SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 1

ORIGINAL ARTICLE

Brain abscess burr hole aspiration in children with congenital heart disease in low facility centers: case series

Yasser Seddeg Abdulghani (1), Mohammed Awad Elzain (2) , Abubakr Darrag Salim Ahmed (3), Salaheldin Awad Abdelhalim (4)

(1) Department of Anatomy, National Ribat University, Khartoum, Sudan

(2) Department of Neurosurgery, King Abdullah Hospital, Bisha, Saudi Arabia

(3) Department of Neurosurgery, Mawada Hospital, Khartoum, Sudan

(4) Department of Neurosurgery, Ahfad University, Omdurman, Sudan

Correspondence to:

Mohammed Awad Elzain

Department of Neurosurgery, King Abdullah Hospital, Bishah, Saudi Arabia

Email: alkarsani [at] yahoo.com

Received: 17 May 2020 | Accepted: 05 December 2020

How to cite this article:

Abdulghani YS, Elzain MA, Ahmed ADS, Abdelhalim SA. Brain abscess burr hole aspiration in children with congenital heart disease in low facility centers: case series. Sudan J Paediatr. 2021;21(1):61–66.

https://doi.org//10.24911/SJP.106-1589487269

ABSTRACT

This is a prospective cross-sectional study on brain abscess burr hole aspiration in children with congenital heart disease (CHD) performed from January 2018 to March 2019. All patients were operated on through a burr hole, and then received intravenous antibiotics for 6 weeks and orally for 2 weeks either empirically or according to the results of abscess culture, if positive. The follow-up of cranial computed tomography or brain magnetic resonance image with contrast was obtained after 2 months (post-operatively) to assess the effectiveness of the procedure and to look for any residual or recurrent abscesses. Data were collected in a designed data collection sheet and analysed using Statistical Package for the Social Sciences-20. Thirteen patients were found to satisfy inclusion criteria. The most common presenting symptoms were fever (n = 11/13, 84.6%), vomiting (n = 7/13, 53.8%), headache (n = 6/13, 46.2%), convulsions (n = 6/13, 46.2%), focal weakness (n = 3/13, 23.1%), and impaired level of consciousness (n = 1/13, 7.7%). No bacterial growth was detected in two-thirds of the cases (69.2%), while the culture was positive in the remaining one-third (30.8%). The follow-up images showed complete resolution of the abscesses except in one case (n = 1/13, 7.7%), which required a second session of aspiration. One patient died (n = 1/13, 7.7%) on the 19th post-operative day due to severe pneumonia. Aspiration of brain abscess in children with CHD through a burr hole is a safe and effective procedure in terms of operative time, duration of anaesthesia and postoperative complications.

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KEYWORDS

Brain abscess; burr hole aspiration; congenital heart disease.

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INTRODUCTION

Brain abscess is a complicated localised brain infection that progresses into a well-formed cavity with pus collection surrounded by a vascularised fibrous capsule [1]. The incidence of brain abscess, in general, is approximately 1,500-2,500 cases per year in U.S. statistics. Although there were no previous studies for brain abscess incidence in Sudan in the literature, it is generally expected to be higher [2].

Brain abscess may develop as a local spread from either a contiguous source (e.g., dental infection, otitis media, mastoiditis, sinusitis, the complication of open traumatic brain injuries, or after a neurosurgical procedure) or spread through hematogenous route particularly in patients with cyanotic congenital heart disease (CHD), or lung disease. In about 15% of cases with brain abscess, the aetiology may not be identified [3].

Patients with CHD are more prone to develop brain abscesses. Surgery for these abscesses is often limited to aspiration under local anaesthesia because excision under general anaesthesia is considered a risky option. Peri-operative haemodynamic instability, cyanotic spells, coagulation defects, electrolyte and acid–base imbalance, and sudden cardiac arrest are among the major anaesthetic concerns. Also, those patients may need major cardiac interventions which are considered risky due to the presence of the brain abscess [4].

Several theories explained how patients with cyanotic CHDs can develop brain abscesses. Cyanotic congenital heart defects can lead to shunting of deoxygenated blood from the right side of the heart across the heart or its major vessels into the systemic circulation, resulting in persistent arterial desaturation and cyanosis. This right to left shunt will allow the contaminated blood to enter directly into the left side of the heart and subsequently into the cerebral circulation. In addition, the deoxygenated blood may result in compensatory polycythemia with an increase in blood viscosity. These changes provide a good media for infection and abscess formation [5].

The commonest presenting clinical features of brain abscess in patients with CHD are headache, vomiting, seizures, impaired consciousness, fever and focal neurological deficit. The presenting symptoms and signs are dependent on the location and the size of abscesses [4].

Brain abscess has four separate stages including early cerebritis, late cerebritis, early capsule formation and late capsule formation, based on imaging findings, gross appearance and histopathology [6].

The management of the brain abscess can be either medical or surgical depending on the stage, size, location, and the number of abscesses besides the clinical status of the patient and the presence of other comorbidities. Surgical interventions include either aspiration of the abscess through a burr hole or complete abscess excision with the surrounding capsule through craniotomy [7].

Surgical management represents the gold standard option for the management of brain abscesses. It helps in alleviation of the mass effect created by the brain abscess, besides giving the chance for obtaining a biopsy for confirming the diagnosis. A number of neurosurgical techniques had been proposed to treat brain abscesses, ranging from the simple aspiration procedure through a burr hole to the more invasive complete surgical excision through a craniotomy. Needle aspiration is sometimes performed under stereotactic navigation with the guidance of ultrasound or computed tomography (CT) scan, especially for deeply seated abscesses (brainstem, cerebellum and basal ganglia) [8].

Surgical excision of the brain abscess should be left for mature abscesses with thick capsules that fail to shrink after weeks of antibiotics because of adhesions to the dura and also for posterior fossa abscesses, especially in the cerebellum, which may compress cerebrospinal fluid pathways and thereby lead to high intracranial pressure and carry a high mortality rate reaching 20%-50% [9].

A study of outcome in 100 patients, who had brain abscess aspiration, concluded that complete resolution of the abscess with good recovery of the preoperative neurological deficit was seen in 77 patients (77%), and recovery with a major neurological deficit was observed in 10 patients (10%) while 13 patients (13%) expired [10]. Another study found a significant statistical difference in recovery and postoperative mortality between patients who underwent burr hole aspiration versus those who underwent formal craniotomy surgery, but there were no differences observed in the length of hospital stay and duration of antibiotic therapy [11]. Another study, conducted in 50 children with brain abscesses secondary to congenital cyanotic heart diseases, concluded that burr whole aspiration of brain abscess in children with cyanotic heart disease was a safe and successful approach for managing children with this problem [12].

Excision of brain abscess through craniotomy needs good neurosurgical setup including a well-prepared operation room and a good intensive care unit (ICU) for postoperative care and management. The duration of anaesthesia besides the use of anaesthetic drugs, especially in patients with co-existing heart disease, also represent another challenge. In addition to that, the prolonged duration of hospital stay may increase the risk for hospital-acquired infections.

In Sudan, paediatric cardiac services are provided only in two centres, while neurosurgical services are provided by five different governmental centres in different locations. Therefore, patients with CHDs who need neurosurgical consultations, management or intervention have to be transferred to one of these neurosurgical centres and then referred back to the paediatric cardiac hospitals in order to continue their management. The lack of medical facilities, paediatric ICU beds and paediatric neurosurgery nursing staff in addition to the poor patient’s medical conditions preoperatively render most of those patients unable to tolerate long anaesthesia duration. All of these factors together, make craniotomy for abscess excision a less favoured surgical option that may lead to poor outcomes and high mortality rates.

The aim of the present study was to assess the effectiveness of brain abscess aspiration through burr hole in children with associated CHDs, to evaluate the postoperative clinical improvement, hospital stay and the adequacy of the procedure.

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MATERIALS AND METHODS

This was a case series study conducted at the Department of Neurosurgery, Omdurman Teaching Hospital, Khartoum state, Sudan, in the period from January 2018 to march 2019.

Settings

Omdurman Teaching Hospital is one of the largest public hospitals in Sudan. It receives patients referred from different states of Sudan and has one neurosurgery unit with one consultant and one referred clinic per week. No paediatric unit or paediatric ICU is available in the hospital.

Inclusive and exclusive criteria for patients’ selection

Inclusion criteria

• Paediatric patients diagnosed with CHDs and complicated with brain abscesses.
• Patients with available preoperative and postoperative registry data and who were regularly coming for a follow-up.
• Paediatric patients who were operated in the centre of the study.

Exclusion criteria

• Patients whose data were incomplete or those lost during follow up.
• Paediatric patients who were operated on other neurosurgical centres.
• Paediatric patients with brain abscesses due to other aetiologies or with no associated CHDs.
• Paediatric patients who were managed through craniotomy rather than the burr hole procedure.

Thirteen patients, diagnosed with brain abscesses complicating CHDs were included in this study. All patients underwent burr hole aspiration of the abscess followed by intravenous (IV) antibiotics. Pre and post-operative brain images were adequately examined and regular clinical assessment findings for the patients were recorded pre and post-operatively.

Post-operatively, all patients received IV antibiotics for 6 weeks and orally for another 2 weeks either empirically or according to the results of abscess culture if positive. Prophylactic anticonvulsants were given to all patients in this study.

Data collection and analysis

Recorded data were the patient’s age, sex, presenting complaints, duration of signs and symptoms, type of CHD, location of brain abscess in imaging [CT scan/brain magnetic resonance image (MRI)] and outcome of the patient after aspiration (through assessing the level of consciousness and if there is any improvement in the neurological symptoms and signs postoperatively). Postoperative complications were also recorded (including any decline in the neurological status, level of consciousness or new onset neurological deficit), and mortality was ascertained.

Repeat CT was performed 8 weeks postoperatively after completing the proposed antibiotic course, to assess the adequacy of abscess drainage. Patients were followed up regularly either directly or through contacting the treating doctors in the paediatric hospital. Data were analysed using Statistical Package for the Social Sciences version 20 and was interpreted by the authors participating in this study.

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RESULTS

Thirteen cases were included in this study. Eight patients (n = 8/13, 61.5%) were males and 5 (n = 5/13, 38.5%) were females. The age ranged from 4 to 8 years with a mean age of 5.2 years and median of 5 years. The most common presenting symptoms are illustrated in Table 1.

The intracranial locations encountered were: frontal (n = 6/13, 46.2%), temporal (n = 4/13, 30.8%), frontoparietal (n = 2/13, 15.4%), and parietal (n = 1/13, 7.6%). More than half of the cases had tetralogy of Fallot while almost one-third of the patients were suffering from an associated infective bacterial endocarditis with their respective cardiac disease. However, none of the patients was in heart failure preoperatively (Table 2).

All of our patients were started on empirical IV antibiotics (ceftriaxone + metronidazole + vancomycin) which were changed to specific IV antibiotics as soon as culture results were available. The results of culture obtained from the aspiration revealed no growth in 9 patients, three grew Staphylococcus aureus and only one grew Pseudomonas aeruginosa.

The mean duration of surgery and anaesthesia was 22 ±− 5.34 minutes, with a minimum duration of 17 minutes and a maximum of 41 minutes. The mean duration of hospital stay was 3 days in the neurosurgery ward before referring the patients to a specialised paediatric hospital to complete the IV antibiotics, besides monitoring and managing their cardiac diseases.

Most patients (n = 11/13, 84.6%) showed marked clinical improvement postoperatively. Improvement parameters included improvement of consciousness level, neurological function and the resolution of symptoms and signs of increased intracranial pressure. Follow-up images showed complete resolution of the abscesses except in one case (n = 1/13, 7.7%) who required a second session of aspiration. One patient died (n = 1/13, 7.7%) on the 19th postoperative day due to severe pneumonia.

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DISCUSSION

A study done for 50 patients with cyanotic heart diseases who underwent aspiration of their brain abscesses, found that this procedure is effective and safe with less postoperative complications and mortalities [12]. These findings are similar to our results as most of the patients improved postoperatively with no major complications. Another study performed in 48 patients with brain abscesses associated with CHDs reported successful favourable outcomes in 44 patients with improved neurological status postoperatively in most of the patients [13].

Table 1. The presenting symptoms and signs in patients of brain abscess associated with CHD.

Symptoms and signs	Frequency	Percent
Fever	11	84.6
Vomiting	7	53.8
Convulsions	6	46.2
Headache	6	46.2
Focal weakness	3	23.1
Decreased level of consciousness	1	7.7

Table 2. Distribution of CHDs among the study group.

CHD	Frequency	Percentage
Tetralogy of Fallot	9	69.2
Patent ductus arteriosus (+endocarditis)	2	15.4
Ventricular septal defect (+endocarditis)	2	15.4
Total	13	100

Our current study tested what is widely known regarding effectiveness of burr hole aspiration of brain abscess in children with CHDs through a simple procedure and allowing the paediatric cardiologists to effectively manage the causative underlying cardiac condition. The same approach was found to be very rewarding and was reported by several authors [10,11]. Considering the low profile setup and the poor patients’ medical condition preoperatively, aspiration of the brain abscess in the present study was found to be an effective and safe surgical option.

In the present study, brain abscesses were found mainly in frontal, parietal and temporal lobes (in the distribution of anterior circulation) which may be explained by the fact that 80% of blood supply to the brain comes through the internal carotid artery and the fact that abscesses that has hematogenous origin is mainly coming through the internal carotid artery. Most authors encountered the same findings while reporting the radiological locations of brain abscesses in their series [12].

Most patients in this study showed clinical improvement in terms of symptom relief and improvement of their neurological deficit as well as radiological improvement in CT or MRI post-operatively. Because of the financial issues, some patients were followed by CT scan while the others had MRI; but in all cases, the imaging studies had to be done with contrast to confirm the adequacy of the procedure.

In the literature, the percentage of patients who required re-aspiration is ranging between 19% and 28% [14,15]. In our study, only one patient (7.6%) needed a second session of aspiration due to abscess recollection 2 weeks after the first operation, although the abscess was adequately drained and the patient received the full antibiotic course. This may be partly explained by the fact that the abscess was in the late capsule stage which makes the antibiotic penetration into the abscess sac less efficient. In most cases, we managed in the early capsule stage where the capsules of the abscesses were not fully mature, and this may explain the low recurrence and the need for re-aspiration in our series.

A study on 12 patients who underwent drainage of cerebral abscesses under stereotactic guidance reported improvement in all patients without any mortality or postoperative complication. A second aspiration was required in only one patient due to recurrence, and it was concluded that stereotaxy is beneficial not only for deeply seated lesions or lesions in the eloquent cortex, but it is also a helpful diagnostic tool especially when the clinician is in doubt [16]. This is consistent with the findings in the present study as all patients were treated through burr whole aspiration with no postoperative complications.

In this study, we had one reported death, but the patient died 3 weeks postoperatively, due to severe pneumonia which was not clearly related to a brain abscess or its management. We believe that the mortality, in general, was not directly related to the procedure itself. Rather, it may be indirectly related to co-existing heart disease and its management. All cases in this study were shifted to a specialised paediatric hospital to continue the management of their cardiac diseases. This might explain the low mortality rate seen in our study because of the good multidisciplinary team collaboration between the neurosurgeons, paediatricians and cardiac surgeons.

Lack of follow up after surgery is one of the major limitations in this study because most of the patients reside far away from the neurosurgery centre and need to travel several miles before reaching there. It was also a single centre study including a small number of patients with short-term follow-up.

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CONCLUSION

Aspiration of brain abscess in children with CHD through a burr hole is a safe and effective procedure in terms of operative time, duration of anaesthesia and postoperative complications. Further studies are required to determine the effectiveness of the procedure and the safety profile of this approach.

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CONFLICT OF INTEREST

The authors declare that there is no conflict of interest regarding the publication of this article.

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FUNDING

None.

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ETHICAL APPROVAL

The study was approved, and an ethical clearance was given by the National Ribat University, Khartoum, Sudan. All parents of patients included in this study had signed/agreed to a written and informed consent after explaining the objectives of the study. Confidentiality was ensured at all levels.

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