Intracranial Subdural Empyema Research Articles

The hidden threat: subdural empyema strikes a healthy teen

BackgroundThe incidence estimates for intracranial subdural empyema are 0.1 per 100,000 individuals, making it a rare clinical condition. It is a highly morbid and fatal illness that is most commonly the result of a primary infection somewhere else.Case presentationThe authors present a young male patient 15 years presented with 1 week history of headache, fever, confusion and seizure attack with initial negative CT head and nearly negative CSF analysis. With few days he developed left sided weakness. MRI brain showed right temporoparietal subdural fluid collection with midline shift. Urgent neurosurgical evacuation was made and revealed subdural empyema. The boy received combination therapy of vancomycin, ceftriaxone, and metronidazole. The culture of the pus was negative but 16S rRNA gene sequencing (bacterial) revealed streptococcus intermedius. He made a good recovery with no recollection or neurological deficit on follow up.ConclusionThis case highlights the possibility of occurrence of this rare infection in otherwise healthy individuals without obvious precipitating factor. It also indicates the superiority of MRI brain over CT head in detection of subdural collection. The rapid diagnosis and intervention improve the outcome of the patient.

Sterile Subdural Empyema Mimicking Subdural Hemorrhage in Pediatric patient with History of Trauma

Intracranial subdural empyema (SDE) is a life-threatening infection. Surgery procedure for culture the empyema is essential to diagnosing and treating the patient. Nevertheless, in rare cases, culture can not identify the causative organism because microorganisms are not grown. A ten-year-old girl with the main complaint of weakness in the right hand since two days before admission. She fell off the bicycle two months before admission, and her head hit the ground. Nevertheless, the patient's condition was stable at that time, and there was no history of loss of consciousness. A head CT scan with and without contrast found a mass suggesting chronic subdural hemorrhage. The patient undergoes surgery with burr hole drainage for chronic SDH but intraoperatively found subdural empyema. SDE could be an uncommon, harmful, pus-filled accumulation of tissue between the outer dura and inner arachnoid mater. Meningitis is the most frequent cause of SDE in children and newborns. Despite the fact that operative cultures can identify the responsible organisms, 7% to 52% of instances result in no growth, which is primarily due to the use of antibiotics in the past or inappropriate anaerobic culture technique. Intracranial subdural empyema (SDE) is an emergency and life-threatening infection. SDE can also mimic chronic SDH and make it difficult to diagnose. Emergency surgery is required for a better outcome for the patient. Culture empyema from collecting pus is not always found in the microorganism pathogen, which could be in sterile conditions.

Subdural empyema as a complication of odontogenic sinusitis: A case report

Odontogenic sinusitis represents between 10 and 40% of all cases of sinusitis in the population and may present with common symptoms such as nasal obstruction, anterior or posterior rhinorrhea, facial pain or pressure; and hypo- or anosmia. Although uncommon, intracranial and systemic suppurative complications have been previously reported in the literature and include brain abscess, epidural abscess and subdural empyema, associated with almost 100% morbidity and mortality, however, they are commonly related to meningitis, otogenic diseases and other sinus diseases. The aim of this study was to report a clinical case of intracranial subdural empyema associated with odontogenic infection in a previously healthy 17-year-old patient. This case highlighted the possibility of relevant complications, including even the patient's death, due to odontogenic sinusitis. Therefore, early dental planning and approach in a hospital environment are relevant and essential both in prevention and in the course of treatment, substantiating the multidisciplinary approach.

Complete recovery of interhemispheric subdural empyema extending to cerebellar tentorium treated with antibiotics as unimodal therapy: a case report and controversial literature review

Link of Video Abstract: https://youtu.be/ep7OSDbighoBackground: Intracranial subdural empyema, although rare, represents an extreme medical and neurosurgical emergency. Multiple burr holes or a craniotomy for drainage and antibiotics are the treatment of choice. This case study aims to evaluate the complete recovery of interhemispheric subdural empyema extending to cerebellar tentorium treated with antibiotics as unimodal therapy. Case Presentation: We present a case of a 40-year-old male with severe headache, a decrease of consciousness GCS E3V1M5, generalized onset tonic-clonic seizure, right abducens palsy, and right hemiparesis. Interhemispheric subdural empyema extending to cerebellar tentorium with associated intracranial abscess was seen from brain magnetic resonance imaging (MRI). Antibiotics were administered without surgical intervention due to the patient's family rejection. The patient regained full consciousness within 1 week and complete neurological function after 4 weeks of continuous use of antibiotics. The patient was discharged, and his recovery was uneventful on subsequent follow-up. Conclusion: The use of antibiotics as monotherapy in subdural empyema is controversial, as it is widely accepted that surgery must be initiated as soon as possible in this pathology. It is indicated in small portions of cases without major neurological deficits or in particular conditions where surgery could not be performed. Still, more recent studies found it justifiable in patients with documented initial good responses. This case report highlights the complete recovery and the clinical outcome of antibiotics as monotherapy for subdural empyema.

Contemporary Management of Intracranial Subdural Empyema: An Institutional Experience.

Intracranial subdural empyema (SDE) is a seemingly uncommon life-threatening ailment with varying presentations and outcomes. A variety of risk factors have been associated with predisposition to intracranial SDEs; however, they may be cryptogenic. There is an increased predilection for intracranial SDE in children and teenagers with paranasal sinusitis or middle ear infections. The clinical presentation is non-specific and thus a high index of suspicion is required. Neuroimaging is an invaluable diagnostic tool for early diagnosis and surgical intervention. There have been multiple proponents for either burr hole or craniotomy to treat intracranial SDEs; however, despite surgical intervention, adverse neurologic sequelae and even mortality still occur. Extended antibiotic therapy is mandatory and impacts significantly on patients' outcomes. This study describes the demographics, clinical presentation, and surgical outcomes in patients with intracranial SDEs over the study period. This is a retrospective single-centre case series. This study takes place in a tertiary referral centre, university hospital. This was a retrospective review of patients presenting with intracranial SDEs over a 10-year period in a tertiary neurosurgical unit serving south-western Nigeria. Demographic, clinical, and radiologic data were retrieved from patient records. Forty-nine patients presented with intracranial SDEs during the review period. These patients aged between 16 months and 75 years, most of whom were 20 years of age and below. The mean age was 21.37 ± 19.29 years with a median age of 15 years. There were 35 males and 14 females giving a male-to-female ratio of 2.5:1. The most common presentations were headache (73.5%), altered sensorium (55.1%), and seizures (38.8%). Forty patients (81.6%) had evacuation of SDE by burr hole and subdural washout. There was a significant post-op residual SDE in six patients. There were eight (16.3%) mortalities in this series. Forty-seven (95.9%) patients had sterile cultures of the subdural pus collection. Intracranial SDE affects mostly children and teenagers. Early diagnosis, emergent surgery, extended antibiotic therapy, and concurrent source control employing a multidisciplinary approach are essential in managing this condition. Burr hole and subdural washout help control the disease process, reduce operation time, and may yield outcomes similar to craniotomies, which are more invasive.

P-OT023. Intracranial subdural empyema mimicking acute on chronic subdural hematoma: a case report

Introduction. Intracranial subdural empyema is a rare localized intracranial infection that forms between dura and arachnoid membrane of the meninges. Its unspecific clinical presentations as well as neuroimaging findings that might resemble subdural hematoma make the definitive diagnosis of subdural empyema difficult. This report aims to highlight the importance of making a differential diagnosis of subdural empyema in a suspected case of subdural hematoma. Results. A 71 years old male presented with acute mild to moderate intermittent headache that was followed by sudden difficulty in word findings and right limbs weakness. No history of fever, trauma, seizure, or prior history of ear, nose, throat, tooth infections, and intracranial surgical procedure. Increased white blood cells count was not found despite the increased neutrophil to lymphocyte ratio as well as C-reactive protein. Non-contrast head CT-scan showed crescentic hyperdense lesion within a wider hypodense lesion in the left frontotemporoparietal region, characterizing acute on chronic subdural hematoma. During burr hole drainage, pus was found, consistent with subdural empyema. An intralesion antibiotic treatment was given after complete removal of the pus. Conclusion. Intracranial subdural hematoma and subdural empyema with the involvement of neurological deficits are emergency conditions. However, it is difficult to differentiate these two conditions even after the examinations of clinical, laboratory, and neuroimaging with non- contrast head CT-scan, particularly without the triad of subdural empyema: fever, headache, vomiting. Our case showed that even without noticeable port d’entry, intracranial subdural empyema could be formed.

Intracranial Subdural Empyema – A Mini Review

Intracranial Subdural Empyema – A Mini Review

Intracranial Subdural Empyema and Brain Abscess Following A Minor-Trauma Induced Chronic Subdural Hematoma

Intracranial Subdural Empyema and Brain Abscess Following A Minor-Trauma Induced Chronic Subdural Hematoma

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...

Check the Ear. The Importance of Ear Examinations in Assessment of Intracranial Subdural Empyema.

Intracranial subdural empyema (ISE) is an uncommon condition previously associated with almost 100% morbidity and mortality. Since the introduction of antibiotics and advancements in diagnosis the complication rates have significantly improved. We report an unusual case of a 32-year-old Aboriginal male diagnosed with ISE. On closer inspection the ISE was found to be a complication of otitis media with a cotton bud lodged in the external acoustic meatus. The report provides a literature review on the relationships of ISE, otitis media and foreign bodies. We conclude that although rare, all patients with suspected ISE should undergo an ear examination as it is at no cost to the patient or health service but may be the difference between life and death.

Intracranial subdural empyemas and epidural abscesses in children

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. 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. 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. 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. EA = epidural abscess; SE = subdural empyema.

A case of posterior quadrant disconnection for post-subdural empyema epilepsy -focal cortical dysplasia might be the underlying cause of refractory epilepsy-

Abstract Introduction Intracranial subdural empyema (ISDE) can cause drug-resistant epilepsy. We attempted to cure post-ISDE refractory epilepsy by operative surgery and assessed the neuropathological findings. Patient and method A 23-year-old right-handed man with refractory epilepsy had ISDE on the right temporal and occipital areas at 14 years old. He underwent ISDE drainage operation at the time. A week after the infection, he developed epileptic seizure, which consisted of epigastric sensation, followed by loss of awareness with gelastic seizure. This type of seizure occurred around five times a day. He underwent right posterior disconnection and the temporal lobe was submitted to histopathological examination. Result The patient has remained seizure-free for more than 3 months. Histopathological diagnosis showed focal cortical dysplasia (FCD) type IB. Conclusion We cured post-ISDE refractory epilepsy by posterior quadrant disconnection. Epileptogenicity of FCD might be triggered by ISDE.

Unusual manifestation of Helicobacter cinaedi infection: a case report of intracranial subdural empyema and bacteremia

BackgroundThere have been various reports concerning Helicobacter cinaedi infections. However, few reports have examined central nervous system infections.Case presentationA 52-year-old man was transferred from the local hospital because of a persistent headache and suspected intracranial subdural empyema. Neurosurgical drainage was performed via burr holes. Gram staining and results from abscess cultures were negative. The blood culture yielded H. cinaedi. He was given an antibiotic regimen consisting of 2 g of ceftriaxone twice a day, but the size of the abscess was not reduced in size at all after 3 weeks of treatment. Neurosurgical drainage was performed again, and the antimicrobial regimen was switched to 2 g of meropenem 3 times a day. The size of the abscess was reduced after 2 weeks of the second drainage and antimicrobial drug change to meropenem. After 4 weeks treatment with meropenem, the patient was discharged, and his symptoms had completely resolved.ConclusionsH. cinaedi infection should be considered in the differential diagnosis of subdural empyema cases for which Gram staining and abscess culture results are negative. Meropenem can be a first-line drug of choice or an effective alternative treatment for H. cinaedi central nervous system infections.

Intracranial subdural empyema after surgery for lumbar lipomyelomeningocele: A rare complication

Background:Surgery is routinely recommended for lumbar lipomyelomeningocele, especially in the setting of tethered cord syndrome. The most common complications are wound infections and cerebrospinal fluid (CSF) leak, which remain confined to the surgical site. To the best of our knowledge, there have been no prior reports relating an intracranial subdural empyema following detethering surgery. Prompt diagnosis is essential since subdural empyema is a neurosurgical emergency.Case Description:The patient was an 11-month-old male who underwent detethering surgery for a lumbar lipomyelomeningocele. This was followed by wound drainage consistent with CSF leak, requiring revision. Cultures grew three aerobes (Escherichia coli, Enterococcus, and Klebsiella) and three anaerobes (Clostridium, Veillonella, and Bacteroides). He was started on cefepime, vancomycin, and flagyl. The patient required two more wound revisions and placement of an external ventricular drain (EVD) secondary to persistent wound leakage. A subsequent magnetic resonance imaging (MRI) brain was carried out due to protracted irritability, which revealed extensive left subdural empyema along the parietooccipital region and the inferior and anterior temporal lobe. He underwent evacuation of the subdural empyema where cultures exhibited no growth. Subsequently, he progressed well. His lumbar incision continued to heal. Serial MRI brains and inflammatory markers were reassuring. He weaned off his EVD and went home to complete a 6-week course of antibiotics. Upon completion of his antibiotics, he returned for a clinic visit; he exhibited no interim fevers or wound issues; cranial imaging documented no evidence of a residual or recurrent subdural empyema.Conclusion:Intracranial subdural empyema may occur after wound complications from detethering surgery despite early initiation of broad-spectrum antibiotics. Possible etiology may be local wound infection that seeds the subdural space and travels to the cranium, leading to meningitis and subdural empyema. Such a scenario should prompt surveillance imaging of the head as undiagnosed subdural empyema may lead to devastating consequences.

Infantile subdural empyema: The role of brain sonography and percutaneous subdural tapping in a resource-challenged region.

Background:This study explored the outcome of children with patent anterior fontanelles who were treated with trans-fontanelle ultrasound scan (TFUSS), which is more affordable and available than CT scan and MRI in the diagnosis of childhood intracranial pathologies and treatment of subdural empyema, in developing countries.Patients and Methods:Seventeen infants with post-meningitic subdural empyema, diagnosed using trans-fontanelle ultrasound alone and treated with subdural tapping over a 31-months period, were studied.Results:Eleven patients presented with grades II and III Bannister and William grading for level of consciousness in intracranial subdural empyema. Aspirate from 7 (41.2%) patients were sterile. The most common organisms isolated were Streptococcus faecalis 3 (17.6%), Haemophilus Influenza 2 (11.8) and Staphylococcus aureus 2 (11.8), multiple organisms were isolated in three of the patients. Ninety-four percent (94%) of the patients had good outcome. Five subjects developed hydrocephalus, one patient had a recurrence of subdural empyema, four patients had residual hemiparesis, two of the four patients had speech difficulties, while one patient (~6%) died.Conclusion:While CT and MRI remain the gold standard for investigating intracranial lesions, transfontanelle ultrasonography is adequate for diagnosis of infantile subdural empyema in resource-challenged areas. Percutaneous subdural tap is an affordable and effective therapy in such patients with financial challenges.

Continuous Subdural Irrigation and Drainage for Intracranial Subdural Empyema in a 92-Year-Old Woman

Intracranial subdural empyema (ISDE) is a life-threatening intracranial infection. Early and precise detection, timely surgery, and appropriate antibiotic therapy are the keys to a more favorable clinical outcome. Treatment is aimed at complete evacuation of the empyema and eradication of the source of infection. However, in the case of elderly patients or patients with poor health, doctors hesitate to perform open cranial surgery under general anesthesia; thus, the choice of appropriate surgical method is fraught with many limitations. We present a case of ISDE in a 92-year-old woman who was successfully treated with continuous irrigation of the subdural space with antibiotics and drainage through 2 burr holes for 1 week without any complications. Continuous subdural irrigation is useful for the evacuation of pus and eradication of the source of infection, thereby resulting in a favorable outcome, especially in elderly patients and patients with poor health.

LES EMPYEMES SOUS DURAUX INTRACRANIENS COMPLIQUANT DES SINUSITES : A PROPOS DE SIX PATIENTS OPERES

Intracranial subdural empyema is located between cranial dura mater and the arachnoïdea. It represents a frequent complication of frontal sinusitis and may be lethal. The aim of this study was firstlyto determine epidemiological, clinical and radiological aspects by CT of such affections and secondly to compare our therapeutic results to those of the literature. It was a retrospective study. From September 2006 to January 2007 six patients were surgically managed in Hôpital Principal de Dakar after clinical examination and craniofacial computer tomography exam. The sex ratio was one and the mean age was 14,8 years (range 9 and 18 years). Headaches, loss of consciousness and fever were founded. Diagnosis was performed meanly by 6 weeks. Three antibiotics were used in association when bacteriological examination after trepanation or sinusitis drainage, found non germs. Four patients recovered and two died. The earlier multidisciplinary management of intracranial subdural empyemas as complication of sinusitis is the main factor of success.

Pediatric intracranial subdural empyema caused by Mycobacterium tuberculosis—a case report and review of literature

Intracranial subdural tubercular empyema is an extremely rare entity. To our knowledge, only one such case has been previously reported in the pediatric population (Cayli et al. J Neurosurg 94(6):988-991, 2001). We report a case of intracranial tubercular subdural empyema in a child, with both convexity and interhemispheric fissure involvement. A 12-year-old boy with history of exposure to an active case of pulmonary tuberculosis (his father) presented to our institution with features of raised intracranial pressure and fever for 1 month and altered sensorium for 2 days. Computerized tomography (contrast enhanced) revealed a left fronto-parietal and interhemispheric subdural space abscess. A left fronto-parietal craniotomy was performed and the subdural empyema was evacuated, and adjacent calvarium was normal. Ziehl-Neelsen staining revealed acid-fast bacilli and the subsequent polymerase chain reaction test was positive. Histopathological examination showed granulation tissue including scattered multinucleated giant cells and caseation. Mycobacterium tuberculosis bacilli were the sole organisms cultured after 6 weeks. Anti-tuberculous treatment was given in appropriate doses for 18 months at the end of which the patient was doing well with no deficits. Intracranial tubercular subdural empyema in the pediatric age group is an extremely rare but curable entity.

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.

Análisis de los empiemas subdurales intracraneales en un hospital de tercer nivel

Intracranial subdural empyema (ISE) is an infrequent infectious disorder of diverse etiology and difficult to diagnose because of its non-specific clinical features. Retrospective study of patients diagnosed of ISE in a third-level university hospital in a 15-year period. Five men were included (mean age: 39.3 years). The most frequent primary source of infection was otic and sinusal (60%). The initial clinical manifestations were fever, headache, alteration of consciousness, and neurological focal symptoms. The mean time elapsed between onset of symptoms and diagnosis was 3.6 days. Diagnosis was performed by computed tomography in all patients. ISE was localized in the left hemisphere in 60% of cases mainly affecting the parietal lobe (80%). Anaerobic and streptococci germs were the most frequently isolated microorganisms. Therapy was based on antibiotics and surgical drainage in 100% of the cases. The surgical procedure used in the evacuation of empyema was craniotomy in all the patients. The mean time elapsed between diagnosis and surgery was 8.4 days. The mean Intensive Care Unit stay was 12.8 days, whereas the overall mean in-hospital stay was 45.2 days. Mortality was 40%. ISE, although infrequent, displays a high morbimortality that can be reduced with an early therapeutic approach which may include the surgical evacuation in all the cases.