Neurosurgery Blog: Brain Abscess as a Cause of Macrocephaly in a Newborn

Wednesday, May 21, 2014

Brain Abscess as a Cause of Macrocephaly in a Newborn

Pediatric Neurology

The authors thank Drs. Gelabert and Aran-Echabe for their interest in our report. We agree that empiric, broad-spectrum antibiotics, followed by culture-directed therapy, is the mainstay of intracranial infection management. In answer to their question, our institution has a protocol to guide such management as we believe this constitutes standard practice. In patients with brain abscess, we use a combination of vancomycin, metronidazole, and ceftazidime, although other intracranial infections are treated with vancomycin and meropenem. Like Drs. Gelabert and Aran-Echabe, we considered that empiric therapy represents a broad-spectrum regimen, fully justified in most clinical settings. Regarding instillation of antibiotics into the abscess cavity, although no systematic approach has been studied in the literature (as far as we know), we empirically use gentamicin, again complying with institutional protocol. Finally, we agree that craniotomy is probably the surgical approach with the lowest recurrence rate, but we believe that certain clinical circumstances make less invasive approaches equally or more adequate. Discussion regarding different surgical options and optimal management is beyond the scope of our article. In the individual we described, our intention was to emphasize his particular clinical presentation, initially managed as an asymptomatic macrocephaly. Our aim was to illustrate an apparent disproportion between lesion size and alarming signs and between mass effect and neurological status. Obviously, the child was managed as an emergency as soon as he was referred to us. Neurosurgical intervention and intensive care surveillance were implemented immediately. The particular clinical setting of this patient gave us the impression that craniostomy allowed immediate relief of mass effect with less risk of complications. The safe resection of the abscess capsule was felt to be hampered by the size, extension, and chronology of the lesion. We hope that Drs. Gelabert and Aran-Echabe will agree with us that sometimes the optimal surgical approach has to be decided on an individual basis. Once again, we thank them for their kind comments about our article.

Original Article: http://www.pedneur.com/article/S0887-8994(14)00088-5/abstract?rss=yes