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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 9
| Issue : 2 | Page : 52-57 |
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Imaging characteristics of brain abscess in children with congenital heart disease
Ke Liu, Ming Zhu, Sudan Dong
Department of Radiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| Date of Submission | 23-Feb-2022 |
| Date of Acceptance | 18-Jun-2022 |
| Date of Web Publication | 8-Nov-2022 |
Correspondence Address:
Sudan 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_14_22
BACKGROUND: Brain abscess is a rare disease in childhood requiring prompt medical and/or surgical treatment. The objective was to discuss the head computed tomography and magnetic resonance imaging characteristics of children with brain abscess in congenital heart disease (CHD) group compared with the group without CHD, further comprehend the imaging findings, and assess the severity of brain abscess in children with CHD.
MATERIALS AND METHODS: The radiological features of brain abscess in children hospitalized in Shanghai Children's Medical Center between September 2014 and September 2021 were retrospectively reviewed.
RESULTS: Forty-four children (14 females, 30 males), with a median age of 8.6 years (range 2–15 years), were enrolled in this study. CHD was found in 22 cases. Twenty-one of these 22 patients were with cyanotic CHD. The remaining 22 cases were without CHD. Among the 22 patients with CHD, superficial abscesses of 2–5 cm in diameter are the main imaging findings, which was the same as in children without CHD. In our study, brain abscesses of CHD are usually single, while other brain abscesses are usually multiple in children without CHD. There was statistically significant difference in the number of abscesses between the group with CHD and the group without CHD (χ2 = 6.3, P = 0.04). Compared with no CHD children, the nearest distance from the ventricular wall to the margin of brain abscess in children with CHD is often <7 mm.
CONCLUSIONS: Brain abscesses in children with CHD have some special imaging characteristics. Superficial abscesses of 2–5 cm in diameter are the main imaging findings. Brain abscesses of CHD are usually single, while other brain abscesses are usually multiple in children without CHD. Compared with no CHD children, the nearest distance from the ventricular wall to the margin of brain abscess in children with CHD is shorter.
Keywords: Brain abscess, children, cyanotic congenital heart disease, magnetic resonance imaging
How to cite this article:
Liu K, Zhu M, Dong S. Imaging characteristics of brain abscess in children with congenital heart disease. Radiol Infect Dis 2022;9:52-7 |
| Introduction | |  |
Brain abscess is a rare disease in childhood requiring prompt medical and/or surgical treatment. The lesions of the central nervous system frequently occur in association with congenital malformations of the heart, including brain abscesses.[1] Congenital heart disease (CHD) is the most common congenital disorder in newborns.[2],[3],[4] The brain abscess is one of the most serious complications of the central nervous system resulting from unoperated CHD.[3],[4] Brain abscess in case of CHD occurs most frequently in patients suffering from cyanotic CHD.[5],[7],[8] The most organism of brain abscess formation in CHD is a right-to-left shunt, which allows the blood to flow in the arterial system, without passing through the lungs, resulting in persistent arterial desaturation and cyanosis.[1],[6],[9] The aim of our study was to discuss the head computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of children with brain abscess in CHD group compared with the group without CHD, further comprehend the imaging findings, and assess the severity of brain abscess in children with CHD.
| Materials and Methods | | |
The ethics commission of our organization authorized the study. All subjects gave written informed consent. All methods of the study were performed in accordance with the relevant guidelines and regulations. The medical records of all children (2–15 years old) with a diagnosis of “brain abscess” were analyzed with regard to the demographics, underlying diseases, and imaging. The World Health Organization International Classification of Diseases code G06.0 (intracranial abscess and granuloma) was used as a diagnosis.
All MRI examinations were performed in our hospital with a 3.0T MR Scanner. High-quality MR images were obtained under the following configurations: an axial T1-weighted images (T1WI) (slice thickness, 5 mm; spacing, 1.5 mm; matrix, 512 × 416; field of view, 24 cm × 24 cm) and an axial T2WI (slice thickness, 5 mm; spacing, 1.5 mm; matrix, 416 × 512; field of view, 24 cm × 24 cm). All MR images were retrieved from the Picture Archiving and Communication System for further image feature extraction. All CT examinations were performed in our hospital. High-quality CT images were obtained under the following configurations including spiral scan and 3D reconstruction; scanning parameters: slice thickness, 1.25 mm and interval, 0 mm. All CT images were also retrieved from the Picture Archiving and Communication System for further image feature extraction.
The diagnosis of a brain abscess was made when CT and/or MRI showed a localized parenchymal lesion with perilesional brain edema and postcontrast ring enhancement combined with clinical history and laboratory test results.
According to the diagnosis criterion, 44 children aged 2–15 years were included from September 2014 to September 2021 with a diagnosis of brain abscess with a complete capsule. Patients with subdural and epidural empyema or fungal, parasitic, protozoa, or tubercular abscesses were excluded.
Localization was classified as superficial when the lesion was located in the cerebral and cerebellar hemispheres; deep when it was in the basal ganglia, thalamus, corpus callosum, brain stem, vermis, or within the ventricle; and combined when the abscess involved both superficial and deep structures.[7] The diameter of the abscess was defined as the largest long diameter in the transverse plane on CT images and MR images. The largest diameter of the multiple abscesses was measured by taking the largest long diameter of the largest lesion.[7]
SPSS 26.0 software (IBM SPSS software) was used for data analysis. According to the data distribution, continuous variables were expressed as averages, standard deviations, or medians (ranges), while categorical data are expressed as frequencies and percentages. Wilcoxon rank-sum test was used to compare the demographic characteristics. The comparison between groups was done by rank-sum test and count data by Chi-square test. P < 0.05 was considered statistical difference.
| Results | | |
A total of 44 cases were diagnosed with one or multiple brain abscesses. Thirty cases were male and other 14 cases were female (ratio 2.1:1). The median age was 8.6 years (range, 2–15 years). The abscesses were found in 22 cases with CHD and 22 cases without CHD. 21 of these 22 CHD cases were with cyanotic CHD [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Clinical characteristics of 44 cases are listed in [Table 1]. | Figure 1: MRI transverse images of the brain from a 17-year-old boy with CCHD. The images show a space-occupying lesion with well-defined margins in the left frontotemporal parietal lobe, with hypointense on T1WI (a), with a slightly hyperintense margin, hyperintense on T2WI (b), with a slightly hypointense margin, hyperintense on DWI (c), and marked ring enhancement on contrast-enhanced T1WI (d). The size of the abscess is 55 mm × 53 mm × 59 mm. MRI = Magnetic resonance imaging, CCHD = Cyanotic congenital heart disease, T1WI = T1-weighted images, DWI = Diffusion-weighted imaging
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 | Figure 2: MRI transverse images of the brain from a 2-year-old boy with CCHD. The images reveal a space-occupying lesion with well-defined margins in the right basal ganglia region, hypointense on T1WI (a), with an isointense thick ring-like wall, high or mixed signal on T2WI (b), with an isointense or hypointense thick ring-like wall, hyperintense on DWI (c), and marked ring enhancement on contrast-enhanced T1WI (d). The size of the combined abscess is 20 mm × 26 mm × 25 mm. CCHD = Cyanotic congenital heart disease, T1WI = T1-weighted images, DWI = Diffusion-weighted imaging
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 | Figure 3: MRI transverse images of the brain from a 10-year-old boy with CCHD. The images reveal a space-occupying lesion with well-defined margins in the right frontal lobe, hypointense on T1WI (a), with a hyperintense thick ring-like wall, high or mixed signal on T2WI (b), an isointense or hyperintense on DWI (c), and marked ring enhancement on contrast-enhanced T1WI (d). The meninges are abnormally enhanced on contrast-enhanced T1WI (d). The size of the abscess is 57 mm × 27 mm × 30 mm. MRI = Magnetic resonance imaging, CCHD = Cyanotic congenital heart disease, T1WI = T1-weighted images, DWI = Diffusion-weighted imaging
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 | Figure 4: MRI transverse images of the brain from a 3-year-old boy with CCHD. The images reveal a space-occupying lesion with well-defined margins in the right temporoparietal lobe, hypointense on T1WI (a), with an isointense ring, high or mixed signal on T2WI (b), with a hyperintense ring, hyperintense on DWI (c), and with marked ring enhancement on contrast-enhanced T1WI (d). The meninges are abnormally enhanced on contrast-enhanced T1WI (d). The size of the abscess is 39 mm × 46 mm × 36 mm. MRI = Magnetic resonance imaging, CCHD = Cyanotic congenital heart disease, T1WI = T1-weighted images, DWI = Diffusion-weighted imaging
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Five of 22 brain abscesses with CHD were only examined by CT, and the remaining 17 cases with CHD were examined by CT and MRI; while 3 of other 22 brain abscesses without CHD were only examined by CT, 1 of other 22 brain abscesses without CHD was only examined by MRI, the 18 remaining cases without CHD were examined by both CT and MRI.
According to the size of brain abscesses, there were five cases with a diameter of <2 cm in both groups, respectively. There were 12 cases with a diameter of 2–5 cm (between ≥2 cm and ≤5 cm) in the CHD group and 11 cases in the group without CHD, while there were five cases with a diameter of >5 cm in the CHD group and 6 cases in the group without CHD. There was no statistically significant difference of diameter of abscesses between the two groups (χ2 = 0.13, P = 0.94) [Table 2]. | Table 2: Comparison of the diameters (cm) of brain abscess in children with and without congenital heart disease
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In the CHD group, 13 cases had one abscess, 3 cases had two abscesses, and the remaining cases had more than 3 abscesses. In the group without CHD, 9 cases had one abscess, while the remaining cases had more than 3 abscesses. There was statistically significant difference in the number of abscesses between the group with CHD and the group without CHD (χ2 = 6.3, P = 0.04) [Table 3]. | Table 3: Comparison of the number of brain abscesses in children with and without congenital heart disease
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In the CHD group, the brain abscesses were found in the superficial location in 20 cases and the combined location in 2 cases. In the no CHD group, the brain abscesses were found in the superficial location in 19 cases, the deep location in 1 case, and the combined location in 2 cases [Table 4]. | Table 4: Comparison of brain abscess location in children with and without congenital heart disease
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In these two groups, the nearest distance between the ventricular wall and the margin of brain abscess is <7 mm in 10 cases with CHD whereas 5 mm in no CHD group [Table 5]. There was no significant difference in the number of abscesses between the group with CHD and the group without CHD (P = 0.20). | Table 5: Comparison of the shortest distance between the ventricular wall and the margin of the brain abscess in children with and without congenital heart disease
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Of 22 brain abscesses with CHD, 17 cases of brain abscesses with CHD were performed by MRI, all images showed a space-occupying lesion with margins in the lobes, hypointense on T1WI, marked ring enhancement on contrast-enhanced T1WI and abnormal signal on T2WI or diffusion-weighted imaging. All 17 brain abscesses were significantly strengthened. 22 cases of brain abscesses with CHDs performed by CT appear hypointense on CT. Contrast-enhanced CT shows ring enhancement of the cyst wall.
| Discussion | | |
In our study, CHD-associated abscesses were often solitary and superficial, which is consistent with previous studies.[8],[9] The formation of the abscess begins in the subcortical area because the mode of spread is hematogenous. Sometimes, it may be seated deep near the ventricular system and multiple as well.[8] Children with CHD usually have low-perfusion areas in the brain due to chronic severe hypoxemia and metabolic acidosis along with the increased viscosity of blood caused by secondary polycythemia. These low-perfusion areas, located at the junction of gray and white matter of the brain, are invaded by microorganisms present in the bloodstream.[10] Therefore, the hematogenous abscesses caused by CHD usually occur at the gray matter junction, which is characterized by poor capsule formation.[8] In addition, after perivascular inflammation in the first stage of brain abscess, a capsule is formed which evolves into a well-vascularized wall surrounding the necrosis over approximately 2 weeks.[11] These above factors may lead to a single and superficial brain abscess associated with CHD.
In our study, the nearest distance between the ventricular wall and the margin of brain abscess is < 7 mm in 10 cases with CHD whereas 5 mm in no CHD group. The risk factors for intraventricular rupture of brain abscess include multilocular morphology and short distance between ventricle and abscess. In addition, a reduction of 1 mm in the distance between the abscess and the ventricle increased the rupture rate by 10%.[11] Tunthanathip et al. suggested that the distance between abscess and ventricle is the only significant factor in increasing intraventricular rupture of brain abscess risk and suggested surgical intervention for abscesses within 7 mm of the ventricular wall.[12] This may suggest that CHD-related brain abscesses have a higher risk of intraventricular rupture of brain abscesses and are associated with a poor prognosis.[13]
Brain abscess is defined as focal suppurative process within the brain parenchyma that begins as a localized area of cerebritis and changes into a collection of pus surrounded by a well vascularized.[14],[18] It can originate from the contiguous structure infection contiguous structure, including otitis media, dental infection, and mastoiditis, as the result of hematogenous spread from a remote site (particularly in people with cyanotic CHD), after skull trauma or surgery.[15],[16],[19],[20] Cyanotic CHD is a congenital defect of the heart that leads to hemodynamic abnormality.[17] Systemic venous return to the right side of the heart is shunted across the defect into the systemic circulation, resulting in persistent arterial desaturation and cyanosis.[6],[18],[19],[24] People with cyanotic CHD are at risk of developing brain abscess.[3] Intracardiac right-to-left shunt bypass, by which the blood is not filtered through pulmonary circulation where bacteria are intercepted by phagocytosis, may allow direct entry to cerebral circulation. In addition, decreased arterial oxygenation can result in compensatory polycythemia.[8],[19] Increased blood viscosity can cause a focal area of ischemia that serves as a nidus for infection. Shunted blood containing microorganisms may be seeded in such lesions, forming a cerebral abscess, and in this case cerebral abscess often clinically manifested by polycythemia, persistent cyanosis, some clubbing of the digits, squatting, and poor exercise tolerance.[13],[14]
Brain abscess is not common and is a rare complication of cyanotic CHD. Other authors have also reported the incidence and clinical characteristics of the brain abscess in their studies. For example, Dou et al.[20] have suggested that children with multiple abscesses and intraventricular rupture of brain abscess/hydrocephalus had higher risk of unfavorable outcomes. As suggested by Takeshita et al.[21] there is need for a well consideration of multiple abscesses and the possible location of brain abscesses in children with CHD in our study. Lee et al.[22] showed that the majority of patients had underlying illnesses, and CHD was the most common cause. This finding is in concordance with the findings in our study. As shown in a study performed by Takeshita et al,[21] they agreed that the growth of the cyanotic brain abscesses may cause a rupture into the ventricles accompanied by mass effect, and intraventricular rupture of brain abscess will lead to a high mortality rate. The incidence of brain abscess in children can be decreased with the treatment of its underlying diseases, such as sinusitis and CHD. The complete evacuation of pus and excision of abscess wall after performing craniotomy along with appropriate antibiotics is the gold standard management of brain abscess in children.[14],[18] However, despite surgical drainage and directed antibiotic therapy, 25% of patients with brain abscesses still require reoperation.[23] Moreover, no evidence of randomized control trials showed the best antibiotic solution for treating the brain abscess with cyanotic CHD.[19],[24] There is a long way to go for the management and therapy of brain abscesses associated with CHD.
Limitations
There are several limitations to this study that should be mentioned. This was a retrospective study, subject to limitations associated with its study design. In addition, due to the small sample size, it is difficult to draw precise conclusions about frequency, location, and margin of brain abscess. However, in the future, we will try our best to increase the number of samples to explore the imaging characteristics of CHD-associated brain abscess, including frequency, location, margin signal, and abscess morphology, and to explain the possible mechanisms under the statistically significant imaging characteristics of CHD-associated brain abscess.
| Conclusions | | |
The diagnosis of brain abscesses in children with head CT or MRI can provide clinicians with more clinical information and guide the treatment. This study shows that superficial abscesses of 2–5 cm in diameter are the main imaging findings in children with CHD. Compared with the group without CHD, brain abscesses of CHD are usually single and the nearest distance from the ventricular wall to the margin of brain abscess in children with CHD is shorter.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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