Infratentorial subdural empyema: clinical and computerized tomography findings. Report of three cases

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.

Pediatric infratentorial subdural empyema: A case report

BACKGROUND

Infratentorial subdural empyemas in children are extremely rare and potentially lethal intracranial infections. Delay in diagnosis and therapy is associated with increased morbidity and mortality.

CASE DESCRIPTION

A 4-year-old boy presented with cerebellar signs following a failed treatment of otitis media. Imaging studies revealed a subdural empyema and left transverse and sigmoid sinus thrombosis. The empyema was evacuated operatively and antibiotic treatment was initiated and administered for 6 weeks. The patient recovered fully and was discharged 4 weeks following the evacuation of the empyema.

CONCLUSION

While prompt identification and treatment of subdural infratentorial empyemas are crucial for favorable outcomes, their diagnosis in children might be initially missed. This is, in part because they are so rare and in part, because imaging artifacts arising from the complex posterior fossa anatomy may obscure their presence in the computer tomography (CT) scan. Therefore, high level of suspicion is necessary, given the appropriate history and clinical presentation. In children, this is a recent history of protracted otitis media and central nervous system symptomatology-cerebellar or other.

Cerebellopontine angle subdural empyema in a 2-years old patient with bilateral mastoiditis - a life-threatening condition. Case presentation and review of literature

Infratentorial subdural empyema is a life-threatening condition, the common source being an ear infection. We present a 2-year old boy treated for bilateral mastoiditis, with infratentorial-left cerebellopontine angle subdural empyema. Clinical presentation encompassed a systemic febrile illness, headaches, and a stiff neck. Empyema was diagnosed with computed tomography and magnetic resonance imaging. The patient was successfully treated with surgery and appropriate antibiotics. Empyema should be considered in patients with ENT infection associated with neurological signs that suggest a posterior fossa lesion.

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.

Infratentorial subdural empyemas mimicking pyogenic meningitis

Infratentorial subdural empyema is an extremely rare condition which unfortunately mimics pyogenic meningitis in 75% of cases. While an ill-planned lumbar puncture in these cases may be fatal, an inadvertent delay in treatment may be detrimental to the outcome for the patient. We present a case of a young boy with long standing history of chronic suppurative otitis media (CSOM) presenting with an infratentorial empyema with features suggestive of pyogenic meningitis. We also review the available literature to further define the condition in terms of clinical features, treatment options, and outcome. A misdiagnosis of this condition with failure to institute appropriate surgical intervention and antibiotic therapy is potentially life threatening. We highlight this rare condition which requires a high degree of suspicion especially in the presence of associated risk factors.

Falcotentorial subdural empyema: analysis of 10 cases

OBJECT

Parafalcine subdural empyema and those along the superior and inferior surface of the tentorium are rare entities. We present a series of 10 patients where we have attempted to describe the pathophysiology, clinical features, and management of subdural empyema.

METHODS

The study group included 10 cases of falcotentorial subdural empyemas managed between 2004 and 2010. The mean age group was 14.4 years. Seven patients had empyema along the falx or superior surface of tent, and the remaining three had empyema along the inferior surface of tent. Fever, raised intracranial pressure symptoms, falx syndrome, and seizures were the usual presenting features. These patients had an indolent presentation as compared to convexity subdural empyemas. The diagnosis was made based on radiology. Chronic suppurative otitis media was a causative factor in five patients; in the remaining patients, the source was ascribed to be hematogenous. All patients were treated with antibiotic therapy (6 weeks) ± surgery. Two patients were treated conservatively, and the remaining eight patients underwent definitive surgery in the form of craniotomy (supratentorial)/craniectomy (infratentorial) and evacuation of pus. The pus was limited within two leaves, one adherent to the falx/tent and the other one to the pia-arachnoid of adjacent parenchyma. The wall along the falx or tent could be peeled off easily and was excised in all cases to lay open the cavity widely. The wall along pia-arachnoid was left as it is. Pus culture was positive in four and blood culture positive in two cases. There was only a single mortality in our series. The outcome was assessed by the Glasgow Outcome Scale. The mean duration of follow-up was for 18.8 months, and all patients who survived had a good outcome.

CONCLUSION

Falcotentorial empyema remains a rare entity. The presentation is indolent as compared to convexity subdural empyemas, possibly due to its limitation secondary to arachnoid adhesions at the junction of falx, tent, and convexity dura. The main stay of management remains craniotomy, evacuation, and partial excision of the wall, laying it completely open, unless it is extremely thin. With appropriate surgery and antibiotic therapy, a good outcome can be expected.

Posterior fossa subdural empyema in children--management and outcome

AIMS

The aims of this study were to analyze the clinical features, radiologic findings, bacteriologic spectrum, and management protocols and outcomes in posterior fossa subdural empyemas in children.

MATERIALS AND METHODS

This study is a retrospective analysis of all children (age, <18 years) treated over a ten-year period (1994-2004) at NIMHANS, India. Clinical, bacteriologic, radiologic, and follow-up data were analyzed.

RESULTS

Twenty-seven children with posterior fossa empyemas were treated during this period, making this the largest series to date dealing with this rare entity. Posterior fossa empyemas are seen more commonly in the summer months and in males. Of the patients, 74.1% were in altered sensorium. The clinical features included the triad of fever, headache, and vomiting, which is a nonspecific picture. Cerebellar signs were elicited only in 40%. The most common source was untreated middle ear infection. Pus usually accumulates over the cerebellar convexity and is associated with hydrocephalus in 74% of patients. Cultures of the empyema pus were positive in 74% of cases, and 18.5% had polymicrobial infections. Only 21% of the patients needed a permanent CSF diversion procedure. Craniectomy is the treatment of choice in these cases.

CONCLUSIONS

The clinical features are nonspecific. Early surgery can salvage most patients and obviate the need for permanent CSF diversion procedures. Surgery (evacuation of empyema and mastoidectomy), antibiotics, and management of hydrocephalus are the mainstays of treatment.

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.

Unusual CNS infection from a subtorcular dermal sinus

A 14-month-old toddler with a previously unrecognized dermal sinus tract presented with hydrocephalus and raised intracranial pressure. CT and MRI revealed a large posterior fossa dermoid mass. Cultures obtained from CSF and posterior fossa subdural empyema were positive for both Staphylococcus aureus and Escherichia coli. To the authors's knowledge, this is the first such report.

CONCLUSION

This case suggests that children who present with CNS infections with unusual pathogens should be carefully evaluated for the presence of anatomic abnormalities including dermal sinus tracts.

Subdural empyema secondary to sinus infection in children

OBJECTIVE

To evaluate the impact, on morbidity and mortality, of aggressive surgical management of subdural empyema of sinus origin in children.

METHOD

The authors conducted a retrospective review of 20 children admitted between 2000-2007 to Alder Hay Children Hospital and The Walton centre for Neurology and Neurosurgery for subdural empyema secondary to sinus infection. Clinical presentation, duration of symptoms, radiological investigations, surgical treatment and post-operative outcome were evaluated.

RESULTS

Outcome was favourable in 19 cases. In four cases, there were re-accumulation requiring surgical evacuation, four patients experienced post-operative seizures but were seizure-free at follow-up. There was only one mortality in the series.

CONCLUSION

Subdural empyema secondary to sinus infection, although uncommon, it could be associated with a relative high morbidity and mortality rate. Early aggressive surgical and medical management with drainage of intracranial or sinus collections and antibiotics therapy lead to a low mortality or morbidity rate and good clinical outcome.

Salmonella Infantis Subdural Empyema in a Healthy Infant

Focal intracranial infections such as brain abscess, subdural empyema, or epidural abscess are unusual manifestations of salmonellosis found almost solely in immuno-compromised patients. We describe an unusual case of an 11-month old immuno-competent girl with a Salmonella Infantis subdural empyema. The case responded well to surgical drainage and long course of antibiotic treatment.

Subdural empyema in a case of Gaucher disease: a rare presentation

Subdural empyema is a surgical emergency; if not recognized and managed early, it may prove fatal. In most of the cases, condition is preceded by paranasal sinusitis, otitis media or trauma. The authors report a previously undescribed case of spontaneous subdural empyema associated with Gaucher disease that had a good outcome following burr hole evacuation of subdural empyema and parenteral antibiotics. Patients with Gaucher disease may be vulnerable to severe bacterial infections, due to defective function of phagocytic cells and hypersplenism.

Pediatric infratentorial subdural empyema: analysis of 14 cases

OBJECT

Pediatric cases of infratentorial subdural empyema (SDE) are both rare and associated with high rates of morbidity and mortality. The goal of this study was to report patient characteristics, treatment, and outcome in an exclusively pediatric series of SDE cases.

METHODS

A series of 14 pediatric cases of infratentorial SDE was retrospectively analyzed. All patients were treated between 1994 and 2004. Sixty-four percent of the patients were boys; the majority of cases occurred during the summer months. Clinical features included headache, fever, vomiting, meningism, and otorrhea. Cerebellar signs were found only in 21% of patients. In 85.7% of the cases, the patients presented with a depressed level of consciousness (Glasgow Coma Scale Scores 11-15). In 79.6%, pus collection was seen over the cerebellar convexity; interhemispheric and tentorial collections were also observed in some cases. Hydrocephalus was present in 92.9% of patients. Five patients required external ventricular drainage during surgery or postoperatively. Shunt placement was required in 21% of cases. All patients were treated with antibiotic therapy and surgery (bur holes in 21% of the cases, craniectomy in 79%). Pus cultures demonstrated microbial infection in 71.4%, and polymicrobial infection in 21%. Four patients required repeated surgery for reaccumulation of pus. Minor postoperative complications developed in three patients. All 14 patients survived. At follow up, the Glasgow Outcome Scale scores were 4 or 5 in all cases.

CONCLUSIONS

Early diagnosis and prompt surgical treatment are crucial in cases of SDE. With appropriate surgery, antibiotic therapy, and management of hydrocephalus, good outcome can be expected.

Empyèmes sous-duraux de l’enfant : stratégie thérapeutique

We report a series of five subdural empyema (SDE) in children and young adults treated in the same neurosurgical department. These five cases were reviewed retrospectively. There were four boys and one girl, aged from three months to 18 years at time of diagnosis (median age: 7 years). SDE following intracranial surgery were excluded from the study. All patients were treated surgically (burr hole evacuation or craniotomy, repeated in some cases), followed by intravenous antibiotic therapy (mean time: 52 days) adapted to the micro-organism. Only the two patients treated by large craniotomy at first had a single surgical procedure. Involved micro-organisms are as follow: Streptococcus intermedius (n=2), Streptococcus pneumoniae (n=1), Escherichia coli (n=1), absence of any identified micro-organism (n=1). The five patients are alive (median follow-up: 22 month) without any sequelae. We advocate an aggressive surgical treatment of SDE in children with a large bone flap to allow the surgeon to remove pus and membranes as much as possible, even in the interhemispheric fissure, followed by intravenous appropriate antibiotherapy and eradication of the source of infection. Even this "aggressive" treatment may sometimes not avoid re-operation. A careful follow-up is mandatory, because of the high risk of recurrence.

Subdural empyema and cerebellar abscess due to chronic otitis media

The infratentorial variety of the subdural empyema, with or without coexisting cerebellar abscess, is a rare clinical entity that carries a high mortality rate. We briefly describe the case of a 49-year-old man presented with severe debility, fever and an obviously neglected chronic otitis media. The patient had refused surgical treatment several months ago. After admission, his level of consciousness began to deteriorate, and the radiological studies showed infratentorial subdural suppuration extending into the right cerebellar hemisphere, along with chronic pyogenic infection of the middle ear and the mastoid process. Radical mastoidectomy was performed first, followed by extensive right posterior fossa craniectomy. The two subdural collections and the cerebellar abscess were successfully evacuated. Subsequently, he received post-operative antibiotic treatment for 6 weeks. At follow-up, 10 months after surgery, his neurological recovery was complete except for a minor residual cerebellar dysfunction on the right. This unusual case highlights that in patients presented with severe intracranial complications of chronic otitis media, early diagnosis and radical surgical intervention may be life saving.

Supra- and Infratentorial Subdural Empyema Secondary to Septicemia in a Patient With Liver Abscess-Case Report-

An 81-year-old man presented with subdural empyema in the left parietotemporal convexity 2 months after treatment under diagnoses of liver abscess and septicemia. Systemic investigation found no evidence of otorhinological or other focal infection except for liver abscess. Emergency drainage of pus was performed via a single burr hole and additional intravenous antibiotics were administered. Six weeks later, magnetic resonance imaging revealed subdural empyema in the right cerebellopontine angle in addition to recurrence of pus in the left parietotemporal subdural space. Ischemic changes were also shown in the right cerebellar hemisphere and brainstem. Although subdural empyema secondary to septicemia is rare, the possibility of this type of intracranial infection must be kept in mind, especially in compromised patients with septicemia.

Brain Abscess, Subdural Empyema, and Intracranial Epidural Abscess

Brain abscess, subdural empyema, and intracranial epidural abscess are three of the most commonly encountered focal suppurative processes of the central nervous system. A great deal has been known about the epidemiology and pathogenesis of these entities for quite some time, but until recent years the associated morbidity and mortality remained very high. New imaging techniques have allowed for more rapid detection and more precise localization of these lesions for surgical drainage. Empiric antimicrobial regimens that are effective within the abscess environment and that are directed against the most likely pathogens have also contributed to the improved outcomes seen in the current literature. This article will discuss some of the more recent advances in the diagnosis and treatment of these suppurative lesions within the central nervous system.

Infratentorial subdural empyema, pituitary abscess, and septic cavernous sinus thrombophlebitis secondary to paranasal sinusitis: case report

OBJECTIVE AND IMPORTANCE

Infratentorial empyema, pituitary abscess, and septic cavernous sinus thrombophlebitis are all rare and potentially lethal conditions. The occurrence of all three in a single patient has not previously been described. We present such a case occurring in a young, otherwise healthy man.

CLINICAL PRESENTATION

A 26-year-old man with a remote history of sinusitis developed rapidly progressive headache, fever, right eye pain, swelling, proptosis, and visual impairment. Magnetic resonance imaging demonstrated diffuse pansinusitis, including sphenoid sinusitis, and extension of inflammation and infection into the adjacent cavernous sinuses, pituitary gland, and posterior fossa.

INTERVENTION

Urgent drainage of the ethmoid and maxillary sinuses was performed; pus was not identified. The patient continued to deteriorate clinically with worsening of visual acuity. Computed tomography of the head performed the next day revealed worsening hydrocephalus and an enlarging posterior fossa subdural empyema. Urgent ventricular drainage and evacuation of the empyema was performed, and subsequently, the patient's clinical course improved. The microbiology results revealed alpha hemolytic streptococcus and coagulase-negative staphylococcus species. The patient survived but during the follow-up period had a blind right eye and pituitary insufficiency.

CONCLUSION

Paranasal sinusitis can have devastating intracranial sequelae. Involvement of the adjacent pituitary gland and cavernous sinuses can result in serious neurological morbidity or mortality, and retrograde spread of infection through the basal venous system can result in subdural or parenchymal brain involvement. A high index of suspicion and aggressive medical and surgical treatment are crucial for patient survival, but the morbidity rate remains high. Our patient survived but lost anterior pituitary function and vision in his right eye.

Infratentorial empyema: analysis of 22 cases

OBJECTIVE

Infratentorial empyema is an uncommon form of intracranial suppuration that is usually secondary to neglected otogenic infection. The diagnosis is frequently delayed and often confused with that of meningitis. The associated mortality is distressingly high, yet it has, as a clinical entity, received scant attention in the literature. We present a 13-year experience of this condition.

PATIENTS AND METHODS

From a retrospective analysis of 3865 patients with intracranial suppuration during a 13-year period, 22 patients with infratentorial empyema were identified. The inpatient notes for these patients were analyzed with reference to clinical, radiological, bacteriological, operative, and outcome data.

RESULTS

Twenty-two patients with infratentorial empyema accounted for 0.6% of admissions caused by intracranial suppuration during the study period. Of these 22 empyemas, 13 were subdural and 9 epidural. Hydrocephalus was present in 17 (77.3%). Except for two epidural empyemas that did not warrant neurosurgical intervention, all patients underwent standard surgical management (wide posterior fossa craniectomy). Nineteen underwent mastoidectomy because the source of infection was otogenic. Concomitant and persistent hydrocephalus was treated aggressively. Five patients died (mortality rate of 22.7%). All fatalities had subdural empyemas, and all three patients with cerebellopontine angle extension of subdural purulent collections died.

CONCLUSION

Although rare, infratentorial empyema, especially when subdural, is a lethal disease. Cerebellopontine angle extension of pus was a particularly ominous sign in our experience. Early surgical drainage via wide posterior fossa craniectomy, aggressive treatment of associated hydrocephalus, eradication of the primary source of sepsis, and, finally, intravenous high dosage of appropriate antibiotics form the mainstay of treatment.

Subdural empyema complicating bacterial meningitis in a child: Enhancement of membranes with gadolinium on magnetic resonance imaging in a patient without enhancement on computed tomography

Subdural empyema is a known yet infrequent complication of bacterial meningitis. Subdural effusions occur frequently with meningitis in children and usually resolve spontaneously or with subdural taps. Subdural empyema should be suspected when a patient fails to respond to antibiotic therapy or worsens neurologically. Computed tomography (CT) scans with contrast often show enhancement of subdural collections when an empyema exists. However, this is not true all of the time. We present a case of subdural empyema complicating bacterial meningitis in a 4 month old in which CT enhancement was not present yet magnetic resonance imaging (MRI) scans with gadolinium demonstrated intense enhancement. For comparison, we present a second case of a child with sterile subdural effusions due to meningitis that demonstrates an absence of contrast enhancement on MRI studies. MRI scans with contrast may offer a more sensitive means of making an early diagnosis of subdural empyema.