BRAIN ABSCESS IN CONGENITAL HEART DISEASE

Abstract

In any patient with congenital cardiovascular disease, particularly if he is cyanotic, the development of focal neurologic abnormalities or evidence of increased intracranial pressure must be considered as indicative of the possible presence of a brain abscess until proved otherwise. This is true whether or not there is any suggestion of septicemia, meningitis or focal infection elsewhere in the body. Cultures of the blood and cerebrospinal fluid are usually negative. The common denominator among patients with congenital heart disease and brain abscess is a central right-to-left shunt, which in the present series has always been accompanied by cyanosis, polycythemia and clubbing. In children under 2 years of age cerebral infarction due to thrombosis is much more common as a cause of neurologic complication than is abscess. In the presence of abscess, the condition is usually of 7 to 10 days' duration and of gradually increasing severity. The cerebrospinal fluid shows some increase in pressure and may frequently show mild increase in protein content or leukocyte count. Roentgenograms of the skull are normal, unless the abscess is of long-standing duration. Contrast studies such as angiography or pneumoencephalography may be urgently indicated if clinical localization is doubtful. Electroencephalography has consistently shown focal abnormality in the form of high-voltage slowing. Treatment consists of repeated aspiration in deep-seated and poorly encapsulated lesions supported by intensive antibiotic therapy, or aspiration followed by total excision in superficial and well-encapsulated abscesses. To prevent neurologic complications in this type of anomaly optimum treatment is obviously prophylactic total anatomic correction of the right-to-left shunt. If a brain abscess has occurred and has been successfully treated, the earliest possible anatomic correction of the cardiac anomaly is still indicated. This paper records the experience of one neurosurgical service with 13 cases of brain abscess in patients with cyanotic congenital heart disease in a 13-year period. Six of the 13 patients in this series had successful surgical treatment. While these results are poor, they have improved remarkably with earlier recognition and treatment. It is of utmost importance, therefore, that all physicians be aware of the frequency of brain abscess in congenital heart disease and suspect it early so that treatment can be carried out before there is irreversible brain damage.