Follow-Up for Brain Abscesses in Children

Frequency of Office Visits

• Discharge instructions: Discharge instructions should cover wound care, activity, follow-up, and medications. (54).
• Frequency of office visits: After discharge the patient should be seen weekly for the first 2 weeks, and then every other week for the next 8 weeks.

Patient and family education

• Educate patient and family: The successful management of abscesses in children is dependent on an educated patient and/or family. Upon discharge, educate the patient and family to monitor for any change in neurological status. For infants, the family should call the physician if they detect any change in alertness, difficulty in arousing, irritability, decreased feeding, bulging fontanelles, seizures, or intractable vomiting. The family should also note fevers, and any temperature greater than 100.5 F (approximately 38 C) warrants a call to the physician.

Frequency of Imaging

• Choose and stick with either MRI or CT scan: Frequent imaging is essential during treatment of patients with a brain abscess. MRI has no proven advantage over the CT scan, and they are equally acceptable. For most accurate comparison, the same imaging modality should be used consistently for each patient (118).
• Imaging every week during treatment: If therapy is effective, imaging should show a decrease in the degree of ring enhancement, the amount of edema, the amount of mass effect, and the size of the lesion. The size of the abscess decreases in 1–4 weeks with antibiotic therapy alone or in combination with stereotactic aspiration, and 95% of abscesses that resolve with antibiotic treatment alone demonstrate a reduction in size within a month (30, 60).
• Scan every 2 weeks until radiographic resolution: Bimonthly examinations should then be performed until the process has radiographically diminished (118).
• Every 3–4 months after radiographic involution for 1 year: Imaging should continue periodically (every 3–4 months) for approximately 1 year to ensure there is no recurrence of the infection (55).
• Scan if clinical status worsens: Imaging is conducted immediately if there is a decline in the patient’s neurological status (51).
• Complete radiographic resolution slow: Complete resolution of the abscess and associated abnormal contrast enhancement may take up to 12–16 weeks, and an area of residual contrast enhancement may be present for up to 6–9 months after antibiotic therapy alone or in combination with stereotactic aspiration or surgical drainage via craniotomy. Prolonged enhancement should not dictate the need for additional therapy. However, these patients bear close observation and follow-up (30, 51, 118).
• Steroid withdrawal can cause confusion: Increase in contrast enhancement is commonly seen with steroid withdrawal, and this does not necessarily indicate regrowth of the abscess (118).
• Diffusion-weighted MRI studies document response: These studies have been shown to help in the evaluation of treatment response of brain abscesses, as low signal intensity at diffusion-weighted imaging with high “apparent diffusion coefficients” correlates with a good therapeutic response (92).