PMC8326064_01
Preoperative (a) axial, (b) coronal, (c) parasagittal T1 postgadolinium demonstrates two large ring-enhancing right frontal lesions causing significant mass effect, subfalcine herniation, and 19 mm midline shift. (d) Axial cerebral blood flow study demonstrates no blood flow within lesions, (e) axial diffusion restriction sequence, (f) axial T2 demonstrates extent of cerebral edema.
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F1
The symptom of facial droop prompted brain magnetic resonance imaging (MRI) [Figure 1].
Preoperative (a) axial, (b) coronal, (c) parasagittal T2 demonstrates slightly larger brain abscesses compared with previous imaging, stable mass effect, arrow points to previous needle tract. Postoperative (d) axial, (e) coronal, (f) parasagittal T2 demonstrates decompression of giant frontal abscess, stable size of the loculated satellite abscess measuring 2 cm.
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F2
Due to radiographic worsening, recurrent symptoms, and worse inflammatory markers, the child was taken back to the operating room for aspiration and placement of an intra-abscess drain, and briefly provided IV vancomycin, changing penicillin to ceftriaxone. [Figure 2] demonstrates pre- and immediate postoperative representative sections from MRI.
T2 MRI following aspiration and drain placement of the right frontal giant abscess at discharge (a) axial and (b) coronal, at 6 weeks follow-up (c) axial and (d) coronal, and at 3 months follow-up (e) axial and (f) coronal. There is progressive improvement in cerebral edema, mass effect, and ultimately obliteration of the abscesses.
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F3
After 13 weeks of ceftriaxone and metronidazole following her second, and definitive, surgery, she is neurologically normal without developmental delay. [Figure 3] demonstrates representative images from multiple time points in the postoperative period throughout 3 months of antimicrobial therapy.