Surgical treatment outcome of subdural empyema: A clinical study

Spontaneous Subdural Empyema: A Case Report

Subdural empyema is the collection of purulent material between the dura mater and arachnoid. Subdural empyema most often occurs due to the direct extension of local infection. But spontaneous subdural empyema is a rare entity. In literature, not many cases of spontaneous subdural empyema by Escherichia coli are reported. Here we report a case of spontaneous subdural empyema along with a review of literature who was previously treated on the suspicion of encephalitis with urinary tract infection and then brought to our hospital.

Surgical Indications and Outcomes of Postmeningitis Subdural Collection in Infants: Single Tertiary Care Center Experience

BACKGROUND

 Postmeningitis subdural collection (PMSC) is a complication in infants with bacterial meningitis. Clinical and radiologic findings enable treating teams to gain more insights into diagnosing and managing PMSC. This study aims to establish the indications for surgical management of PMSC in infants based on a single pediatric tertiary care center experience.

METHODS

 We reviewed the hospital records of infants diagnosed with PMSC between January 2015 and December 2021. They were diagnosed based on clinical suspicion that was confirmed through imaging using computed tomography (CT) scanning or magnetic resonance imaging (MRI). All patients received antibiotic treatment, and surgical interventions using subdural drain placement or craniotomy were performed. The patients were followed up for outcomes and prognosis for 1 to 5 years.

RESULTS

 A total of 17 infants were included in the study. Infants younger than 4 months represented most cases of PMSC (64.7%). Initially, bacterial growth was seen in the cerebrospinal fluid (CSF) of 15 (88.2%) patients. The causative agents included Streptococcus pneumoniae (58.8%), Salmonella spp. (11.7%), Streptococcus agalactiae (5.9%), Escherichia coli (5.9%), and Micrococcus luteus (5.9%). Growth in subdural fluid revealed the presence of E. coli (5.9%) and Staphylococcus hominis (5.9%). All the patients received treatments including combinations of antibiotics regimens. Major indications predisposing patients with PMSC to surgery included persistent fever, seizures, and bulging fontanel in the presence of PMSC on CT or MRI. All the patients underwent surgical operations, including subdural drain placement (76.5%) and craniotomy (23.5%).

CONCLUSIONS

 Persistent fever, seizures, and bulging fontanel, in the presence of PMSC, were found to be the indications for surgical intervention in PMSC. Drainage of PMSC and continuation of antibiotics is a safe and effective modality for treatment in PMSC, with a reasonable outcome and acceptable rate of morbidity and mortality. Craniotomy should be reserved for those with thick pus collection, as burr hole surgery can be used to achieve the goal in the majority of patients.

Subdural empyema due to mixed infections successfully treated medically: A case report with review literature

Subdural empyema is a rare intracranial infection with an accumulation of purulent material between the dura and arachnoid matter. We report a case of 17 years old presented with an altered conscious level. CSF analysis showed increased WBCs. His situation has improved after treating by acyclovir, ceftriaxone, vancomycin, and dexamethasone.

Efficacy of endoscopic sinus surgery alone versus in combination with neurosurgical intervention for the treatment of pediatric subdural empyema

OBJECTIVES

To compare treatment outcomes for sinogenic subdural empyema (SE) between those managed with initial endoscopic sinus surgery (ESS) alone versus those treated with a combination of ESS and craniotomy over the last decade at our institution. To better characterize subdural empyema with regard to presentation, causative pathogens, and treatment course.

METHODS

Retrospective single-center chart review to identify and evaluate pediatric SE patients between 2009 and 2019. Patients meeting inclusion criteria were classified in one of two groups: those who initially underwent ESS or frontal trephination without concurrent neurosurgical procedure and those who underwent craniotomy or burr hole in addition to a sinus procedure. Presenting characteristics and treatment outcomes were compared between the two groups.

RESULTS

Eighteen patients met inclusion criteria. The ESS alone and the ESS + craniotomy subgroups each had 9 patients with similar baseline characteristics. The ESS + craniotomy group was more likely to present with neurological symptoms (p = 0.039) and have multiple intracranial fluid collections (p = 0.046). 74.1% of patients presented to the Emergency Department (ED) or to their primary medical doctor and were treated with outpatient management prior to hospitalization with definitive surgical management. The most common presenting symptoms were fever, headache and nausea/vomiting. There were no differences between treatment groups in rate of return to the operating room (OR) (p = 1.00), length of stay (LOS) (p = 0.553), or adverse neurological outcomes (p = 0.456). 44.4% of patients in the ESS alone group eventually required neurosurgical intervention.

CONCLUSIONS

Surgical SE patients often present to medical professionals in the primary care setting or ED and are managed with outpatient treatment before admission with definitive treatment. In this small retrospective cohort patients who underwent sinus intervention alone had similar rates of return to OR, LOS and adverse neurological outcomes use as those who underwent a sinus procedure in coordination with a neurosurgical intervention. There may be a group of patients with SE who may be managed with endoscopic procedures alone and further studies should seek to determine the characteristics of this population.

Subdural false twins: concomitant appearance of subdural haematoma and spontaneous subdural empyema

A 55-year-old man was taken to the emergency department due to right arm weakness for the past 3 days and fever (39.5°C). There was no impaired consciousness, no history of trauma and meningeal signs were absent on physical examination. Blood analysis and inflammatory markers were not evocative of a systemic infection. A cranial CT scan was requested, revealing hypodense bilateral hemispheric subdural collections, suggestive of chronic subdural haematomas. He was submitted to surgical drainage by burr holes, which confirmed the chronic subdural collection on the left side. Unexpectedly, after dural opening on the right side, a subdural purulent collection was found, which was later confirmed as an empyema due to Escherichia coli infection. A second surgical drainage was performed by craniotomy due to recurrence of the right subdural collection. Spontaneously appearing subdural empyemas due to E. coli are extremely rare and their treatment is not always straightforward. The reported case is an example of an apparently straightforward and frequent pathology that turned out to be a challenging case, requiring a multidisciplinary approach.

Immediate replacement of bone flap after craniotomy for empyema in children

PURPOSE

Optimal management of the bone flap after craniotomy for intracranial infection has not been well defined in the pediatric population. This study reviewed the outcomes of a single Canadian center where immediate replacement of the bone flap was standard practice.

METHODS

This is a retrospective study of all patients who underwent craniotomies for evacuation of epidural or subdural empyema at a single center from 1982 to 2018. Patients were identified using the prospective surgical database maintained by the Division of Pediatric Neurosurgery at BC Children's Hospital. Primary outcome was treatment failure, defined as reoperation at the site of initial surgery for removal of an infected bone flap or repeat drainage of empyema under the replaced bone flap. Secondary outcome was any reoperation for recurrent infection at any site.

RESULTS

Twenty-four patients met the inclusion criteria with a minimum of 3-month follow-up from the index intervention. Treatment failure occurred in four patients (17%), all of whom required repeat surgery for further drainage of pus underlying the bone flap. Mean time to repeat surgery was 13 days. Any reoperation for recurrent infection at any site occurred in three patients. Seven out of 24 patients required a second surgery to evacuate empyema (29.2%). Age, sex, epidural or subdural location, osteomyelitis, and bone flap wash were not associated with the primary outcome of treatment failure.

CONCLUSION

Immediate replacement of the bone flap in the surgical management of pediatric subdural or epidural empyema is reasonable. Replacing the flap at the time of first surgery avoids the morbidity and costs of a subsequent reconstructive operation.

Infantile supratentorial subdural empyema managed by percutaneous aspiration: an outcome study in a Nigerian city

Subdural empyema (SDE), a common neurosurgical emergency in the developing countries, accounts for 15%-20% of localised paediatric intracranial infections. In regions where modern diagnostic tools are scarce and inaccessible, detection of SDE may be delayed with subsequent poor outcome. Percutaneous subdural aspiration in patients with open anterior fontanel may be the only surgical option in resource-poor regions of the world. This review focuses on the management outcome, including neurological outcome of these children. Clinical charts of children with SDE and treated by percutaneous subdural tap between February 2006 and August 2014 were reviewed. Demographic, clinical, radiological, bacteriological parameters and outcome data were analysed. Forty-five children with a mean age of 10.6 ± 6.2 months (range: 2-17 months) and followed up for a median duration of 16.4 months were included. The most frequent clinical features were enlarged head circumference, fever, focal neurologic deficits and altered level of consciousness. Diagnosis of SDE was confirmed using trans-fontanel ultrasound scan in 32 (71.1%) children, computerised tomography in 12 (26.7%) children and magnetic resonance imaging in one (2.2%) child. SDE was unilateral in 73.3% and bilateral in 26.7%. In 23 (51.1%) children with a positive culture, Staphylococcus aureus (n = 10), anaerobes (n = 7), Escherishia coli and Haemophilus influenza (n = 6 each) were the most common organisms. Forty-three children (95.6%) survived, 36 of which had good Glasgow outcome score. Seven children still had moderate deficits at 3 months. Treatment of SDE in young children with patent fontanel using percutaneous subdural tap has good therapeutic and neurological outcome.

Predictors of outcome of subdural empyema in children

OBJECTIVE

The aim of this study was to report the etiology, clinical features, microbiology, surgical outcome, and predictors of outcome of spontaneous subdural empyema (SDE).

METHODS

The authors conducted a retrospective study in a tertiary hospital. Children up to 18 years of age, with a diagnosis of SDE with infective etiology, were included in the present cohort. Patients with posttraumatic, postsurgery, and tubercular origin of SDE were excluded from the study. The Glasgow Outcome Scale was used for outcome assessment at the end of 3 months. For analysis purposes, the demographic data, clinical features, radiological data, microbiology, type of surgery, and complication data were categorized, and univariate and multivariable logistic regression analyses were performed to identify the factors associated with outcome.

RESULTS

Ninety-eight children were included in the study and the mean age was 10.9 years. Otogenic origin (34.7%) was the most common source of infection, followed by meningitis (14.3%). The mean duration of symptoms was 12 days. Seventy-six children presented with Glasgow Coma Scale (GCS) score > 8 and the supratentorial location was the most common location. Almost 75% of the children underwent craniotomy or craniectomy and the rest had burr-hole evacuation. Beta-hemolytic Streptococcus (10%) was the most common organism isolated. Cerebral venous thrombosis (CVT; 10.2%) was the most frequent complication in this cohort. The other complications were infarction (6.1%), new-onset seizure (4.1%), and bone flap osteomyelitis (4.1%). Thirteen cases had a recurrence of pus collection, which was more common in the craniotomy group than in the burr-hole group. Age (p = 0.02), GCS score ≤ 8 (OR 8.15, p = 0.001), CVT (OR 15.17, p = 0.001), and presence of infarction (OR 7, p = 0.05) were strongly associated with unfavorable outcome. In multivariable logistic regression analysis, only GCS score ≤ 8 (p = 0.01), CVT (p = 0.02), and presence of infarction (p = 0.04) had a significant impact on unfavorable outcome.

CONCLUSIONS

Prompt diagnosis and immediate intervention is the goal of management of SDE, especially in children as a delay in diagnosis can result in unconsciousness and secondary complications such as CVT and infarction, which adversely affect outcome.

Intracranial subdural empyemas and epidural abscesses in children

OBJECTIVE

The authors conducted a retrospective analysis of a consecutive series of children with intracranial subdural empyemas (SEs) and epidural abscesses (EAs) to highlight the important clinical difference between these two entities. They describe the delays and pitfalls in achieving accurate diagnoses and make treatment recommendations based on clinical and imaging findings.

METHODS

They reviewed their experience with children who had presented with intracranial SE and/or EA in the period from January 2013 to May 2018. They recorded presenting complaint, date of presentation, age, neurological examination findings, time from presentation to diagnosis, any errors in initial image interpretation, timing from diagnosis to surgical intervention, type of surgical intervention, neurological outcome, and microbiology data. They aimed to assess possible causes of any delay in diagnosis or surgical intervention.

RESULTS

Sixteen children with SE and/or EA had undergone evaluation by the authors’ neurosurgical service since 2013. Children with SE (n = 14) presented with unmistakable evidence of CNS involvement with only one exception. Children with EA alone (n = 2) had no evidence of CNS dysfunction. All children older than 1 year of age had sinusitis. The time from initial presentation to a physician to diagnosis ranged from 0 to 21 days with a mean and median of 4.5 and 6 days, respectively. The time from diagnosis to neurosurgical intervention ranged from 0 to 14 days with a mean and median of 3 and 1 day, respectively. Delay in treatment was due to misinterpretation of images, a failure to perform timely imaging, progression on imaging as an indication for surgical intervention, or the managing clinician’s preference. Among the 14 cases with SE, initial imaging studies in 6 were not interpreted as showing SE. Four SE collections were dictated as epidural even on MRI. The only fatality was associated with no surgical intervention. Endoscopic sinus surgery was not associated with reducing the need for repeat craniotomy.

CONCLUSIONS

Regardless of the initial imaging interpretation, any child presenting with focal neurological deficit or seizures and sinusitis should be assumed to have an SE or meningitis, and a careful review of high-resolution imaging, ideally MRI with contrast, should be performed. If an extraaxial collection is identified, surgical drainage should be performed expeditiously. Neurosurgical involvement and evaluation are imperative to achieve timely diagnoses and to guide management in these critically ill children.

ABBREVIATIONS

EA = epidural abscess; SE = subdural empyema.

Subdural empyema in children

BACKGROUND

Subdural empyema denotes the collection of purulent material in the subdural spaceand is commonly seen in infants and older children. In infants, the most common cause is bacterialmeningitis. In older children, sinusitis and otitis media are usually the source for subdural empyema. Theclinical symptomatology is varied and has a wide range including prolonged or recurrent fever, seizures,meningeal irritation, and raised intracranial pressure. It can mimic as well as complicate meningitis and aheightened clinical awareness is therefore paramount.

AIMS AND OBJECTIVES

The clinical profile, etiopathogenesis, imaging features and management of subdural empyema in children is discussed and the relevant literature is reviewed.

CONCLUSION

Subdural empyema is a neurosurgical emergency and rapid recognition and treatment canavoid life-threatening complications. In most cases, surgical decompression through burr hole or craniotomyis warranted. Near complete evacuation of the purulent material and appropriate long-term intravenous antibiotics are necessary for a gratifying outcome.

Rapidly progressing interhemispheric subdural empyema showing a three-fold increase in size within 12 hours: Case report

BACKGROUND

Subdural empyema is a rare form of intracranial infection. It is described as accumulation of purulent infective material between the inner layer of dura mater and outer layer of arachnoid membrane.

CASE DESCRIPTION

A 17-year-old girl was admitted to the emergency department with acute left hemiplegia and was diagnosed with interhemispheric subdural empyema that showed a three-fold increase in size within 12 hours. Complete recovery was achieved with emergency surgical evacuation and additional 3 weeks of antibiotic treatment.

CONCLUSION

Subdural empyema should be diagnosed and managed early in time since it may progress very rapidly and can cause high morbidity and mortality. Complete recovery can be achieved if it is diagnosed early and treated in time.

Aspiration of parafalcine empyemas with flexible scope

PURPOSE

Subdural empyemas are considered neurosurgical emergencies, and the parafalcine location is particularly insidious. We revised the experience of general surgeons who are used to manage chronic pleural purulent collections with video-assisted thoracoscopy.

METHODS

With a similar technique, we successfully aspirated a parafalcine empyema using a flexible scope avoiding a more invasive craniotomy. A review of the treatment options of empyematous collections is also provided, focusing particularly on the hazardous parafalcine location.

RESULTS

The management of subdural empyemas poses different decision-making problems compared to common brain abscesses, urging a more rapid and holistic surgical treatment with minimally invasive approach. Endoscopic aspiration of parafalcine empyema was followed by complete recovery in our patient.

CONCLUSIONS

Flexible endoscopy is a promising method to obtain complete pus removal even from loculated collections through a bur hole, avoiding large craniotomies and consequent potential complications.

Intracranial hypotension after syringopleural shunting in posttraumatic syringomyelia: Case report and review of the literature

We report a case of a 45-year-old male with a syringopleural shunt who developed intracranial hypotension. The patient presented with 2 weeks history of worsening headache and back pain, on a background of having had a syringopleural shunt inserted for a thoracic posttraumatic syrinx. Computerized tomography imaging of the brain revealed bilateral subdural fluid collections. Magnetic resonance imaging appearances of spinal and intracranial pachymeningeal enhancement confirmed intracranial hypotension. We present a rare case of intracranial hypotension secondary to syringopleural shunting in a patient with posttraumatic syringomyelia.

Delayed Occurrence of Escherichia coli Subdural Empyema Following Head Injury in an Elderly Patient: A Case Report and Literature Review

Subdural empyema is a rare but serious intracranial infection that warrants prompt management to reduce morbidity and avoid mortality. However, clinical and radiologic features may be subtle or ambivalent. Thus a diagnosis of subdural empyema should not be discounted, especially in a patient with a history of head trauma. Treatment consists of surgery to establish bacteriologic identification and subsequently guide antibiotic therapy. Here we present a case of delayed Escherichia coli subdural empyema following a head injury in an elderly patient without significant risk factors. Computed tomography imaging was equivocal for subdural empyema. The patient underwent surgery and was treated with intravenous antibiotic therapy. Although initial improvement in the patient's clinical condition was observed, he eventually succumbed to nosocomial pneumonia. In this article, we discuss the presentation, diagnostic tools, and treatment options for subdural empyema with an emphasis on the challenges. The management conundrum that follows prompted us subsequently to review the literature.

[Intracranial empyemas: Epidemiological, clinical, radiological and therapeutic aspects. Retrospective study of 100 observations]

INTRODUCTION

Intracranial empyema is a frequent complication of ear-nose-throat (ENT) infections. Limited studies have been carried-out on cerebral empyema during recent years in Senegal. Despite new imaging techniques, diagnostic and therapeutic problems as well as outcome still remain in our regions. We report our experience compared to that of the literature. The study focused on epidemiological aspects, difficulties in diagnosis and treatment as well as prognosis of this condition.

METHODS

This was a retrospective study conducted from January 2008 to December 2011 of 100 clinical cases. Diagnosis was made based on contrast CT-scan. Twenty-one percent of patients received medical treatment alone, while 79% underwent surgery. The duration of the treatment varied from 4 to 8 weeks. The follow-up was clinical and radiological with a mean follow-up time of 12 months.

RESULTS

Cerebral empyema represented 44.4 % of all intracranial suppuration cases and the mean age was 21 years. The etiology was ENT in 35%, meningitis 10%, unknown 25%. Localization was sub-dural in 57%, extra-dural in 22%, inter-hemispheric in 10% of the cases. Empyema was associated with an abscess in 7 cases. One case was located in the posterior fossa. The evolution was favorable in 78% of the cases and in 12.5% some neurologic sequelae were observed. Eleven patients died and 3% of the patients had recurrences.

CONCLUSION

The frequency of intracranial empyema is still high in Senegal. Difficulties in diagnosis, therapeutics and low economic incomes account for the gravity of intracranial empyema. In spite of these risks, early stage and effective treatment is necessary to reduce the morbi-mortality, especially in young aged children.

Escherichia coli positive infratentorial subdural empyema secondary to mastoiditis and underlying cholesteatoma

Infratentorial subdural empyema is a neurosurgical emergency that is associated with an alarmingly high morbidity and mortality if appropriate management is delayed. It is an important differential to consider when confronted with a patient with a reduced Glasgow Coma Scale, focal neurology and symptoms of raised intracranial pressure in the presence of a head and neck infection. It is also important that the primary team managing these patients is aware of the many pathogens that may be involved, including Escherichia coli. Early recognition, prompt diagnosis, timely involvement of the appropriate multidisciplinary teams, including neurosurgery, otorhinolaryngology, radiology and microbiology should be sought, and urgent intervention are imperative in avoiding a fatal outcome. This article presents a case of E coli-positive infratentorial subdural empyema secondary to mastoiditis due to underlying cholesteatoma, and a review of the pertinent literature.

Neurosurgical management of extraaxial central nervous system infections in children

OBJECT

Extraaxial infections of the CNS, including subdural empyema and epidural abscess, are rare but potentially life-threatening conditions. Symptoms are usually progressive, and early diagnosis is therefore important. Early intervention with appropriate treatment offers the best opportunity for eradicating the infection and promoting maximal neurological recovery.

METHODS

The medical records of children with extraaxial CNS infection over the last 24 years at the Hospital for Sick Children were analyzed. Only those patients with radiological and/or operative confirmation of the diagnosis of subdural empyema or epidural abscess were included in the study. Demographic and clinical data were collected to determine the outcomes after such infections and factors that predict for such outcomes.

RESULTS

The authors identified 70 children who fulfilled the inclusion criteria. Sinusitis was the most common etiology and was seen in 38 patients. All of these patients were older than 7 years of age at diagnosis. Subdural empyemas were diagnosed in 13 patients following bacterial meningitis, and they were found primarily in infants within the 1st year of life. Other etiological factors included otogenic infection (4 cases), postneurosurgical infection (7 cases), and hematogenous spread of infection (7 cases including 6 cases of spinal epidural abscess). Streptococcus anginosus and Staphylococcus aureus were the most common pathogens identified. Sixty-four patients (91.4%) underwent at least 1 neurosurgical procedure. Seizures and cerebral edema from cortical vein thrombosis were the most common complications.

CONCLUSIONS

Due to variable etiology, identification of the responsible microorganism through neurosurgical drainage followed by long-term intravenous antibiotics remains the mainstay in treating extraaxial CNS infections. Optimal outcome is achieved with early diagnosis and therapy.

Obscure manifestations of Salmonella subdural empyema in children: case report and literature review

PURPOSE

Salmonella intracranial infections, including subdural empyema and brain abscess, are rare clinical manifestations in children. The aim of this study is to investigate the clinical course of Salmonella subdural empyema in infants and children.

METHODS

We report a 9-month-old female infant diagnosed as Salmonella subdural empyema with clinical features of prolonged fever for more than 2 months and episodic focal seizures. Literature published between 1986 and 2010 relevant to Salmonella subdural empyema in children were reviewed. The clinical presentations and laboratory findings were analyzed.

RESULTS

Seventeen cases with Salmonella subdural empyema, including our index case, has been reported with detailed clinical presentation. Fever (17/17; 100%), symptoms and signs of increased intracranial pressure (8/17; 47%), seizures (8/17; 47%), and limb paralysis (8/17; 47%) were the most frequent clinical features. Among these cases, unknown causative organism prior to surgery (11/17; 65%) and prolonged fever for more than 3 weeks (5/17; 29%) were also noticed. Sixteen out of 17 patients (94%) required surgical intervention for treatment. The morbidity rate and mortality rate were 29% (5/17) and 6% (1/17), respectively.

CONCLUSION

Subdural empyema is considered to be a disease with rapid progression. However, the cases caused by Salmonella species may present a slow disease course. Surgical intervention is sometimes the only way to detect the pathogen.

Focal intradural brain infections in children: an analysis of management and outcome

INTRODUCTION

Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients.

MATERIALS AND METHODS

This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data.

RESULTS

There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions.

CONCLUSIONS

Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Escherichia coli subdural empyema following subdural hygroma in elderly patient

Subdural empyema of the brain is an uncommon disorder that occurs more frequently in children than in adult. Authors report a very rare of subdural empyema following the subdural hygroma after mild head injury. The exact mechanism of infection is not known. However, we have to consider subdural infection as one of differential diagnosis in elderly patient with subdural hygroma when new abnormal density lesion is developed in the subdural space.

The treatment and outcome of postmeningitic subdural empyema in infants

OBJECT

The management of subdural empyema (SDE) has been debated in the literature for decades. Craniotomy and bur hole drainage have been shown to achieve a favorable outcome. However, there is a lack of comparative data for these modes of management of SDE subsequent to meningitis in infants.

METHODS

The authors conducted a retrospective review of 33 infants identified with SDE due to meningitis at the Department of Neurosurgery, Chang Gung Memorial Hospital between 2000 and 2006. Preoperative clinical presentation, duration of symptoms, radiological investigations, CSF data, and postoperative outcome were analyzed and compared between these 2 surgical groups.

RESULTS

At diagnosis, there were no differences between the groups in age, weight, degree of consciousness, CSF analysis, or duration of fever. The outcome data showed no difference in the number of days until afebrile, number of days of postsurgical antibiotic treatment, neurological outcome, recurrence rate, or complication rate. There was only 1 death in the series.

CONCLUSIONS

Subdural empyema due to meningitis in infants is unique with respect to the pathophysiology, presentation, and treatment of SDE. Early detection and removal of SDE provide a favorable outcome in both surgical intervention groups. Bur hole drainage is less invasive, and it is possible to expect a clinical outcome as good as with craniotomy in postmeningitic SDE.

Meningitis with subdural empyema due to non-typhoid Salmonella in a 9-month-old girl

We report a case of a 9-month-old baby admitted to the hospital because of low-grade fever, focal seizures in a context of watery diarrhea for 14 days' duration. The patient workup revealed a mild neutrophilic pleocytosis on cerebrospinal fluid (46 cells/microl), a positive stool culture for Salmonella pomona sensitive to ceftriaxone and ciprofloxacin, and a subdural empyema (SDE) on the cerebral MRI. The child received an intravenous third-generation cephalosporin for 4 weeks which resulted in cure. This case highlights an unusual extra-intestinal complication of non-typhoid salmonella infection. Involvement of the central nervous system with non-typhoidal salmonellosis is an important complication that can result in significant morbidity if not recognized and treated promptly. A focal intra-cranial infection must be considered in the differential diagnosis of any child presenting with focal seizures and gastroenteritis due to Salmonella. Appropriate diagnostic imaging of the head (cerebral CT scan with contrast and/or MRI) is mandatory to exclude the presence of an intra-cranial complication, even in the presence of negative CSF culture for Salmonella. Subfrontal and subtemporal SDE are sometimes missed on axial CT scans and better appreciated on MRI. Non-surgical treatment of small subdural empyemas with prolonged intravenous antibiotic therapy is a therapeutic option.

Paediatric intracranial empyema: differences according to age

No recent studies are available which consider the epidemiology and outcome of paediatric intracranial empyema (PICE). We retrospectively studied all PICE cases admitted in our institution from 1993 to 2006. Outcome was assessed using the Glasgow Outcome Scale (GOS) at 24 months. Aetiology, clinical features, therapeutic considerations and risk factors of poor outcome were analysed according to age. Data from 38 patients were studied; 33/38 presented with subdural empyema (SDE) and 5/38 with extradural empyema (EDE); 10/38 were infants <1 year of age with SDE, all related to bacterial meningitis; 28/38 were children, with 23/28 showing SDE and 5/28 EDE. Oto-sinogenic infections were the main causes in children. All infants recovered completely as did children with EDE. However, two out of 23 children with SDE had permanent neurological deficit, already detected on admission, and one out of 23 died. Thirty-three out of 38 were operated; 16 of which underwent multiple surgical procedure because of recurrence. Burr hole was performed in six infants and craniotomy in one, while 21/23 children underwent burr hole or craniotomy. Burr hole was more often associated with recurrence. In children with SDE, factors associated with poor outcome were neurological deficit (p = 0.002) and cerebral herniation on CT scan (p = 0.02) on admission. In this study, we gained further insights into modern epidemiology of PICE by highlighting age-related aetiology, symptoms, treatment strategy, and outcome differences. Meningitis was the main aetiology in the infants and sinusitis was prevalent in children. Finally, early diagnosis by neuro-imaging investigations and timely and appropriate multidisciplinary treatment may offer the best chance of recovery.

Two surgical methods used in 90 patients with intracranial subdural empyema

We studied the efficacy of two surgical methods used for the treatment of intracranial subdural empyema (ISDE) at our centre. A cross-sectional study (1999-2005) of 90 patients with non-traumatic supratentorial ISDE revealed that the two surgical methods used for empyema removal were burr hole/s and drainage (50 patients, 55.6%) and a cranial bone opening procedure (CBOP) (40 patients, 44.4%). Patients in the CBOP group had a better result in terms of clinical improvement (chi-squared analysis, p=0.006) and clearance of empyema on brain CT scan (chi-squared analysis, p<0.001). Reoperation was more frequent among patients who had undergone burr hole surgery (multiple logistic regression, p<0.001). The outcome and morbidity of ISDE survivors were not related to the surgical method used (p>0.05). The only factor that significantly affected the morbidity of ISDE was level of consciousness at the time of surgery (multiple logistic regression, p<0.001). We conclude that CBOP and evacuation of the empyema is a better surgical method for ISDE than burr hole/s and drainage. Wide cranial opening and empyema evacuation improves neurological status, gives better clearance of the empyema and reduces the need for reoperation. Level of consciousness at the time of presentation is a predictor of the morbidity of ISDE. Thus, aggressive surgical treatment should occur as early as possible, before the patient deteriorates.

Superimposed propionibacterium acnes subdural empyema in a patient with chronic subdural hematoma

The authors present a case of subdural empyema in a macrocephalic patient. A 23-year-old male was admitted due to headache and fever. One month ago, he had mild head injury by his coworkers. Physical examination showed a macrocephaly and laboratory findings suggested purulent meningitis. Neuroimaging studies revealed a huge size of epidural space-occupying lesion. Under the impression of epidural abscess, operation was performed. Eventually, the lesion was located at subdural space and was proven to be subdural empyema. Later, histological examination of the specimen obtained by surgery demonstrated finings consistent with the capsule of the chronic subdural hematoma. Two weeks after operation, Propionibacterium acnes was isolated. The intravenous antibiotics were used for total of eight weeks under monitoring of the serum level of the C-reactive protein. Follow-up brain computed tomography (CT) scan showed the presence of significant amount of remaining subdural lesion. However, he has complained of minimal discomfort. It is suggested that the subdural empyema occurred with preexisting chronic subdural hematoma after head injury about one month prior to admission and it took a long time to treat Propionibacterium acnes subdural empyema with systemic antibiotics, at least over eight weeks.

Vascular and Parameningeal Infections of the Head and Neck

Vascular and parameningeal infections of the head and neck are rare but frequently life threatening. These infections include intracranial and extracranial septic venous thrombophlebitis, arterial mycotic aneurysms and erosions, subdural empyema, and epidural abscesses. They usually arise as complications of otogenic, oropharyngeal, or paranasal sinus infections, and management involves an aggressive combined medical-surgical approach.