Cryptogenic subdural empyema mimicking subacute-subdural hematoma on CT imaging in the pediatric group: a clinical case series

Abstract

Introduction: Subdural empyema (SDE) is a rare but potentially life-threatening intracranial infection that is invariably fatal if left untreated. As clinical and radiologic features may be subtle or uncertain, early diagnosis may be a challenge but is crucial in reducing morbidity and mortality. SDE should always be suspected especially in a paediatric group with a history of fever, focal seizures, meningism and neurological deficit. The management of SDE has been debated in the literature for decades. Being one of the most serious neurosurgical emergencies, goals include surgical evacuation where both burr-hole drainage and craniotomy are primary surgical options, treatment of pus, and establishing the etiologic agent which subsequently guides antibiotic therapy for a favourable outcome.
 Case presentation: We present three cases of immunocompetent patients, 4 and 6-month-old infants with a 14-year-old adolescent presenting with SDE without underlying risk factors. Non-contrast computed tomography imaging was equivocal for SDE. All of them required surgery. The two infants underwent burr holes and subsequently a wide craniotomy with intravenous antibiotics therapy while the adolescent required craniectomy because of swollen brain. They all had a favourable outcome on long term follow up.
 
 Conclusion: Paediatric supratentorial SDE, although rapidly fatal if not identified promptly, can be effectively managed with early surgical drainage preferably craniotomy, eradication of the source, and sensitive IV broad-spectrum antibiotics. In this article, we discuss the clinical presentation, diagnostic tools, treatment options and outcomes for SDE with an emphasis on the challenges.