Paeds · infectious-diseases
Brain abscess and intracranial suppuration
Also known as Cerebral abscess · Intracranial abscess · Subdural empyema · Epidural empyema · Intracranial suppuration
Fellowship guide to brain abscess and intracranial suppuration in children: the febrile child with evolving focal neurology, the cyanotic-heart-disease and sinus-otitis sources, the polymicrobial anaerobe-heavy microbiology, the contrast CT and MRI with diffusion-weighted imaging strategy, empiric third-generation cephalosporin plus metronidazole, the aspiration-versus-excision neurosurgical decision, the corticosteroid controversy, subdural empyema as a neurosurgical emergency, and the ANZ, UK and ESCMID guideline differences.
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Target exams
Red flags
- A febrile child with new headache, vomiting and any focal neurological sign, seizure or depressed consciousness — image now; the classic triad of fever, headache and deficit is present in fewer than a quarter of cases
- Subdural empyema behaves as a neurosurgical emergency — rapid deterioration, septic thrombophlebitis and herniation can develop over hours, so urgent evacuation is mandatory
- A child with cyanotic congenital heart disease and headache or neurological change — haematogenous brain abscess is a recognised complication and the threshold to image is low
- Rupture of an abscess into the ventricular system — sudden clinical collapse with profound meningism and hydrocephalus; mortality is extremely high
- Do not perform a lumbar puncture when an intracranial mass is suspected — it adds no useful information and risks herniation
Life stages
Care settings
Clinical exam formats
Board mappings
- Infectious Diseases
- Central nervous system infections
- Brain abscess and intracranial suppuration
- Infectious Diseases (Paediatric) — CNS infection management
- General Paediatrics learning goal — recognise and stabilise CNS infection
- Neurocritical care and source-control principles
- Clinical Applications
- Neurology and neurosurgical infection
- Long Cases
- Short Cases
- Communication scenarios
- Infection: recognises and manages intracranial infection
- Neurology: focal CNS infection and raised intracranial pressure
- Patient management across acute and surgical care
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Central nervous system infection
- Clinical
- History
- Communication
- Acute neurology assessment
- General Pediatrics Content Outline — Domain 4: Infectious Diseases
- General Pediatrics Content Outline — Domain 14: Neurology
- Subspecialty: Pediatric Infectious Diseases — CNS infection
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Medical Knowledge 1: Clinical Knowledge of CNS infection
- Systems-Based Practice 1: multidisciplinary neurosurgical and ID care
- Medical Expert
- Collaborator
- Pediatrics: Core EPA — recognise and manage CNS infection
Overview & Definition
Picture the nine-year-old with a week of frontal headache and low-grade fever, treated as sinusitis, who this morning cannot name his sister and is dragging his right leg. The headache that would not settle, the fever, and the new focal sign together reframe a "simple" sinus infection as something far more dangerous — a collection of pus forming behind his eye. That is the clinical heart of brain abscess: a focal, space-occupying infection whose neurological signs often arrive late and whose mortality is governed by how quickly you image and act. [1] [4]
An abscess is a localised region of suppurative cerebritis that has progressed through inflammation and necrosis to a walled-off collection of pus within the brain substance. Intracranial suppuration is the umbrella term that also covers pus in the subdural (subdural empyema) and epidural (epidural empyema) spaces, which differ sharply in behaviour — the subdural space offers no barrier to spread, so subdural empyema is fulminant and is treated as an emergency. [1] [9]
The condition is uncommon in children but not rare, and it is one of the few diagnoses in paediatrics where hours change outcomes. Cyanotic congenital heart disease, chronic sinus or ear disease, penetrating head injury and immunocompromise are the classic settings, but a substantial minority are cryptogenic, so the absence of an obvious source never excludes the diagnosis. [6] [11]
References15ShowHide
- [1]Brouwer MC, Tunkel AR, McKhann GM II, van de Beek D Brain abscess. N Engl J Med, 2014.PMID 25075836
- [2]Brouwer MC, Coutinho JM, van de Beek D Clinical characteristics and outcome of brain abscess: systematic review and meta-analysis. Neurology, 2014.PMID 24477107
- [3]Bodilsen J, D'Alessandris QG, Humphreys H, et al. European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults. Clin Microbiol Infect, 2024.PMID 37648062
- [4]Mameli C, Genoni T, Madia C, et al. Brain abscess in pediatric age: a review. Childs Nerv Syst, 2019.PMID 31062139
- [5]Gilard V, Beccaria K, Hartley JC, et al. Brain abscess in children, a two-centre audit: outcomes and controversies. Arch Dis Child, 2020.PMID 31431437
- [6]Bonfield CM, Sharma J, Dobson S Pediatric intracranial abscesses. J Infect, 2015.PMID 25917804
- [7]Sahbudak Bal Z, Eraslan C, Bolat E, et al. Brain Abscess in Children: A Rare but Serious Infection. Clin Pediatr (Phila), 2018.PMID 28969451
- [8]Brook I Brain abscess in children: microbiology and management. J Child Neurol, 1995.PMID 7594262
- [9]Muzumdar D Subdural empyema in children. Childs Nerv Syst, 2018.PMID 30014307
- [10]Garin A, Thierry B, Leboulanger N, et al. Pediatric sinogenic epidural and subdural empyema: The role of endoscopic sinus surgery. Int J Pediatr Otorhinolaryngol, 2015.PMID 26304070
- [11]Udayakumaran S, Onyia CU, Kumar RK Forgotten? Not Yet. Cardiogenic Brain Abscess in Children: A Case Series-Based Review. World Neurosurg, 2017.PMID 28780403
- [12]Atiq M, Ahmed US, Allana SS, et al. Brain abscess in children. Indian J Pediatr, 2006.PMID 16741324
- [13]Simjian T, Muskens IS, Lamba N, et al. Dexamethasone Administration and Mortality in Patients with Brain Abscess: A Systematic Review and Meta-Analysis. World Neurosurg, 2018.PMID 29705232
- [14]Sáez-Llorens X, Nieto-Guevara J Brain abscess. Handb Clin Neurol, 2013.PMID 23622320
- [15]Sheehan JP, Jane JA, Ray DK, et al. Brain abscess in children. Neurosurg Focus, 2008.PMID 18518751