Pediatric headache patient with cerebral abscesses: a brief review of the literature and case report

Abstract

Background: Pediatric headache is a common cause of pediatric emergency department (ED) visits, and 8.8% of cases require imaging. Alarmingly, 12.5% of imaged cases have a pathologic cause. A pediatric patient with a complicated medical history presented to the pediatric ED with multiple cerebral abscesses. The possible causes and contributors to this rare cause of pediatric headache and a review of pediatric headache emergency management are presented.Case Presentation: A 12-year-old male patient with a complex medical and surgical history, including post-repair pulmonary valve stenosis, visited the pediatric ED for intractable and worsening left frontoparietal headache, refractory to ibuprofen, for 6 days. A physical examination revealed severe photophobia and restlessness secondary to severe head pain. Non-contrast brain computed tomography demonstrated two round, bilateral, parietal hypodense lesions with surrounding vasogenic edema. The lesions were consistent with abscesses on magnetic resonance imaging. Eventually, the patient underwent successful surgical abscess drainage and made a full recovery. The patient was lost to follow-up; therefore, no causative bacterial species was determined.

Conclusion: Managing pediatric headache in emergency settings requires a robust history and physical examination. Cerebral abscesses are an infrequent but fatal cause of pediatric headache and therefore should be considered among the differential diagnoses.

Keywords: Cerebral abscess; brain imaging; case report; congenital defect; pediatric brain lesion; pediatric headache.

Figure 1.

Brain computed tomography without contrast. (a, b) Right and left hemispheres with hypodense lesions (red dots) and surrounding vasogenic edema and (c, d) Sagittal images that also demonstrate the right and left hemisphere lesions (red dots), respectively. e: Both lesions (red dots) on a single coronal image.

Figure 2.

Diffusion-weighted imaging (DWI) of the brain with contrast showing restricted diffusion, leading to a high DWI signal in the lesion, likely caused by a fluid component. (a, b) Lesions (red dots) in the right temporoparietal juncture and left parietal lobe, respectively, with vasogenic edema and (c) Coronal view of both lesions (red dots) with vasogenic edema in one plane.

Figure 3.

T1-weighted brain magnetic resonance imaging with contrast demonstrating peripheral enhancement of the lesions with low T1 signal. Leptomeningeal enhancement is present in all images (see panel a (yellow arrows) as an example). (a) Lesion in the right gyrus rectus (red arrow). (b, c) Lesions (red dots) in the right temporoparietal juncture and left parietal lobe, respectively, with a thick rim of enhancement and vasogenic edema. (d) Coronal view of both lesions (red dots). (e) Gyrus rectus lesion on coronal view (red arrow) and (f, g) Sagittal view of the lesions (red dots) in the left and right lobes, respectively, with surrounding vasogenic edema

Figure 4.

T2-weighted brain magnetic resonance imaging with contrast demonstrating high T2 signal in the lesions with peripheral enhancement. (a) Lesion in the right gyrus rectus (red arrow). (b, c) Lesions (red dots) in the right temporoparietal juncture and left parietal lobe, respectively, with a thick rim of enhancement and vasogenic edema and (d, e) Sagittal view of the lesions (red dots) in the left and right lobes, respectively, with surrounding vasogenic edema.

Figure 5.

Pediatric headache algorithm. AMS, altered mental status; NF1, neurofibromatosis 1; MRI, magnetic resonance imaging; CT, computed tomography; NSAIDs, nonsteroidal anti-inflammatory drugs.