients with CHD is 30%.[12]
| Etiology | | |
Brain abscess is a focal, intracerebral infection that occurs as a collection of pus surrounded by a well-vascularized capsule. It is the result of the infectious biological invasion of the brain parenchyma, which can be caused by the spread of a continuous infection of otogenic, nasal, hematogenous, traumatic, or cryptogenic origin.[13],[14] CCHD-related brain abscesses are most commonly hematogenous brain abscesses, which may indicate possible pathological mechanisms associated with CCHD-related brain abscesses.[15],[16] CCHD is a congenital heart defect that leads to hemodynamic abnormality and includes conditions, such as Tetralogy of Fallot (the most common condition), pulmonary atresia, double-outlet right ventricle, transposition of great arteries, and total anomalous pulmonary venous drainage.[11] In CCHD, a right-to-left shunt allows blood to circulate in the arterial system without passing through the lungs, which results in persistent arterial desaturation and cyanosis.[17] In the setting of abnormal cardiovascular circulation, shunted blood containing microorganisms may be seeded in such lesions, thus forming cerebral abscesses.[15] Other authors have noted that low mean arterial oxygen saturation in the ascending aorta is significantly associated with the incidence of brain abscesses.[18]
| Clinical Features | | |
Brain abscess are a serious disease, with high mortality in children; children with brain abscesses associated with CCHD often have a fever, vomiting, headache, hemiparesis, and focal seizures.[19],[20] Predisposing conditions consist of contiguous or metastatic foci of infection. In brain abscesses associated with CCHD, the most commonly isolated organisms are Streptococcus and Staphylococcus species.[21] Since the intraventricular rupture of brain abscesses results in an increased mass effect, altered sensorium with nuchal rigidity may occur.[22]
Children with CCHD have a high risk of embolic stroke or brain abscesses, probably because systemic venous blood has direct access to the aorta without being filtered by the lungs.[23] Accordingly, CCHD accounts for a large proportion of all cases of brain abscesses in children with chronic adjacent infections originating from the ear or sinuses, and the incidence rate in children is the highest.[22] The recent improvements in prognosis have been attributed to the advent of computed tomography (CT) and magnetic resonance imaging (MRI), as well as to improved medical and surgical therapies.[24]
| Radiologic Characteristics | | |
The application of CT and MRI has vastly improved the accuracy and sensitivity of diagnosing brain abscesses. In particular, the sensitivity of MRI, especially proton MR spectroscopy (MRS)[25] and diffusion tensor imaging,[26] in detecting brain abscesses has greatly improved. CCHD-related hematogenous brain abscesses are often distributed in the supply areas of the middle cerebral artery, frontal lobe, and parietal lobe, and multiple small abscesses can be observed [Figure 1], [Figure 2], [Figure 3].[2],[12],[27] Frontal and parietal abscesses tend to be asymptomatic for a relatively long time until the lump effect is achieved. In addition, the pathophysiology of septic microembolism due to cardiac right-left-shunt in brain abscess complicating CCHD is gender-independent.[16],[17],[28] The corresponding pathological mechanism may thus be a result of hypoxic attacks or emboli associated with CCHD, which leads to a reduction in brain capillary blood flow and subsequent microinfarction.[29] Fischbein et al.[30] reported that children with low oxygen saturation are more likely to develop brain abscesses than children with high oxygen saturation. | Figure 1: Transverse images of the brain of an 11-year-old boy with cyanotic congenital heart disease. The images reveal a space-occupying lesion with well-defined margins in the left parietal lobe, with an irregular hypodensity shadow on computed tomography (a), a hypointense mass with a hyperintense thick ring-like wall and marked ring enhancement on contrast-enhanced T1-weighted imaging (b), an isointense or hyperintense signal on diffusion-weighted imaging (c), and a high or mixed-signal on T2-weighted imaging (d). The size of the abscesses was 28.8 mm × 22.8 mm × 35 mm
Click here to view |
 | Figure 2: Transverse images of the brain of a 2-year-old boy with cyanotic congenital heart disease. The images reveal a space-occupying lesion with well-defined margins in the left parietal lobe, with marked ring enhancement on contrast-enhanced computed tomography (a), a hypointense mass with a hyperintense thick ring-like wall and marked ring enhancement on contrast-enhanced T1-weighted imaging (b), an isointense or hyperintense signal on diffusion-weighted imaging (c), and high or mixed-signal on T2-weighted imaging (d). The size of the abscesses was 44 mm × 39.7 mm × 31 mm
Click here to view |
 | Figure 3: Transverse images of the brain of a 5-year-old boy with cyanotic congenital heart disease. The images reveal multiple space-occupying lesions with well-defined margins in the right frontotemporal parietal lobe, with rim enhancement on contrast-enhanced computed tomography (a), a hypointense mass with a hyperintense thick ring-like wall and marked ring enhancement on contrast-enhanced T1-weighted imaging (b), an isointense or hyperintense signal on diffusion-weighted imaging (c), and high or mixed-signal on T2-weighted imaging (d). The size of the biggest abscesses was 37.8 mm × 25.5 mm × 29.1 mm
Click here to view |
CT can be used to locate and identify a large number of abscesses and evaluate encephalitis areas and mass effects.[31] Typically, brain abscesses appear hypointense on CT. In the early stages, brain abscesses appear as a focal area of edema (a hypodensity). With the subsequent injection of intravenous contrast medium, brain abscesses gradually develop as a ring-enhancing, well-defined lesion with a hypodense center, which is usually accompanied by surrounding cerebral edema [Figure 2]a and [Figure 3]a.[32] This alteration in brain density may be caused by an increase in blood vessels and changes in the blood–brain barrier. In addition, the rims of brain abscesses are usually thinner than those of neoplastic lesions.[22] Contrast-enhanced CT is helpful for the early detection and accurate localization, characterization, sizing, and staging of brain abscesses. It can also be used to detect hydrocephalus, elevated intracranial pressure, edema, and related infections, such as subdural empyema and ventriculitis, to help with treatment planning. Furthermore, it is valuable in evaluating the adequacy of treatments and follow-up.[20] However, in CT, it is often difficult to distinguish between abscesses and tumors.
MRI has higher tissue contrast than CT in the brain.[31],[33] Typically, brain abscesses appear hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging [Figure 2]b, [Figure 2]d and [Figure 3]b, [Figure 3]d. Diffusion-weighted imaging (DWI) [Figure 2]c and [Figure 3]c can also be used to diagnose brain abscesses in some circumstances.[24] For example, DWI can differentiate abscesses from cystic or necrotic lesions; both the sensitivity and specificity of DWI in differentiating brain abscesses from other cystic lesions are estimated to be 96%. Brain abscesses are observed using DWI as masses with high-signal intensity because of water restriction in the central necrotic area (containing proteins and bacterial and cellular debris) and are hypointense using apparent diffusion coefficient (ADC) because of restricted diffusion through the abscesses capsule. During the treatment of brain abscesses, a progressive increase in ADC values may be an earlier indicator of drug response than the narrowing of lesions and/or the appearance of peripheral enhanced space, which is a late sign of drug response. In contrast, constant low-ADC values over time indicate an ineffective therapy, and the recurrence of low-ADC values indicates the recurrence of active disease.[34] Moreover, it is likely that the differential diagnosis of brain abscesses from other brain lesions, such as nonpyogenic or necrotic tumors, can only be achieved using functional sequences of MRI technology.[34]
MRS can give information about the metabolic characteristics of lesions and appear to be a very promising sequence in the diagnosis of brain abscesses. The use of MRS is helpful to distinguish between the different bacteria that cause abscesses. After drug treatment, abscesses can show nonspecific lipid and lactate peaks that are also present in cystic tumors.[34] A combination of DWI and MRS can achieve 100% specificity and sensitivity for the diagnosis of abscesses.[35] In addition, diffusion tensor imaging can be used to quantitatively evaluate brain abscesses and further distinguish them from glioblastoma or metastases.[36] These imaging methods are especially helpful for the diagnosis of brain abscesses when clinical manifestations do not clearly indicate abscesses.
| Current Treatments | | |
Treatments include antibiotics either alone or combined with surgical interventions such as aspiration of the abscesses and/or abscesses excision. The gold standard treatment of brain abscesses in children is to completely remove the pus and excise the abscesses wall after craniotomy, together with appropriate antibiotic treatment.[37] As reported by Takeshita,[18] for children with CCHD, the intraventricular rupture of brain abscesses should be actively treated by aspiration of the abscesses coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology. In general, antibiotics are essential in the treatment of brain abscesses. Furthermore, selected infections can be treated without surgical intervention but with long courses of antibiotics.[38] However, there is no evidence from randomized controlled trials to indicate the best antibiotic regimen for treating brain abscesses with CCHD.[15]
| Outcomes | | |
With more effective treatments and more timely radiological examinations, the prognosis of children with brain abscesses has gradually improved.[7] In a study by Udayakumaran et al.,[24] no children with brain abscesses associated with CHD required long-term anticonvulsant therapy, and no neurologic deficits were noted during the follow-up period. However, brain abscesses in children with CCHD continue to be associated with high rates of neurologic impairment and death because of the inherent cardiopulmonary pathology and a wide variety of coagulation defects.[24] Children with multiple abscesses and intraventricular rupture of brain abscesses/hydrocephalus still have a relatively high risk of unfavorable outcomes. With regard to multiple brain abscesses, consideration should be given to the intraventricular rupture of brain abscesses, which is associated with poor outcomes in children with CCHD.[18] Fortunately, most children with brain abscesses who receive appropriate treatments have a good outcome; accordingly, the incidence of neurological sequelae is now lower than in the previous years.
| Conclusions | | |
A brain abscess in children with CCHD is a serious condition that requires aggressive treatment. Prognosis has improved over time thanks to advancements in surgical techniques, diagnostic imaging, and new antibiotics. However, we need to continue to decrease mortality and improve the outcomes of brain abscesses in CCHD. The early recognition of complicated brain abscesses in children with CCHD is very important for their timely clinical treatment. Brain imaging techniques, such as MRI and CT, are crucial for the early recognition of brain abscesses in CCHD.
Ethic statement
The manuscript was approved by the Ethics Committee of Shanghai Children's Medical Center (SCMCIRB-K2016001).
Acknowledgments
We would like to thank Bronwen Gardner, PhD, from Liwen Bianji (Edanz) (www.liwenbianji.cn), for editing the English text of a draft of this manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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