Subdural Empyema Research Articles

Spinal subdural empyema in an immunocompetent patient: illustrative case.

Spinal subdural empyemas are a rare presentation of rapid neurological decline, progressing from radiculopathy to complete paralysis and sensory loss. Although pathogenic mechanisms have been hypothesized, their occurrence in this population of patients remains unclear. The authors present the third documented case of an isolated spinal subdural empyema of unclear etiology in an immunocompetent patient with no established risk factors. Successful treatment requires prompt clinical suspicion, radiological diagnosis, and surgical evacuation along with empirical antibiotic treatment. Radiological clarification of the subdural versus the epidural location of the empyema is difficult, while intraoperative durotomy for exploration risks subdural dissemination. In these cases, intraoperative ultrasonography would be a useful adjunct and decision aid. https://thejns.org/doi/10.3171/CASE24464.

The World's first 3D-printed PEEK cranial implant: a new horizon in precision and personalized neurosurgery.

Cranioplasty is a reconstructive neurosurgical procedure that fixes the cranial bone defects after the craniotomy for brain surgeries like tumours, aneurysms, arterio-venous malformations, subdural empyemas and hematomas. Personalized 3D-printed implants offer various advantages, including anatomical accuracy, functional restoration, time-sparing surgery, excellent cosmetic outcomes through their impeccable adjustment to cranial vault defects, and better clinical outcomes. PEEK has a meritorious profile in terms of high success rate, low complication rate, fracture resistance and low toxicity profile, high strength, high toughness, and excellent biocompatibility in cranioplasty. On the other hand, the need for more cost-effective yet ideal biomaterials must be met for nations and patients with financial constraints. Nevertheless, this additively manufactured 3D-printed cranial implant marks the dawn of a new era in precision and personalized neurosurgery.

Increase of pyogenic bacterial infections after relaxation of social distancing measures linked to COVID-19 pandemic.

After the relaxation of COVID-19 mitigation measures, we observed a dramatic increase in pyogenic infections. Based on this observation, we retrospectively analysed all cases of invasive bacterial infections of brain, lung and complicated ear-nose-throat (ENT) infections, in the period from 1 August to 31 March from the years 2018-2019 to 2022-2023. The study was conducted in two Paediatric Emergency Departments, at IRCCS 'Burlo Garofolo' of Trieste and at Treviso Hospital. Electronic medical records were searched for all cases with a definitive diagnosis at discharge of mastoiditis, suppurative cervical lymphadenitis, retropharyngeal, parapharyngeal and peritonsillar abscess (ENT group), bacterial brain abscesses, epidural empyema, subdural empyema (central nervous system group), thoracic empyema and necrotising pneumonia (lung group). In 2022-2023, we observed an increase in infections compared to the previous years. Total number of cases were 22, 29, 8, 27 and 63 in 2018-2019, 2019-2020, 2020-2021, 2021-2022 and 2022-2023, respectively. The greater increase occurred in thoracic empyema, with a peak incidence of +120% in 2022-2023 in respect of 2021-2022. We reported an important increase in paediatric bacterial complicated infections in two North East Italian regions, possibly correlated with the relaxation of COVID-19 social distancing measures.

Subdural empyema—a rare complication of chronic otitis media: a case report

BackgroundSubdural empyema is an extremely rare and fatal intracranial complication of chronic otitis media. Due to its rarity and vague symptoms, it is often diagnosed late if not completely missed; specially in developing countries where the diagnostic modalities are hardly available or accessible. To the best knowledge of the authors, this is a preliminary reported case of subdural empyema as a complication of chronic otitis media in Eritrea. It aims to provide vital information on the clinical presentation, preferred diagnostic modalities, and the proper management of such cases.Case reportAn 8 years old female patient from the Rashaida ethnic group presented with fever, right ear purulent discharge, right post-auricular swelling, and altered mental status. Prior to her admission, she had history of recurrent purulent discharge from her right ear for almost 2 years, and had been diagnosed with chronic otitis media. Upon admission her GCS was 13/15 which later on deteriorated to be 3/15 on day 3. MRI was done and showed a right fronto-tempo-parietal subdural empyema with mass effect, shifting the midline to the left. She was immediately started on empirical broad-spectrum antibiotics. After the diagnosis was made, craniotomy was done, and 30 ml of pus was removed from the subdural space. Culture and sensitivity of the pus obtained intraoperatively was done but produced no yield. Hence, she was continued on the empirically started antibiotics. The patient’s condition was well improved by post-operative day 4.ConclusionIt is important to have a high index of suspicion of intracranial complications in patients with history of chronic otitis media or other otologic complaints, who present with neurologic manifestations. Subdural empyema still being uncommon even among the intracranial complications of COM, it is often missed. Hence, timely diagnosis with MRI, immediate surgical evacuation of the empyema along with the prolonged administration of broad-spectrum antibiotics is highly recommended.

Subdural Empyema Secondary to Sinusitis: Presenting with Cluster-like Headache, Status Epilepticus, and Orbital Apex Syndrome

A 67-year-old man suffered cluster-like headache for 8 months. He underwent endoscopic sinus surgery 2 months prior to the onset of headache. The patient experienced status epilepticus 7 months after the onset of cluster-like headache, and 8 months after its onset, orbital apex syndrome developed. Brain magnetic resonance imaging (MRI) showed subdural empyema. This case emphasizes the association between subdural empyema caused by sinusitis and the potential manifestation of various neurological symptoms, including cluster-like headache, status epilepticus, and orbital apex syndrome.

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.

Subdural Empyema as a Rare Complication Caused by Neisseria meningitidis B

Subdural empyema (SDE) is an intracranial collection of purulent material located between the dura and the arachnoid mater. It is a serious central nervous system infection which can cause neurological sequelae and high mortality. We report one of the rare cases of SDE secondary to Neisseria meningitidis to underline the interest of evoking this diagnosis especially in patients not responding to standard antimicrobial therapy.

De novo primary malignant lymphoma of the dura following recurrent episodes of subdural abscess presenting as chronic subdural hematoma: illustrative case.

Chronic inflammation of the thorax, as in tuberculosis-related pyothorax, can cause secondary malignant lymphomas. However, primary malignant lymphoma of the central nervous system, specifically of the dura mater, developing after intracranial infection or inflammation has rarely been reported. Herein, the authors describe a case of primary dural lymphoma that developed secondary to subdural empyema, with an initial presentation mimicking a chronic subdural hematoma. A 51-year-old man had undergone single burr hole drainage for subdural empyema 2 years prior. The patient subsequently underwent multiple craniotomy and drainage procedures, with successful remission of the subdural empyema. He was subsequently referred to the authors' hospital approximately a year after his initial treatment because of a recollection of subdural fluid, which was suspected to be recurrent empyema. After another single burr hole drainage, which revealed only a subdural hematoma, a histopathological diagnosis of B-cell lymphoma of the dural/subdural membrane was made. Subsequent radiation therapy was completed, with good local control and no recurrence of the subdural hematoma confirmed at 2 months posttreatment. Intracranial lymphoma triggered by chronic inflammation is rare but should be considered a differential diagnosis in subdural hematomas for which the background pathology is unclear. https://thejns.org/doi/10.3171/CASE24153.

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.

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.

Empyema of odontogenic origin: a case report

A subdural empyema of odontogenic origin is an uncommon, but significant sequela of dental disease with associated morbidity. This article discusses the case of a 15-year-old boy who presented with a subdural empyema of odontogenic origin. The case highlights the multidisciplinary care required to manage such cases, including the involvement of the dental team. It discusses the complexities in its diagnosis and management as well as the associated morbidity and mortality. CPD/Clinical Relevance: Subdural empyema of odontogenic origin has implications for the dental team in terms of prevention and management of dental disease.

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 Caused by Brucellosis: A Case Report and Review of the Literature

Subdural Empyema Caused by Brucellosis: A Case Report and Review of the Literature

The Epidemiology, Management and Therapeutic Outcomes of Subdural Empyema in Neonates with Acute Bacterial Meningitis.

Background: Subdural empyema is one of the more serious complications of bacterial meningitis and therapeutic challenges to clinicians. We aimed to evaluate the clinical characteristics, treatment, and outcome of subdural empyema in neonates with bacterial meningitis. Methods: A retrospective cohort study was conducted in two medical centers in Taiwan that enrolled all cases of neonates with subdural empyema after bacterial meningitis between 2003 and 2020. Results: Subdural empyema was diagnosed in 27 of 153 (17.6%) neonates with acute bacterial meningitis compared with cases of meningitis without subdural empyema. The demographics and pathogen distributions were comparable between the study group and the controls, but neonates with subdural empyema were significantly more likely to have clinical manifestations of fever (85.2%) and seizure (81.5%) (both p values < 0.05). The cerebrospinal fluid results of neonates with subdural empyema showed significantly higher white blood cell counts, lower glucose levels and higher protein levels (p = 0.011, 0.003 and 0.006, respectively). Neonates with subdural empyema had a significantly higher rate of neurological complications, especially subdural effusions and periventricular leukomalacia. Although the final mortality rate was not increased in neonates with subdural empyema when compared with the controls, they were often treated much longer and had a high rate of long-term neurological sequelae. Conclusions: Subdural empyema is not uncommon in neonates with acute bacterial meningitis and was associated with a high risk of neurological complications, although it does not significantly increase the final mortality rate. Close monitoring of the occurrence of subdural empyema is required, and appropriate long-term antibiotic treatment after surgical intervention may lead to optimized outcomes.

186 Outbreak of Bacterial Subdural Empyema in Pediatric Patients After Relaxation of COVID-19 Non-pharmaceutical Interventions (NPIs)

INTRODUCTION: Non-pharmaceutical interventions (NPIs), in response to the COVID-19 viral pandemic altered viral transmission. In addition, endemic viral strains (influenza, RSV, etc) also experienced unprecedentedly low infection rates. Endemic viral infections typically followed seasonal outbreak spikes, but these spikes were noticeably absent in the COVID-19 control period. After many COVID-19 restrictions were ceased, there was an unusually high spike in endemic viral infections. Many COVID-19 measures were relaxed in the early/middle part of 2021, and we noted a sharp increase in post-viral, complicated sinusitis/subdural empyema cases. METHODS: Data collection was via retrospective chart review of subdural empyema cases at our institution. “Post-viral” was defined as positive viral test or VURI symptoms within 30 days. RESULTS: Our group previously published our case series on the management of subdural empyema. That served as an historical cohort of 16 patients and 23 procedures over an 8 year period (July 2013-June 2021). During the previous academic year, July 2021 to June 2022, there were a total of 14 patients and 19 surgeries, which nearly doubles the previous 8 years combined. The current academic year (to date) has had 9 empyema patients and 12 surgical cases. 100% of patients in the previous 2 years has had historical symptoms of viral URI symptoms or positive viral URI testing within 30 days. None were documented positive for COVID-19. In less than 2 years since many NPIs were lifted, post-viral, bacterial empyema cases have increased dramatically by a fold of 2.56. CONCLUSIONS: NPIs may have created an endemic viral “immunity gap” and an immunologically susceptible population, and thereby could have contributed to a sharp increase in bacterial subdural empyema.

Post-traumatic subdural empyema: about a case, Hospital General Puyo 2022.

Introducción: Presentamos el caso clínico de un paciente masculino de 17 años con el antecedente de haber sufrido un traumatismo craneoencefálico tres semanas antes de su ingreso al servicio de Emergencia , con un diagnóstico de empiema subdural, el cual suele ser una complicacion de la sinusitis, o la otitis media, pero pueden producirse tras otras infecciones óticas, traumatismo o cirugía de cráneo y, pocas veces, bacteriemia. Objetivo: Describir un caso clínico de empiema subdural post-traumático, conocer el cuadro clínico, métodos diagnósticos y manejo terapéutico. Metodología: Reporte y análisis de caso clínico con un enfoque observacional y retrospectivo, con apoyo en la revisión de bibliografía actualizada.Resultados: Se pudo establecer que el cuadro clínico de un empiema subdural post-traumático es variado, conocer los signos, síntomas y factores de riesgo, permiten incrementar la sospecha diagnóstica en el área de emergencia e implementar su tratamiento oportuno. Conclusiones: El empiema subdural intracraneal es poco común, la morbilidad y la mortalidad son significativamente altas, es necesario un diagnóstico oportuno y la posterior implementación de antibióticos y drenaje quirúrgico con el propósito de reducir la mortalidad. Se requiere un equipo multidisciplinario que incluya emergencia, unidad de cuidados intensivos, neurocirugía, muchos requieren medicamentos antiepilépticos a largo plazo y fisioterapia para una mayor recuperación.

Underwater versus Closed Drainage System for Surgical Treatment of Chronic Subdural Hematoma

Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage. Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay. Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence. The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.

Results of Comparison of Burr Hole Evacuation Versus Surgical Excision of Multiloculated Subdural Empyema

Objectives: We studied the results of results of comparison of burr hole evacuation versus surgical excision of multiloculated subdural empyema. Material and Methods: A total of 40 patients were admitted with the disease. We will analyze the results of 20 patients. It is a comparative observational study of 20 patients treated at the Punjab Institute of Neurosciences (PINS), Lahore. Presenting complaints of patients were fever, vomiting, headache, fits, etc. Results: The age range was 15 – 60 years. The mean age was 36 years, Medical management was given to 20 patients (100%) for 3 weeks. All patients were advised to take complete bed rest for 3 weeks. Anti-epileptic, Mannitol, antibiotics, and painkillers were the medications that were given. In this study, we will focus on the 20 patients treated surgically, and the analysis of 20 patients will be presented in complete detail. Our 10 (50%) patients were managed by burr hole evacuation of multiloculated subdural empyema. Surgical excision was done in 10 (50%) patients with multiloculated subdural empyema. Burr hole evacuation was done in patients who were old and unfit for surgery. Recurrence occurred in 5 (25%) patients who underwent management with burr hole evacuation and 1 (5%) patient in the excision group. Conclusion: The results of surgical excision of multiloculated subdural empyema are better than burr hole evacuation if the patient is for surgical excision.

Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BackgroundCOVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017–2019), COVID (2020–2021), and post-COVID period (2022–June 2023) looking for possible epidemiological and/or clinical changes.Material and methodsAn English language questionnaire was sent to ESPN members about year of the event, patient’s age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.ResultsTwo hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.ConclusionsThese results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

Subdural Empyema from Streptococcus suis Infection, South Korea.

In Jeju Island, South Korea, a patient who consumed raw pig products had subdural empyema, which led to meningitis, sepsis, and status epilepticus. We identified Streptococcus suis from blood and the subdural empyema. This case illustrates the importance of considering dietary habits in similar clinical assessments to prevent misdiagnosis.