Intracranial Empyema Research Articles

Intracranial Empyemas: Experience of the Neurosurgery Department of Conakry University Hospital

Introduction: Intracranial empyemas are rare intracranial suppurations but carry serious and potentially fatal prognosis In the absence of adequate treatment. The objective of our study was to determine the epidemiological, clinical features, therapeutic and evolutionary characteristics of these suppurations in our department. Materials and methods: It was a descriptive retrospective study of 88 intracranial empyemas files collected over a period of 5 years (January 2014-December 2018) in the archives of the neurosurgery department of Conakry University Hospital. Results: The frequency was 43.1% for all intracranial suppurations. The mean age was 14.6 years (2-42 years) with a sex ratio of 1.8 (57 males/31 females). The port of infection was dominated by otorhinolaryngological infections, 76.5% and unknown in 19%. The clinical manifestations were dominated by fever (90%), intracranial hypertension (66%) and focal signs (45%). The site was subdural in 59 cases and extradural in 29 cases. Surgical treatment involved 91% of patients and 9%were treated with antibiotic therapy alone. The evolution was favorable in 68.1% of cases with a mortality rate of 13.6%. Conclusion: Intracranial empyemas are medical and surgical emergency. The forms of otorhinolaryngology origin are more frequent. Despite the therapeutic difficulties, the prognosis remains acceptable in our study with 13.6% of deaths.

Ten-year statewide cross-sectional review of pediatric sinogenic intracranial abscess and empyema in Queensland, Australia: microbial profile before and after COVID-19.

Sinogenic intracranial infections in children, such as subdural empyema or intracranial abscess, are a rare disease process with significant associated morbidity. Recent literature has suggested that there may have been an increase in frequency of these infections following the COVID-19 pandemic, but the literature has been conflicting, perhaps related to the heterogenous management of COVID-19 lockdowns in various states and differences in data capture between methods. The collection of statewide Australian data overcomes these limitations by capturing a comprehensive sample though the public healthcare system of patients who were subject to a homogeneous statewide approach to public health policy during the COVID-19 pandemic (population 5.6 million, including 1.3 million children). The objective of this study was to present population-level data to address the question of whether the incidence of intracranial infections changed in pediatric patients before and after the COVID-19 pandemic. The authors present a retrospective 10-year statewide description of sinogenic intracranial infections in Queensland, Australia. A comparison was made between the incidence and microbiological profile before and after the onset of COVID-19 lockdowns on March 22, 2020. Forty-four pediatric intracranial infections undergoing neurosurgical intervention were identified within the review period. After exclusion of postsurgical and cardioembolic causes, 33 sinogenic intracranial infections were included (16 before and 17 after 2020, with a mean annualized incidence of 0.25 vs 0.37 cases per 100,000 children, respectively; p > 0.05). The most frequent organisms identified were Streptococcus milleri (n = 19), polymicrobial (n = 4), and S. aureus (n = 3). No significant differences in antimicrobial profile, susceptibility, parenchymal involvement, or clinical outcome were identified between the pre- and post-COVID-19 groups. No statistically significant differences in the epidemiology of pediatric intracranial infection have occurred in the state of Queensland, Australia, before and after March 22, 2020, and the COVID-19 pandemic.

Presumed intracranial and spinal subdural empyema secondary to periorbital abscesses in a golden retriever

AbstractIntracranial and spinal subdural empyema was presumptively diagnosed in a 2‐year‐old golden retriever secondary to periorbital abscesses. The patient initially presented to the referring veterinarian for right eye conjunctivitis, intermittent left head turn and reluctance to eat on the left side. The patient then suffered neck trauma from a rope, developing neck pain, left‐sided conscious proprioceptive deficits and right‐sided Horner's syndrome. Most signs resolved with medical management at the referring veterinarian, but neck pain persisted. Severe acute neurological deterioration occurred before presentation at our hospital, culminating in decerebrate rigidity and opisthotonos. Neurological exam revealed multifocal intracranial disease. Magnetic resonance imaging showed periorbital abscesses and extensive intracranial and cervical spinal subdural empyema. The owners elected for euthanasia and declined postmortem examination. Cerebrospinal fluid sampled immediately postmortem confirmed empyema. This is the first report of a presumed case of intracranial and cervical spine subdural empyema caused by periorbital abscesses in a dog.

Pediatric intracranial empyema complicating otogenic and sinogenic infection

ObjectiveTo describe and compare clinical and microbiological features, surgical and medical management, and outcomes of children with otogenic and sinogenic intracranial empyema (IE) in an institution with an established multidisciplinary protocol. To use the study findings to inform and update the institutional algorithm. MethodsRetrospective analysis was carried out on the electronic healthcare records of all children with oto-sinogenic IE admitted in a 5-year period. ResultsA total of 76 patients were identified and treated according to an institutional protocol. Two distinct groups were identified: intracranial empyema related to otogenic infection (OI-IE, n = 36) or sinogenic infection (SI-IE, n = 40). SI-IE was seen in older children and had a significantly higher morbidity. Sub-dural IE was seen in a minority (n = 16) and only in SI-IE and required urgent collaborative ENT-neurosurgery. Extra-dural IE occurred more frequently and was seen in both SI-IE and OI-IE. No death and overall low morbidity were observed. Particularities found in SI-IE and OI-IE groups (as thrombosis, microbiology, antibiotic treatment, duration and outcome) permitted the delineation of these groups in our updated algorithm. ConclusionThe presence of a collaborative multidisciplinary protocol permits the step-wise co-ordination of care for these complex patients in our institution. All patients received prompt imaging, urgent surgical intervention, and antibiotic treatment. Microbiological identification was possible for each patient and antibiotic rationalization was permitted through use of Polymerase chain reaction (PCR) testing in cases of sterile cultures. Of note, intracranial empyema related to sinogenic infection is shown to have significantly more severe clinical presentation, a higher morbidity, and a longer duration of antibiotic therapy than that related to otogenic infection. Study findings allowed for the update and clarification of the institutional protocol, which now clearly demarcates the clinical presentation, biological evidence, radiology, surgical and medical treatments in children with oto-sinogenic IE.

Intracranial Empyema in Children: A Single-center Retrospective Case Series.

We conducted a retrospective, observational study of 42 children with intracranial empyema admitted to a pediatric neurosurgical center over a 9-year period. Intracranial empyema is rare, but causes significant morbidity and mortality. Twenty-eight cases had neurosurgical source control, more commonly for subdural collections. Streptococcus anginosus group bacteria are important pathogens in subdural empyema, whose isolation predicts more complicated postoperative courses.

Intracranial Empyemas in the COVID-19 Era: A New Phenomenon? A Paediatric Case Series and Review of the Literature

Introduction: We present the largest series of paediatric intracranial empyemas occurring after COVID-19 infection to date, and discuss the potential implications of the pandemic on this neurosurgical pathology. Methods: Patients admitted to our centre between January 2016 and December 2021 with a confirmed radiological diagnosis of intracranial empyema were retrospectively reviewed, excluding non-otorhinological source cases. Patients were grouped according to onset before or after onset of the COVID-19 pandemic and COVID-19 status. A literature review of all post-COVID-19 intracranial empyemas was performed. SPSS v27 was used for statistical analysis. Results: Sixteen patients were diagnosed with intracranial empyema: n = 5 prior to 2020 and n = 11 after, resulting in an average annual incidence of 0.3% prior to onset of the pandemic and 1.2% thereafter. Of those diagnosed since the pandemic, 4 (25%) were confirmed to have COVID-19 on recent PCR test. Time from COVID-19 infection until empyema diagnosis ranged from 15 days to 8 weeks. Mean age for post-COVID-19 cases was 8.5 years (range: 7–10 years) compared to 11 years in non-COVID cases (range: 3–14 years). Streptococcus intermedius was grown in all cases of post-COVID-19 empyema, and 3 of 4 (75%) post-COVID-19 cases developed cerebral sinus thromboses, compared to 3 of 12 (25%) non-COVID-19 cases. All cases were discharged home with no residual deficit. Conclusion: Our post-COVID-19 intracranial empyema series demonstrates a greater proportion of cerebral sinus thromboses than non-COVID-19 cases, potentially reflecting the thrombogenic effects of COVID-19. Incidence of intracranial empyema at our centre has increased since the start of the pandemic, causes of which require further investigation and multicentre collaboration.

An in Depth Look Into Intracranial Abscesses and Empyemas: a Ten-year Experience in a Single Institute.

Background:As the incidence of intracranial infections increase due to diagnostic procedures improvement, more real-life data is needed to reach a more solid informed management approach.Objective:This study aims to describe and analyse clinical features of intracranial abscesses patients treated at a tertiary hospital in North Jordan during a 10-year period.Methods:We retrospectively identified 37 patients treated at King Abdullah University Hospital (KAUH) from 2011 to 2020 in Irbid, North Jordan. Treatment consisted of either aspiration, open craniotomy excision (OCE) or conservative therapy. Extracted variables included demographic data such (age, gender), clinical presentation, lab findings, radiological findings as well as management plan. Retrieved data was compared between the patients who underwent a single operation and those who underwent reoperation after the initial procedure.Results:Thirty-seven patients with 55 intracerebral abscesses were identified, 29 of whom had intraparenchymal brain abscesses, 4 patients had epidural empyema, and 4 had subdural empyema. The mean age was 28.8 (± 20.7) years, with a male predominance (78.4%). Sixteen patients underwent open craniotomy excision (OCE), 14 patients were treated by aspiration and 7 patients were treated conservatively. When comparing the single operation and the reoperation groups, there was no statistically significant difference across variables.Conclusion:Our study presents valuable insight from a tertiary hospital in north Jordan on intracranial abscesses and empyemas. Our findings confirm that good recovery can be established after aspiration or OCE in the majority of patients. Similar results were obtained when comparing the SOP and the ROP groups.

Repeated intracranial empyema following cranioplasty in a patient with atopic dermatitis: a case report

BackgroundAtopic dermatitis is a chronic inflammatory skin disease associated with pruritus. Skin affected by atopic dermatitis not only shows a high percentage of Staphylococcus aureus colonization, but corneal barrier dysfunction is also known to occur. It is considered a risk factor for bacterial infections in various areas of the body. However, the relationship between atopic dermatitis and bacterial infection following neurological surgery has not yet been reported. Here, we present a case of atopic dermatitis in which the surgical site became infected twice and finally resolved only after the atopic dermatitis was treated.Case presentationA 50-year-old Japanese woman with atopic dermatitis underwent cerebral aneurysm clipping to prevent impending rupture. Postoperatively, she developed repeated epidural empyema following titanium cranioplasty. As a result of atopic dermatitis treatment with oral antiallergy medicines and external heparinoids, postoperative infection was suppressed by using an absorbable plastic plate for cranioplasty. The patient’s postoperative course was uneventful for 16 months.ConclusionsAtopic dermatitis is likely to cause surgical-site infection in neurosurgical procedures, and the use of a metal implant could promote the development of surgical-site infection in patients with dermatitis.

Cerebrospinal fluid analysis lacks diagnostic specificity in dogs with vestibular disease.

Although, vestibular syndrome is a common neurological presentation, little is known about the diagnostic value of cerebrospinal fluid (CSF) analysis in vestibular syndrome in dogs. Medical records were retrospectively reviewed, and dogs with vestibular disease that had undergone magnetic resonance imaging of the head, CSF analysis and were diagnosed with central or peripheral vestibular syndrome were included. Disorders affecting the central vestibular system included meningoencephalitis of unknown origin (MUO), brain neoplasia, ischaemic infarct, intracranial empyema or metronidazole toxicity. Disorders affecting the peripheral vestibular system included idiopathic vestibular disease, otitis media/interna or neoplasia affecting the inner ear structures. Total nucleated cell concentration (TNCC), total protein concentration (TP) and cytologic assessment were recorded. A total of 102 dogs met the inclusion criteria. The sensitivity and specificity of increased CSF TNCC to differentiate central from peripheral vestibular syndrome was 49% and 90%, while the sensitivity and specificity of increased TP was 58% and 39%, respectively. The TNCC and TP in dogs with MUO were significantly higher than in dogs with idiopathic vestibular disease (p=0.000 and p=0.004). MUO was associated with lymphocytic pleocytosis, while idiopathic vestibular disease and ischaemic infarct were associated with the presence of activated macrophages or normal cytology (p=0.000). Although consistent CSF abnormalities were observed in dogs with MUO, CSF analysis did not allow reliable differentiation between central and peripheral vestibular syndrome. CSF analysis is not reliable as the sole diagnostic technique in dogs with vestibular disease.

Intracerebral and interhemispheric abscesses as a complication of acute purulent polysinusitis

A clinical case of an interdisciplinary approach to the treatment of a 20-year-old patient with acute purulent polysinusitis, complicated firstly by intracranial episubdural empyema, and then by intracerebral and interhemispheric abscesses, is presented. Despite the timely initiation of antibiotic therapy, the patient had intracranial purulent-inflammatory complica tions of acute purulent polysinusitis, which required the participation of a multidisciplinary team of medical specialists, the appointment of reserve antibiotics and repeated surgical interventions. The described clinical observation confirms that the influence on the course and outcome of the disease in patients with EnT-associated intracranial purulentinflammatory complications is exerted by: a multidisciplinary approach involving a neurosurgeon, otorhinolaryngologist, neurologist, radiologist, clinical pharmacologist, and anesthesiologist-resuscitator; early diagnosis, including computed tomography and/or magnetic resonance imaging of the brain and paranasal sinuses; early verification of the pathogen and determination of its sensitivity to antibiotics; timely etiotropic high-dose parenteral antibiotic therapy with drugs that penetrate the blood-brain barrier; radical rehabilitation of EnT-organs and intracranial foci of infection.

Clinical reasoning in canine vestibular syndrome: Which presenting factors are important?

Although the use of clinical reasoning has been evaluated for several neurological presentations, this approach has not yet been investigated for dogs with vestibular syndrome. Two hundred and thirty-nine dogs presenting with vestibular syndrome were included in this retrospective study. Univariate analysis of variables (clinical history, signalment, clinical presentation and neurological examination findings) was performed. Variables with p < 0.3 were selected for logistic regression. Ninety-five percent of dogs were represented by eight conditions: idiopathic vestibular disease (n = 78 dogs), otitis media interna (n = 54), meningoencephalitis of unknown origin (n = 35), brain neoplasia (n = 26), ischaemic infarct (n = 25), intracranial empyema (n = 4), metronidazole toxicity (n = 3) and neoplasia affecting the middle ear (n = 3). Idiopathic vestibular disease was associated with higher age, higher bodyweight, improving clinical signs, pathological nystagmus, facial nerve paresis, absence of Horner's syndrome and a peripheral localisation. Otitis media interna was associated with younger age, male gender, Horner's syndrome, a peripheral localisation and a history of otitis externa. Ischaemic infarct was associated with older age, peracute onset of signs, absence of strabismus and a central localisation. Discrete clinical features can be used to identify the most likely diagnosis in dogs with vestibular syndrome.

Clinical reasoning in feline vestibular syndrome: which presenting features are the most important?

The aim of this study was to evaluate whether clinical variables from the history, clinical presentation, and physical and neurological examinations of cats with vestibular syndrome were statistically predictive of the underlying diagnosis. In total, 174 cats presenting with vestibular syndrome between January 2010 and May 2019 were investigated. Univariate statistical analysis of clinical variables was performed and those statistically associated with a diagnosis were retained for multivariable binary logistic regression modelling. The seven most prevalent diagnoses represented 95% of vestibular presentations, which included: otitis media/interna (n = 48), idiopathic vestibular syndrome (n = 39), intracranial neoplasia (n = 24), middle ear polyp (n = 17), feline infectious peritonitis (n = 13), thiamine deficiency (n = 13) and intracranial empyema (n = 11). Idiopathic vestibular syndrome was commonly associated with non-purebred cats and had 17.8 times the odds of an improving clinical progression (95% confidence interval [CI] 1.3-250.0; P = 0.03). Intracranial neoplasia was associated with older age and chronic onset of clinical signs, and was significantly more likely to have a central vestibular neuroanatomical localisation (95% CI 8.5-344,349,142.0; P = 0.015) with postural deficits on neurological examination. Thiamine deficiency was more common in female cats, with 52.6 times the odds of a waxing and waning clinical progression (95% CI 1.2-1000; P = 0.038) and 6.8 times the odds of presenting with bilateral vestibular signs (95% CI 1.0-45.7; P = 0.047) and wide excursions of the head (95% CI 1.0-45.7; P = 0.047). Middle ear polyps were associated with 8.8 times the odds of presenting with Horner syndrome (95% CI 1.5-50.0; P = 0.015). Although it may be difficult to identify the underlying diagnosis in cats with vestibular syndrome from the presenting features alone, there are instances in which discrete clinical features may help to guide clinical reasoning when evaluating cats with vestibular presentations.

Neuronavigation-Guided Endoscopic Endonasal Drainage of Pediatric Anterior Cranial Base Epidural and Subdural Empyema

In children, epidural and/or subdural intracranial empyema can complicate frontal sinusitis or pansinusitis. The standard transcranial approach used to treat epidural or subdural empyema has many drawbacks, but these can be avoided with an endoscopic expanded endonasal approach (EEA). To support the feasibility and advantages of this approach, we report the successful drainage through endoscopic EEA of a bifrontal empyema caused by an intracranial extension of pansinusitis. Our case and the ones previously reported in the literature establish well that endoscopic EEA offers several advantages over the standard craniotomy. Hence, EEA should be considered as an alternative to the transcranial approach when surgically draining anterior skull base empyema resulting from pansinusitis in children.

Brain abscesses and intracranial empyema due to dental pathogens: Case series

IntroductionSpontaneous brain abscess and intracranial empyema are rare but life-threatening diseases. They can result from potential complications of oral chronic infections. Given the similarity between most of the germs commonly found both in cerebral abscess and in oral cavity and its anatomic proximity, the oral cavity represents a major source of cerebral infections. Presentation of casesWe report here a series of seven cases of intracranial abscesses and empyema due to dental pathogens that occurred in the neurosurgery department of our institute. Five of those seven cases were then cared in the oral surgery department of our institute. DiscussionBacteriological examination of the brain abscesses identified an oral commensal bacterium belonging to streptococci group in six patients (85.7%) and Porphyromonas Gingivalis, a pathogen oral germ involved in periodontal diseases in the seventh patient. For all patients examined, oral status and oral health were poor or moderate with the presence of dental caries, missing teeth and abundant dental plaque. Except the oral cavity, no other front door or infectious site were found. ConclusionThis rare series of cases highlights the importance of systematically explore the oral cavity in presence of intracranial infection and to radically eradicate the potential infectious foci.

Evaluation of cerebral blood flow with transcranial Doppler ultrasound in a dog with surgically treated intracranial subdural empyema

A three-year-old spayed female Yorkshire terrier presented with a three-week history of lethargy and weight loss. Physical examination showed left exophthalmos with left nasal discharge. A lesion in the left...

Cerebral Empyema Complicating a Dental Abscess

Cervico-facial cellulitis can cause serious complications including neuro-meningeal infections. Among these neuro-meningeal infections are intracranial empyemas, which are rarer than brain abscesses. We report the case of a young patient of 25 years, immunocompetent, having presented a cerebral empyema secondary to diffuse cervicofacial cellulitis of dental origin. The diagnosis was suspected in the presence of cervicofacial cellulitis, febrile meningeal syndrome and consciousness disorder, confirmation was reported by brain MRI. The evolution was favorable after the recourse to the surgical treatment.

Retrospective evaluation of the clinical presentation, magnetic resonance imaging findings, and outcome of dogs diagnosed with intracranial empyema (2008-2015): 9 cases.

To describe the clinical presentation, advanced imaging findings, and short- and long-term outcomes in dogs with intracranial empyema. Retrospective case series. Client-owned dogs diagnosed with intracranial empyema. Medical records from 2 referral hospitals were searched for dogs diagnosed with intracranial empyema. To be included in this study, dogs had to fulfill 1 or more of the following 3 inclusion criteria: a magnetic resonance imaging (MRI) scan with space occupying accumulation of extra-axial material suggestive of empyema, a cerebrospinal fluid analysis suggestive of empyema, or direct visualization of purulent material during intracranial surgery. Nine dogs with intracranial empyema were included, with a median age of 3.5 years (range: 4 mo-12.5 y). All presented as emergencies with 7 of the 9 dogs showing neurological abnormalities and 2 of the 9 with retrobulbar swelling and exophthalmos. Six had surgical intervention, 1 was medically managed, and the remaining 2 dogs were euthanized. Typical MRI findings included extra-axial, T1-weighted hypo- to isointense, T2-weighted hyperintense material compared to gray matter with varying degrees of contrast enhancement, with 6 of 8 showing evidence of contiguous infection from adjacent structures on MRI. For 7 dogs, ≥1 samples were sent for culture and sensitivity, with Enterococcus (surgical swab), Streptococcus pneumonia (from cerebral spinal fluid), and coagulase positive Staphylococcus (ear swab) being cultured. The median antimicrobial course length was 6 weeks (range: 2-28 wk). All dogs for which treatment was attempted survived to discharge, with a median hospitalization time of 7 days (range: 4-10d). Four of the 7 are still alive at the time of writing (1 lost to follow-up; 2 euthanized for other reasons) with all 4 considered neurologically normal with a successful long-term outcome. Although intracranial empyema in dogs is a rare condition, excellent outcomes are possible in those cases treated appropriately.

Positive predictive value of ICD-10 diagnosis codes for brain abscess in the Danish National Patient Registry.

PurposeTo evaluate the positive predictive value (PPV) of ICD-10 diagnosis codes for brain abscess in the Danish National Patient Registry (DNPR).Patients and methodsWe examined medical records of all patients with a first-time diagnosis code of brain abscess in the DNPR from 2007 to 2016. Patients were categorized with either confirmed or disproved brain abscess using a priori defined criteria. We computed the PPV as the proportion of confirmed diagnoses.ResultsWe identified 709 patients, of whom the medical records could not be retrieved for 15 patients, leaving 694 for further analyses. Of these, 444 had a confirmed brain abscess and 250 had another proven diagnosis, including 47 cases of intracranial empyema. The overall PPV was 64% (95% CI: 60–68) ranging from 24% to 96% among the different codes evaluated. By including only patients with either 1) both a diagnosis and surgical procedure code for brain abscess or 2) patients admitted to hospital with certain primary diagnosis codes (DG060[C,E,F] or DG079B) without newly diagnosed central nervous system (CNS) cancer, spondylodiscitis/intraspinal abscess, or procedure codes for evacuation of intracranial empyema, the PPV increased to 84% (95% CI 80–87) and 89% (395/444) of all confirmed cases were identified.ConclusionThe overall PPV of diagnosis codes for brain abscess in the DNPR was moderate. However, by exclusion of newly diagnosed CNS tumors, spondylodiscitis/intraspinal abscess, and intracranial empyemas, the PPV was high and therefore suitable for future registry-based studies of brain abscess.

Suspected exaggerated reaction to dopamine infusion in a cat with increased intracranial pressure

An 11-year 8-month-old, male, neutered domestic shorthair cat was presented for investigation of progressive right vestibular signs following recent ear canal surgery. The investigations showed otitis media/interna, intracranial empyema and...

Lethal complication in Pott's Puffy tumor: A case report

Abstract A man in his fifties was found dead in his bed. Using postmortem CT, the frontal sinus wall was seen to have been destroyed and a subcutaneous / intra-cranial mass-like lesion was detected. Postmortem blood biochemical examination demonstrated high values of urea nitrogen, c-reactive protein, procalcitonin, and precepsin, which were thought to be due to sepsis. Needle aspiration showed reddish viscous fluid, and the presence of Klebsiella oxytoca was confirmed by culture inspection. Based on these results, Pott's puffy tumor with intracranial empyema, and dehydration with sepsis in the agonal period was assessed as the cause of death. Using autopsy evaluation, it was possible to come to a concrete conclusion, but a minimally invasive autopsy might be an alternative approach to investigate the cause of death.