Changes in the epidemiology of pediatric brain abscesses pre- and post-COVID-19 pandemic: a single-center study.

BACKGROUND: An increased incidence of brain abscesses was observed post-COVID-19 pandemic. However, it remains unclear how the COVID-19 pandemic influenced the epidemiology of brain abscesses. This study aimed to investigate changes in the epidemiology of brain abscesses pre- and post-COVID-19 pandemic. METHODS: A retrospective study of demographic, clinical, radiological, and laboratory characteristics of patients with brain abscesses in Children's Hospital of Soochow University from 2015-2023 was performed. RESULTS: A total of 34 patients were admitted to the hospital during the study. The post-COVID-19 cohort had an average of 5.5 cases/year, which is a 129.2% increase compared to the pre-COVID-19 cohort's average of 2.4 cases/year. Additionally, the rates of fever upon admission (86.36% vs 50%, p = 0.04) and experiencing high-grade fever within 6 weeks before admission (40.91% vs 8.33%, p = 0.044) were significantly increased. A potential rise in the rate of intensive care unit admission was observed (36.36% vs 8.33%, p = 0.113). The average value of globulin in the post-COVID cohort was significantly higher compared to the pre-COVID cohort (31.60 ± 5.97 vs 25.50 ± 5.08, p = 0.009). Streptococcal infections were the predominant cause of brain abscesses in both cohorts (40% vs 43.75%, p = 0.57). CONCLUSIONS: There was a significant increase in the number of brain abscess patients after the COVID-19 pandemic. This underscores the importance of children receiving the streptococcal vaccine.

Brain abscesses: the first report of disseminated Nocardia beijingensis infection in an immunocompetent individual in China.

Nocardia is widely distributed in the natural environment and typically cause opportunistic infections. However, it is important to note that the pathogenicity of different Nocardia species may vary significantly. Here we reported the first case of brain abscess caused by Nocardia beijingensis (N. beijingensis) infection in China. A 70-year-old male immunocompetent individual came to our hospital for treatment due to headache. After examination, it was found that he had a brain abscess caused by N. beijingensis. By utilizing a combination of surgical intervention and antibiotic therapy, the patient ultimately achieved full recovery. In addition, we isolated this strain and displayed its ultrastructure through scanning electron microscopy. The phylogenetic tree was analyzed by 16 S rRNA sequence. A literature review of N. beijingensis infections in all immunocompetent and immunocompromised patients was presented. It highlighted that abscess formation appears to be a common manifestation of N. beijingensis infection, and N. beijingensis has become an emerging pathogen in immunocompetent individuals.

Surgical Management of Tuberculosis-related Cerebral Disorders: A Retrospective Single-center Study.

BACKGROUND: Tuberculosis (TB) remains a significant global health concern, with extrapulmonary manifestations, including central nervous system involvement, posing substantial morbidity and mortality. While medical treatment with anti-TB drugs is the mainstay of therapy, certain TB-related cerebral complications, such as hydrocephalus, abscesses, and large symptomatic tuberculomas, may require surgical intervention. This study aimed to evaluate the outcomes of surgical management in patients with TB-related cerebral disorders. METHODS: A retrospective analysis was conducted on 24 patients who underwent surgical intervention for TB-related cerebral disorders, including tuberculomas, hydrocephalus, and abscesses, at a tertiary care center between 2005 and December 2020. Demographic data, clinical presentations, radiological findings, surgical techniques, and treatment outcomes were analyzed. RESULTS: The study cohort had a mean age of 35.8 ± 13.6 years, and the majority (62.5%) were male. Underlying immunodeficiency, primarily HIV infection, was present in 75% of the patients. The most common presenting symptoms were headache (83.3%), focal neurological deficits (75%), and altered mental status (54.2%). Radiological findings revealed 13 (54.2%) tuberculomas, 8 (33.3%) instances of hydrocephalus, and 3 (12.5%) abscesses. VP shunt inserted in 8 (33.3%) cases. Microscopic craniotomy performed in 7 (29.16%) cases. Aspiration through burr hole was done in 3 (12.5%) cases and stereotactic biopsy was performed in 6 (25%) cases. After 12 months of follow-up, favorable outcome achieved in 18 cases (75%) and the mortality occurred in 2 patients (8.3%). Surgical interventions included lesion resection (n = 10), stereotactic biopsy (n = 7), and ventriculoperitoneal (VP) shunt placement (n = 7). At 12-month follow-up, 18 (75%) patients had a favorable outcome, defined as clinical improvement or stabilization. Unfavorable outcomes were observed in 6 (25%) patients, including 2 deaths. CONCLUSION: Surgical management, in conjunction with appropriate anti-TB medical therapy, may be a valuable component of the comprehensive treatment approach for select patients with TB-related cerebral disorders. The favorable outcome rate observed in this study suggests that timely and tailored surgical intervention can contribute to improved patient outcomes. However, larger, prospective, multicenter studies are needed to further elucidate the role and long-term efficacy of surgical management in this patient population.

AB054. Pituitary abscess: a case report of patient after two-time endonasal endoscopic transphenoid approach for pituitary adenoma.

BACKGROUND: Endonasal endoscopic approach (EEA) has become an integral part of neurosurgery, particularly for managing various pathologies involving the sellar and parasellar region and removing lesion in that area. But there is a rare condition in this area that not so common in literature is pituitary abscess (PA) after EEA for pituitary adenoma. CASE DESCRIPTION: A healthy 57-year-old man presented with a recurrent of bitemporal hemianopsia, persistent hypoadrenocorticism. In the history, he underwent two times of endonasal endoscopic transphenoid to remove pituitary adenoma. Magnetic resonance imaging (MRI) showed a sphenoid and sellar lesion with suprasellar extension and compression of the optic chiasm, with homogenous signal inside. Endoscopic transphenoid surgery was performed and the lesion was found is an abscess inside sphenoid and sellar with frank pus was obtained. But culture of the fluid was negative. After the operation, the patient was treated with antibiotics. His symptoms resolved after EEA, he improved visual field at this time but still in hypoadrenocorticism condition. An MRI was obtained after the operation to reveal that the lesion in sphenoid and sellar totally removed. We report on a rare case of a PA after two times of endonasal endoscopic transphenoid surgery of pituitary adenoma, and discuss the management of these conditions. We report a patient that came with us with recurrent of bitemporal hemianopsia and persistent hypoadrenocorticism. The patient undergone endonasal endoscopic sphenoid two times in the past. He didn't have clinical signs of infection. Imaging feature on MRI was high T2 and also high on T1 with homogenous signal inside with size 3.2 cm × 3.2 cm. Another EEA for this patient was performed to remove abscess and obtain pus from the lesion, but the result of culture was negative. He improved visual field but still in hypoadrenocorticism. CONCLUSIONS: In this case we report on a rare complication of transphenoid surgery, a PA progresses after EEA for a pituitary tumor. With this clinical experience, the correct diagnosis of PA before surgery, so it is a key leading to an exactly treatment for this condition. endonasal endoscopic transphenoid approach to drainage and removing abscess, and using antibiotics are necessary to improve the outcome of PA.

Concomitant Listeria monocytogenes and Streptococcus equinus brain abscess in an immunocompetent individual: a case report.

BACKGROUND: Listeria monocytogenes brain abscess is a rare phenomenon that is common in immunocompromised patients. Streptococcus equinus brain abscess has never been reported in the literature to our knowledge. In this case report, we describe a case of brain abscess secondary to Listeria monocytogenes and Streptococcus equinus in an immunocompetent patient with transient low CD4 count. CASE PRESENTATION: A 27-year-old white, male patient, previously healthy, nonalcoholic, and occasional smoker, presented to the emergency department for confusion and headache. The patient was found to have a left parietal abscess, which was drained and the fluid was sent for culture. Culture grew Listeria monocytogenes and Streptococcus equinus. The patient was treated with intravenous ampicillin followed by oral amoxicillin for a total of 6 weeks. The CD4 count was low initially. However, after the resolution of the infection, the CD4 count came back within normal range. Another brain magnetic resonance imaging was done that showed a significantly decreased hyperintensity within the left parietal subcortical white matter at the site of surgery with significantly decreased enhancement and almost total resolution of the previous abscess. CONCLUSION: Transient low CD4 count is a rare phenomenon that exposes patients to unusual and atypical infections. Since low CD4 count is transient, patients treated promptly recover from their illness. Our patient developed a Listeria monocytogenes and Streptococcus equinus brain abscess, which is considered rare and has not been previously described in the literature to our knowledge.

Brain Abscess in the Contralateral Frontal Lobe Associated with Frontal Sinusitis that Spread from Odontogenic Maxillary Sinusitis.

We encountered a case involving a brain abscess in the right frontal lobe of a 12-year-old girl who was diagnosed with a chief complaint of headache and nausea. Left maxillary sinusitis, a dental infection related to dental caries and apical periodontitis, was observed in the left maxillary first molar in addition to left frontal sinusitis also being present. In addition to administering antibacterial agents, extraction of the left maxillary first molar and drainage of the paranasal sinuses and brain abscess were performed. Follow-up over the course of 1 year and 5 months indicated that the patient had progressed without any sequelae; therefore, the prognosis was good. In this case, although bone destruction was observed in the posterior wall of the frontal sinus, which could be a route for bacteria to enter the skull, we considered the possibility of direct invasion from the same site to be low because the brain abscess occurred on the opposite side. We believe that a route for hematogenous invasion from apical periodontitis, in addition to sinusitis, is also possible. Regardless of the route, the outset was an infection in the dental field; therefore, this case reaffirmed the importance of dental cavity treatment in childhood.

Synchronous Splenic and Intracerebral Abscesses in a Child.

ABSTRACT: Splenic abscess is a life-threatening condition, which is very rare in children. There is usually an infective focus or pre-disposing factors such as immunodeficiencies towards developing splenic abscesses. Only one case of splenic abscess with brain abscesses in an adult has been reported in the English literature. We, therefore, report a case of an 11-year-old boy who was otherwise healthy, but presented with fever and weight loss for 2 months, right upper abdominal pain, vomiting, hypochondrial tenderness for 1 week and later on developed a left hemiplegia and right facioparesis 2 days before presentation. Diagnosis of splenic abscess and right intracerebral abscesses was confirmed with abdominopelvic ultrasound scan and abdominal and cranial computerised tomographic scans. He subsequently had percutaneous ultrasound-guided drainage of the splenic abscess which was not successful necessitating splenectomy with aggressive antibiotics treatment to which the patient responded with resolution of the brain abscesses and recovery of power in affected limbs. This report aimed to highlight the need for increased suspicion of splenic abscesses in children who are apparently immunocompetent and to add to the knowledge of management of this rare condition in children. We conclude that splenic abscess with intracerebral abscess is a rare but life-threatening condition which is amenable to treatment with drainage of abscess and aggressive guided antimicrobial therapy.

A Rare Complication of Proteus Brain Abscess Due to Coccidioidomycosis Causing Hydrocephalus.

Proteus mirabilis is a very common gram-negative facultative anaerobe seen in urinary tract infections. This rod-shaped bacterium tends to cause urolithiasis via its ability to alkalinize the urine. However, in some cases, this bacterium has been shown to cause bacteremia as well as other complicated infections. Here we would like to present a rare case of Proteus mirabilis that has invaded the brain in a patient that has a ventriculoperitoneal (VP) shunt placed due to coccidioidal meningitis causing hydrocephalus. We would also like to discuss the importance of the monitoring of VP shunt and discuss their likelihood of infections and the medical as well as surgical management.

A Rare Case of Cerebral Abscess due to Fusobacterium nucleatum with Native Aortic Valve Infective Endocarditis and Pyogenic Liver Abscess.

Fusobacterium nucleatum is a commensal pathogen typically found in the oral cavity, digestive tract, and urogenital system which has been associated with Lemierre's syndrome, periodontal diseases, sinusitis, endocarditis, and intra-abdominal and brain abscesses. Our case is of a 62-year-old male who presented with headaches, nausea, and vision loss. Brain imaging identified a right occipito-parietal brain abscess. Following surgery and abscess drainage, Fusobacterium nucleatum was isolated from intraoperative cultures, and the infectious disease service was consulted for antibiotic recommendations. Additional history uncovered that he had also been experiencing night sweats, generalized weakness and 40-pound weight loss for 2 months, and had a prior history of colon polyps and diverticulitis. Furthermore, the patient disclosed having substandard oral hygiene practices, particularly in relation to the care of his dental appliances. Despite negative blood cultures, suspicion for hematogenous seeding was high. Imaging ruled out periodontal disease, but identified a colovesical fistula and liver abscesses, indicating potential translocation of bacteria via portal circulation to his liver. Echocardiogram workup revealed a 1-cm mobile vegetation on the aortic valve. His course was complicated by breakthrough seizures, renal failure, and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, and he ultimately completed 16 weeks of antibiotics. This case illustrates an uncommon presentation of brain abscess in an immunocompetent adult, with a prior episode of diverticulitis as the probable primary infection source, leading to development of a colovesical fistula and bacterial dissemination to the liver, heart, and brain. It highlights the importance of a comprehensive diagnostic approach, including consideration of atypical pathogens in immunocompetent adults.

Pediatric abscessed craniopharyngioma: A case report and review of literature.

BACKGROUND: Craniopharyngiomas are rare sellar and suprasellar tumors affecting children and adults. The spontaneous abscessation of this lesion is an extremely rare occurrence with a total of 10 cases reported in the literature including 2 cases in the pediatric population. OBSERVATION: We report a case of abscessed craniopharyngioma in a 10-year-old girl, revealed by intracranial hypertension and diabetes insipidus with a double component (solid and cystic) lesion of the sella visualized on cerebral MRI. The patient underwent surgical decompression via endoscopic endonasal transsphenoidal approach coupled with antibiotic treatment with an uneventful postoperative course and improvement of her symptoms. CONCLUSION: Abscessed craniopharyngiomas are rare and challenging entities. We highlight through our case and literature review the importance of an in-depth patient's history as well as a clinical-radiological correlation in allowing for a positive preoperative diagnosis even in patients with no meningeal or infection signs.

Cerebellar abscess secondary to metastatic lung adenocarcinoma: a case report.

BACKGROUND: Cerebellar abscesses are rare, life-threatening infections often originating from bacterial sources, while metastatic brain lesions from lung adenocarcinoma are relatively common. However, the coexistence of a cerebellar abscess secondary to metastatic lung adenocarcinoma is exceedingly rare and presents unique diagnostic and management challenges. CASE PRESENTATION: We report a case of a 35 year-old Pakistani female patient with persistent headaches, nausea, and vertigo, who was found to have a large cerebellar mass with features suggestive of metastatic lung adenocarcinoma. Further investigation revealed a concomitant cerebellar abscess. Surgical excision and broad-spectrum antibiotics were initiated, resulting in a favorable outcome. CONCLUSION: This case showcases the rarity and complexity of cerebellar abscesses due to metastatic lung adenocarcinoma. Timely intervention, including surgery and targeted therapy, is crucial for successful management. Further research is needed to enhance treatment strategies.

Raney clip left behind the titanium mesh after cranial surgery: Case report.

RATIONALE: Raney clips are commonly used in neurosurgical procedures to hold the scalp in place and stop bleeding during surgery. The removal of Raney clips is often the last process during cranial surgery prior to the closure of skin incision. Thus, a Raney clip found underneath the titanium mesh resulting in fever is a very rare occurrence. PATIENT CONCERNS: An 18-year-old male patient underwent cranial surgery due to intracranial abscess in the frontal lobe and subsequently underwent frontal skull repair using titanium mesh during which a Raney clip was unintentional left underneath the titanium mesh resulting in fever. DIAGNOSIS: A thin-slice computed tomography (CT) scan was used to identify the Raney clip. INTERVENTION: A third surgery was performed to remove the Raney clip. OUTCOMES: The patient fever total resolved after the third surgery with no further neurological deficits and 2-years follow-up revealed the patient is well and go about his daily activities. LESSONS: It is crucial to ensure that all foreign objects are removed after the surgery by counting all instruments used at and after each step during the operation, including all Raney clips. This will help prevent complications and ensure the safety as well as the well-being of the patient.

Intracranial dissemination of Klebsiella pneumoniae originating from pulmonary infection: a case report.

BACKGROUND: Metastatic brain abscesses caused by Klebsiella pneumoniae are extremely rare but life-threatening conditions. To depict a unique case of the middle-aged hypertensive man with an unusual presentation of metastatic brain abscesses originating from a pleural abscess caused by Klebsiella pneumoniae and subsequently leading to loss of consciousness (LOC). CASE REPORT: A 52-year-old Iranian man with a history of hypertension presented to the emergency department with a five-day history of worsening cough, high-grade fever, shortness of breath, chest pain, fatigue, and a productive cough. Laboratory tests revealed leukocytosis, elevated C-reactive protein, and respiratory alkalosis. A chest computed tomography scan confirmed pneumonia, and a brain scan revealed multiple hypodense lesions. Despite antibiotic therapy, the patient's condition worsened, leading to confusion, disorientation, and loss of consciousness. Magnetic resonance imaging revealed multiple ring-enhancing lesions, suggesting an abscess formation. Bronchial washings and BAL samples confirmed a lower respiratory tract infection. Cultures from the bronchial washings grew Klebsiella pneumoniae. CONCLUSIONS: Metastatic brain abscesses caused by Klebsiella pneumoniae are exceedingly rare but life-threatening conditions. Timely diagnosis and effective antimicrobial treatment are critical for patient outcomes. This case underscores the significance of recognizing atypical presentations of bacterial infections, as early detection and appropriate management can significantly impact patient outcomes.

Undetected permanent dental inflammation as a possible trigger for brain abscesses? A retrospective analysis over the last 2 decades.

BACKGROUND: Recently, there is increasing evidence that the proportion of odontogenic brain abscesses is greater than previously known. In this study, we aim to differentiate the oral infections as triggers more precisely and to classify them in the clinical setting. METHODS: For analysis, we conducted a retrospective single center study. We reviewed patients with brain abscesses who have undergone treatment in the University Hospital of Freiburg, Germany in the period between 2000-2021. Inclusion required two main criteria: 1. The brain abscess must not have an other focus than odontogenic. 2. The microbial spectrum identified in the brain abscess must be consistent with an odontogenic origin. RESULTS: Of 217 brain abscess patients, 26 met the inclusion criteria. 42% (11 patients) suffered from immunosuppressive conditions. Odontogenic foci were diagnosed in 18 cases (69%). Neurologic deficits included vigilance reduction and hemiparesis. Pathogens of the Streptococcus anginosus group were the most frequent causative agent (21 cases, 81%). Metronidazole (54%) and ceftriaxone (42%) were part of the targeted antibiotic therapy. All brain abscesses were surgically treated. Teeth were extracted in 14 of 17 cases for focus control. 18 cases (72%) showed complete or partial resolution of neurologic symptoms and 3 cases were fatal. CONCLUSION: Apparently silent or chronic oral infections are sufficient to cause bacterial colonization of the brain, especially in immunocompromised patients. Therefore, special care should be taken to maintain good oral health. An interdisciplinary management should become a standard to prevent and treat the occurrence of brain abscesses.

Multiple brain abscesses caused by Nocardia farcinica infection after hand injury: A case report and literature review.

RATIONALE: Nocardia infection is commonly regarded as an opportunistic pulmonary pathogen affecting debilitated or immunocompromised individuals. Brain abscesses caused by Nocardia farcinica are rare and pose a diagnostic challenge. Traditional diagnostic techniques for identifying Nocardia species, such as blood culture, microscopy, and pathology, have shown inadequate performance. In the reported case, we applied metagenomic next-generation sequencing (mNGS) to diagnose a case of brain abscess due to N. farcinica. PATIENT CONCERNS: A 66-year-old female developed a brain abscess after sustaining a hand injury. The patient exhibited a gradual change in personality and experienced tremors in her right upper limb for a duration of 1 month. DIAGNOSES: The pathogen responsible for the multiple brain abscesses was identified in the cerebrospinal fluid as N. farcinica through mNGS. INTERVENTIONS: Antibiotic treatment included trimethoprim-sulfamethoxazole, linezolid, amikacin, meropenem, and moxifloxacin. OUTCOMES: The patient's symptoms and signs improved significantly after administration of antibiotics to which the pathogen is known to be sensitive. After 5 months of follow-up, magnetic resonance imaging of the head showed that the abscess was basically cured. The patient lived a normal life with no adverse drug reactions. LESSONS: Nocardia brain infection is characterized by an insidious onset and lacks distinctive clinical and imaging features. mNGS was advantageous for the timely identification and management of Nocardia-associated brain abscess in the present case and obviated the need for invasive brain surgery. Expeditious and precise diagnosis coupled with prompt antibiotic therapy can significantly reduce the mortality rate associated with this condition.

Polymicrobial brain abscesses: A complex condition with diagnostic and therapeutic challenges.

Brain abscesses (BA) are focal parenchymal infections that remain life-threatening conditions. Polymicrobial BAs (PBAs) are complex coinfections of bacteria or bacterial and nonbacterial pathogens such as fungi or parasites, with diagnostic and therapeutic challenges. In this article, we comprehensively review the prevalence, pathogenesis, clinical manifestations, and microbiological, histopathological, and radiological features of PBAs, as well as treatment and prognosis. While PBAs and monomicrobial BAs have some similarities such as nonspecific clinical presentations, PBAs are more complex in their pathogenesis, pathological, and imaging presentations. The diagnostic challenges of PBAs include nonspecific imaging features at early stages and difficulties in identification of some pathogens by routine techniques without the use of molecular analysis. Imaging of late-stage PBAs demonstrates increased heterogeneity within lesions, which corresponds to variable histopathological features depending on the dominant pathogen-induced changes in different areas. This heterogeneity is particularly marked in cases of coinfections with nonbacterial pathogens such as Toxoplasma gondii. Therapeutic challenges in the management of PBAs include initial medical therapy for possibly underrecognized coinfections prior to identification of multiple pathogens and subsequent broad-spectrum antimicrobial therapy to eradicate identified pathogens. PBAs deserve more awareness to facilitate prompt and appropriate treatment.

Metagenomic next-generation sequencing could play a pivotal role in validating the diagnosis of invasive mold disease of the central nervous system.

Background: Invasive mold diseases of the central nervous (CNS IMD) system are exceedingly rare disorders, characterized by nonspecific clinical symptoms. This results in significant diagnostic challenges, often leading to delayed diagnosis and the risk of misdiagnosis for patients. Metagenomic Next-Generation Sequencing (mNGS) holds significant importance for the diagnosis of infectious diseases, especially in the rapid and accurate identification of rare and difficult-to-culture pathogens. Therefore, this study aims to explore the clinical characteristics of invasive mold disease of CNS IMD in children and assess the effectiveness of mNGS technology in diagnosing CNS IMD. Methods: Three pediatric patients diagnosed with Invasive mold disease brain abscess and treated in the Pediatric Intensive Care Unit (PICU) of the First Affiliated Hospital of Zhengzhou University from January 2020 to December 2023 were selected for this study. Results: Case 1, a 6-year-old girl, was admitted to the hospital with "acute liver failure." During her hospital stay, she developed fever, irritability, and seizures. CSF mNGS testing resulted in a negative outcome. Multiple brain abscesses were drained, and Aspergillus fumigatus was detected in pus culture and mNGS. The condition gradually improved after treatment with voriconazole combined with caspofungin. Case 2, a 3-year-old girl, was admitted with "acute B-lymphoblastic leukemia." During induction chemotherapy, she developed fever and seizures. Aspergillus fumigatus was detected in the intracranial abscess fluid by mNGS, and the condition gradually improved after treatment with voriconazole combined with caspofungin, followed by "right-sided brain abscess drainage surgery." Case 3, a 7-year-old girl, showed lethargy, fever, and right-sided limb weakness during the pending chemotherapy period for acute B-lymphoblastic leukemia. Rhizomucor miehei and Rhizomucor pusillus was detected in the cerebrospinal fluid by mNGS. The condition gradually improved after treatment with amphotericin B combined with posaconazole. After a six-month follow-up post-discharge, the three patients improved without residual neurological sequelae, and the primary diseases were in complete remission. Conclusion: The clinical manifestations of CNS IMD lack specificity. Early mNGS can assist in identifying the pathogen, providing a basis for definitive diagnosis. Combined surgical treatment when necessary can help improve prognosis.

Neonatal sepsis with meningitis, ventriculitis and brain abscess caused by Edwardsiella tarda.

A case of neonatal sepsis caused by Edwardsiella tarda, an uncommon pathogen typically associated with aquatic lifeforms, is described. The infant presented in septic shock with seizures and respiratory failure and was found to have meningitis, ventriculitis and a brain abscess requiring drainage. Only a small number of case reports of neonatal E. tarda infection, several with sepsis with poor auditory or neurodevelopmental outcomes or meningitis, have been described in the literature. This case report suggests that E. tarda, while uncommon, can be a cause of serious central nervous system disease in the neonatal population and that an aggressive approach to pursuing and treating complications may lead to improved neurodevelopmental outcomes.