Subdural Empyema Research Articles

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.

Faciocranial complications of sinusitis

Sinusitis is one of the most common conditions. The aetiology of sinusitis has not been fully discovered; however, viruses and bacteria are usually the dominant causes. The chief symptoms include nasal congestion, profuse nasal discharge and a compromised sense of smell. Inflammation of any sinus can be the source of complications. Complications develop usually as a result of exacerbation of chronic sinusitis. Sinusitis may result in inflammation spreading inside the cranium and to the orbital area and in the development of osteomyelitis or superior sagittal sinus thrombosis. Due to the anatomical location and proximity of important structures, sphenoid sinusitis may lead to meningitis or subdural empyemas, temporal lobe abscesses and cavernous sinus thrombosis. Fungal sinusitis is very dangerous since it is characterised by a rapid course often complicated by intracranial and orbital spread. Invasive fungal paranasal sinusitis with orbital complications is a life-threatening emergency. If there is concern about possible orbital or intracranial complications of sinusitis or if there is no improvement after initial empirical therapy, the use of diagnostic imaging is necessary, including computed tomography and magnetic resonance imaging. Early diagnosis of sinusitis and multidisciplinary management involving a combination of antibiotic therapy and surgical treatment, including neurosurgery and maxillofacial procedures can be effective in the prevention of complications and may significantly reduce morbidity and mortality.

Infantile supratentorial subdural empyema managed by percutaneous aspiration: an outcome study in a Nigerian city.

Subdural empyema (SDE), a common neurosurgical emergency in the developing countries, accounts for 15%-20% of localised paediatric intracranial infections. In regions where modern diagnostic tools are scarce and inaccessible, detection of SDE may be delayed with subsequent poor outcome. Percutaneous subdural aspiration in patients with open anterior fontanel may be the only surgical option in resource-poor regions of the world. This review focuses on the management outcome, including neurological outcome of these children. Clinical charts of children with SDE and treated by percutaneous subdural tap between February 2006 and August 2014 were reviewed. Demographic, clinical, radiological, bacteriological parameters and outcome data were analysed. Forty-five children with a mean age of 10.6 ± 6.2 months (range: 2-17 months) and followed up for a median duration of 16.4 months were included. The most frequent clinical features were enlarged head circumference, fever, focal neurologic deficits and altered level of consciousness. Diagnosis of SDE was confirmed using trans-fontanel ultrasound scan in 32 (71.1%) children, computerised tomography in 12 (26.7%) children and magnetic resonance imaging in one (2.2%) child. SDE was unilateral in 73.3% and bilateral in 26.7%. In 23 (51.1%) children with a positive culture, Staphylococcus aureus (n = 10), anaerobes (n = 7), Escherishia coli and Haemophilus influenza (n = 6 each) were the most common organisms. Forty-three children (95.6%) survived, 36 of which had good Glasgow outcome score. Seven children still had moderate deficits at 3 months. Treatment of SDE in young children with patent fontanel using percutaneous subdural tap has good therapeutic and neurological outcome.

Неотложная помощь при внутричерепных осложнениях воспалительных заболеваний носа и околоносовых пазух

Suppurative inflammatory intracranial complications of acute and chronic diseases of ear, nose and paranasal sinuses are the most severe and life-threatening pathology, the interest in it has been growing over the recent years, due to epidemiological and clinical features of these diseases, with the absence of clear algorithms for diagnostics and treatment of this group of patients. Today, the rates of hospital mortality and disability due to intracranial complications remain high, which is associated with diagnostic, tactical difficulties in providing specialized medical care to these patients. The article presents a clinical case of an interdisciplinary approach to the treatment of a patient with intracranial complications (meningoencephalitis, subdural empyema, severe sepsis associated with chronic acute polisinusitis exacerbation). The article provides a plan of complex examination of the patient, the tactics of surgical and conservative treatment of this patient.

From dental infection to extradural empyema: a case report

Introduction: Brain infections of dental origin are rare, but well-known and accurately described. There are two different brain infections: brain abscess, the most frequent, and extradural or subdural empyema. Here, we discuss the case of an extradural empyema. Observation: A 28-year-old man with a very poor dental condition showed neurological and eye infection signs. A brain and face CT scan revealed extradural empyema, orbit abscess and pansinusitis. These infections had all dental origin: an apical lesion of tooth 26. Discussion: Such severe cases must be surgically and medically treated with a strong antibiotic therapy. A systematic investigation and the treatment of dental infected areas are both necessary.

Intra and extracranial complications of middle earths: literature review

Otitis media (OM) has several forms and among the main are otitis media (AOM), OM with effusion and chronic otitis media (COM) (cholesteatomatous or not). For the most part, the OM progressed well, but there are risks of complications and sequelae. These are divided into extra and intracranial, the first being the most common, but less lethal. Among the extracranial are: labyrinthine fistula, subperiosteal abscess, mastoiditis, temporozigomatic abscess, Bezold's abscess, parapharyngeal abscess, facial palsy, petrositis and labyrinthitis. Among the intracranial are: meningitis, epidural abscess, subdural empyema, brain abscess, the sigmoid sinus thrombophlebitis and otological hydrocephalus. The aim of this study is to identify the main complications of otitis media, distinguishing them from the incidence, degree of morbidity and mortality and analyze the development, management and treatment required for each entity. Brain abscess is the most common entity and subperiosteal abscess is the most common extracranial complication. Labyrinthine fistula occurs most often related to OMC. This has the physiopathology erosion of the bone covering the semicircular canal, usually the lateral semicircular canal. Labyrinthitis results from the spread of infection from the cochlear window membrane and can be presented in two ways: serous or suppurative labyrinthitis. The most common intracranial complication is meningitis, rarely associated with cholesteatoma and most often associated with AOM, of higher incidence in children. CT with contrast is the gold standard when you suspect any complications in patients with otitis media after undergoing a thorough history and physical examination. When the physician knows the possible complications and their signs and symptoms, the diagnosis is early and the prognosis best. Treatment of complications in general is based on patient hospitalization, myringotomy with culture and sensitivity, intravenous antibiotic therapy as early as possible and mastoidectomy in all cases related to COM or recurrent complications.

Multiple Septic Emboli in the Skin, Lungs, and Brain due to Corynebacterium Striatum Bacteremia in a Patient with Acute Myelogenous Leukemia

A 29-year-old man developed fever after chemotherapy for acute myelogenous leukemia. Corynebacterium striatum was detected via blood culture, and antibacterial treatment with vancomycin started. In the course of treatment, papules of the skin, multiple nodular shadows of the lung, cerebral infarction, and subdural empyema appeared. A diagnosis of multiple septic emboli in the skin, lungs, and brain due to C. striatum bacteremia was made from the clinical course. The antibacterial treatment improved skin and pulmonary lesions. The subdural empyema was considered as a postoperative infection of burr-hole craniotomy. It improved by performing craniotomy twice with drainage and empiric antibiotic therapy. In our case, neutropenia was present as an immunodeficiency, which made bacteremia severe. There has not been reported a case of septic emboli of three lesions; skin, lung, and brain. C. striatum bacteremia may result in septic emboli and should immediately be treated with antibiotics.

Case report of Actinomyces turicensis meningitis as a complication of purulent mastoiditis

BackgroundCentral nervous system (CNS) infections caused by Actinomyces spp. including brain abscess, actinomycoma, subdural empyema and epidural abscess are well described, however reports of Actinomyces-associated meningitis are scarcely reported.Case reportWe present the case of a 43-year-old Hungarian male patient with poor socioeconomic status who developed acute bacterial meningitis caused by Actinomyces turicensis originating from the left side mastoiditis. The bacterial cultures of both cerebrospinal fluid (CSF) and purulent discharge collected during the mastoid surgery showed slow growing Gram-positive rods that were identified by automated systems (API, VITEK) as A. turicensis The bacterial identification was confirmed by 16S rRNA PCR and subsequent nucleic acid sequencing. No bacterial growth was detected in blood culture bottles after 5 days of incubation. Hence, multiple antibacterial treatments and surgical intervention the patient passed away.ConclusionsAnaerobes are rarely involved in CNS infections therefore anaerobic culture of CSF samples is routinely not performed. However, anaerobic bacteria should be considered as potential pathogens when certain risk factors are present, such as paranasal sinusitis, mastoiditis in patients with poor socioeconomic condition. To the best of our knowledge, our case report is the first description of A. turicensis meningitis that has been diagnosed as consequence of purulent mastoiditis.

Neurological Complications in Young Infants With Acute Bacterial Meningitis.

We aimed to evaluate the occurrence, treatment, and outcomes of neurological complications after bacterial meningitis in young infants. A case series study from a retrospective cohort from two tertiary-level medical centers in Taiwan between 2007 and 2016 was conducted. Eighty-five young infants aged < 90 days with bacterial meningitis were identified. 25 (29.4%) were born at preterm. Group B Streptococcus (GBS) and Escherichia coli caused 74.1% of identified cases. Despite the majority (90.6%) initially received microbiologically appropriate antibiotics, 65 (76.5%) had experienced at least one neurological complication identified at a median of 6 days (range: 1–173) after onset of bacterial meningitis. The most common neurological complication was seizure (58.8%), followed by subdural effusion (47.1%), ventriculomegaly (41.2%), subdural empyema (21.2%), hydrocephalus (18.8%), ventriculitis (15.3%), periventricular leukomalacia (11.8%), and encephalomalacia (10.6%). Nine patients (10.6%) died (including 4 had critical discharge on request) and 29/76 (38.2%) of the survivors had major neurological sequelae at discharge. Nighteen (22.4%) received surgical intervention due to these complications. After multivariate logistic regression, initial seizure (adjusted odds ratio [aOR]: 4.76, 95% confidence interval [CI]: 1.7–13.0, P = 0.002) and septic shock (aOR: 6.04; 95% CI: 1.35–27.0, P = 0.019) were independent predictors for final unfavorable outcomes.Conclusions: Neurological complications and sequelae are common in young infants after bacterial meningitis. Patients presented with early seizure or septic shock can be an early predictor of final unfavorable outcomes and require close monitoring. Further research regarding how to improve clinical management and outcomes is warranted.

Bilateral subdural empyemas with meningitis secondary to acute barosinusitis

IntroductionIntracranial complications of acute rhinosinusitis are rare, but may turn life-threatening. Case summaryWe report a healthy 30-year-old male who complained of frontal headache, which developed while on a plane. A brain CT showed a low-density lesion on the left frontal convexity with right maxillary and ethmoid sinusitis. Despite receiving intravenous antibiotics, a follow-up brain CT showed two lesions with adjacent dural and leptomeningeal enhancement. A paranasal sinus CT revealed aggravated left frontal sinusitis and right maxillary sinusitis. The patient underwent craniotomy and brain abscess removal along with endoscopic sinus surgery. Seventeen days after the surgery, the patient was discharged with no neurological sequelae. ConclusionTo the best of our knowledge, this case is the first report regarding the association between barotrauma and intracranial complications of acute rhinosinusitis. A high index of suspicion and well-timed surgical evacuation may ensure a full recovery.

STREPTOCOCCUS PYOGENES: A DEVASTATING CAUSE OF MENINGITIS IN A YOUNG ADULT

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Streptococcus pyogenes is a rare but aggressive cause of bacterial meningitis. CASE PRESENTATION: A 27-year-old healthy gentleman presented to the emergency department with a 3 day history of headache. His symptoms began with an upper respiratory infection and fever which had resolved. Vital signs were normal, but he appeared in mild distress. His neurologic exam was non-focal without nuchal rigidity. There was tenderness to palpation over the right maxillary sinus. A CT head showed paranasal mucosal thickening and air-fluid levels in the right maxillary sinus. He was treated with intravenous fluids, acetaminophen, and promethazine with improvement in his headache. He was discharged home with a diagnosis of sinusitis. Within 24 hours, he returned to the emergency room after he developed confusion and suddenly collapsed. On presentation, he was hypotensive and febrile. His mental status was obtunded. Laboratory studies were notable for a leukocytosis with 55% bands, lactic acidosis, and acute renal failure. A lumbar puncture was performed with an opening pressure of 57 cm of water and had 11,000 white blood cells with 98% neutrophils. He was given dexamethasone, vancomycin, and ceftriaxone. Gram stain of the cerebral spinal fluid revealed gram positive cocci in chains and later grew Streptococcus pyogenes. A repeat CT head showed progression of sinusitis and effacement of the sulci concerning for cerebral edema. In the intensive care unit, he had multiple episodes of cardiac arrest, septic shock requiring vasopressors, and acute respiratory distress syndrome with refractory hypoxemia. On exam, brainstem reflexes were absent and he passed away 34 hours after admission. DISCUSSION: Streptococcus pyogenes, or Group A Streptococcus (GAS), is a rare cause of bacterial meningitis in the United States. In 1985, the incidence of bacterial meningitis due to GAS was 0.2% (1). A review of the literature showed a prospective study in the Netherlands where GAS was the cause of 2% of cases of bacterial meningitis. Of the patients with GAS meningitis, 92% initially presented with otitis media or sinusitis, 52% of patients developed neurologic sequelae, and 19% of the patients died. The most common neurologic complications were subdural empyema and hearing loss, while the most common systemic complications were respiratory failure and septic shock (2). Of note, this patient had preceding upper respiratory symptoms and presented during influenza season. There are reports of increased invasive GAS co-infection with influenza in healthy patients, some of which resulted in death (3). CONCLUSIONS: Although GAS is a rare cause of meningitis, this invasive organism may present with benign features of otitis media or sinusitis, and develop aggressively to meningitis associated with high rates of morbidity and mortality. It is important to consider GAS infection especially during influenza season. Reference #1: Schleck, W. et al. “Bacterial Meningitis in the United States, 1978-1981.” JAMA. 1985; 253(12): 1749-1754. Reference #2: Marjolein, L. et al. “Group A Streptococcal meningitis in adults.” Journal of Infection. 2015; 71(1): 37-72. Reference #3: Jean, C. et al. “Invasive Group A Streptococcal Infection Concurrent with 2009 H1N1 Influenza.” Clinical Infectious Disease. 2010; 50(10): e59-e62. DISCLOSURES: No relevant relationships by Chloe Castro, source=Web Response No relevant relationships by Edward Warren, source=Web Response

Conservative treatment of subdural empyema: a complication of odontogenic sinusitis

Conservative treatment of subdural empyema: a complication of odontogenic sinusitis

A Rare Complication of Frequent Sphenoid Sinusitis Is Subdural Empyema: Case Report

Subdural empyema is a fluid collection between dura and arachnoid layers and can develop secondary to states like meningitis, middle ear infection, paranasal sinus infection, trauma or cranial surgery. It can develop secondary to paranasal sinus infections which are rare observed and lead to a life-threatening situation. Early diagnosis and treatment cause a decrease in mortality and morbidity. As well as nonspecific symptoms and signs might cause, the most common symptom triad of fever, headaches and vomiting. Computerized tomography is the first choice for the diagnosis; however Magnetic Resonance İmaging is more efficient and useful. Broad spectrum antibiotherapy is chosen for the treatment, in most cases surgical drainage becomes necessary. In this paper, we aimed to present a rarely seen subdural empyema case secondary to frequently seen sphenoid sinusitis.

Brain Infection After Cesarean Section: A Case of Subdural Empyema Post-Cesarean Section

: We report a rare case of parieto-frontal subdural empyema after a cesarean section. A 23 years old woman with a history of cesarean section, two weeks prior to admission, presented to the emergency room with the chief complaints of a headache, fever (39.5°C), nausea, vomiting, aphasia, tonic colonic movements, and a Glasgow coma scale score of 10/15 two weeks after a cesarean section. A subdural fluid collection in parieto-frontal on the left side was demonstrated in the brain MRI. She received rapidly an anticonvulsant drug (diazepam) and empirical board-spectrum antibiotics (vancomycin, metronidazole, and ceftriaxone) and subsequently underwent an urgent craniotomy. Antibiotic therapy continued for 4 weeks, the patient symptoms and signs improved, and she was discharged with a Glasgow coma scale score of 15/15 without neurological deficit and seizure.

Subdural empyema as a complication of odontogenic maxillary sinusitis

Subdural empyema as a complication of odontogenic maxillary sinusitis

Pyogenic brain abscess and subdural empyema: presentation, management, and factors predicting outcome.

To describe the presentation and management of bacterial brain abscess and subdural empyema in adults treated at two tertiary centers. In addition, to identify factors that may predict a poor clinical outcome. A retrospective analysis of data obtained from clinical records was performed, followed by multivariate regression analysis of patient and treatment-related factors. 113 patients were included with a median age of 53years and a male preponderance. At presentation symptoms were variable, 28% had a focal neurological deficit, and 39% had a reduced Glasgow coma scale (GCS). Brain abscesses most frequently affected the frontal, temporal, and parietal lobes while 36% had a subdural empyema. An underlying cause was identified in 76%; a contiguous ear or sinus infection (43%), recent surgery or trauma (18%) and haematogenous spread (15%). A microbiological diagnosis was confirmed in 86%, with streptococci, staphylococci, and anaerobes most frequently isolated. Treatment involved complex, prolonged antibiotic therapy (> 6 weeks in 84%) combined with neurosurgical drainage (91%) and source control surgery (34%). Mortality was 5% with 31% suffering long-term disability and 64% achieving a good clinical outcome. A reduced GCS, focal neurological deficit, and seizures at presentation were independently associated with an unfavorable clinical outcome (death or disability). Complex surgical and antimicrobial treatment achieves a good outcome in the majority of patients with bacterial brain abscess and subdural empyema. Factors present at diagnosis can help to predict those likely to suffer adverse outcomes. Research to determine optimal surgical and antibiotic management would be valuable.

Subdural empyema in children.

Subdural empyema denotes the collection of purulent material in the subdural spaceand is commonly seen in infants and older children. In infants, the most common cause is bacterialmeningitis. In older children, sinusitis and otitis media are usually the source for subdural empyema. Theclinical symptomatology is varied and has a wide range including prolonged or recurrent fever, seizures,meningeal irritation, and raised intracranial pressure. It can mimic as well as complicate meningitis and aheightened clinical awareness is therefore paramount. The clinical profile, etiopathogenesis, imaging features and management of subdural empyema in children is discussed and the relevant literature is reviewed. Subdural empyema is a neurosurgical emergency and rapid recognition and treatment canavoid life-threatening complications. In most cases, surgical decompression through burr hole or craniotomyis warranted. Near complete evacuation of the purulent material and appropriate long-term intravenous antibiotics are necessary for a gratifying outcome.

Cranially Migrated Ventriculoperitoneal Shunt In Patient With Bilateral Subdural Empyema

A right-sided ventriculoperitoneal (VP) shunt was placed in patient with congenital hydrocephalous in the first month of life. Three-month review visit showed no improvement and after evaluation and computerised tomogram (CT) scan brain, another VP shunt was placed on the left side without handling the previous right sided VP shunt. Patient did not improve and again presented with fever and fits. CT scan brain with and without contrast was repeated, which showed bilateral subdural empyema and right-sided cranially migrated VP shunt. Cerebrospinal fluid (CSF) analysis demonstrated infection. Bilateral burr hole drainage of subdural empyema with subsequent removal of right-sided migrated VP shunt was done. Cranial end of left-sided VP shunt was converted into external ventricular drain (EVD) and its abdominal end removed. Patient was placed on intravenous as well as intraventricular antibiotics through the EVD. Later, right-sided VP shunt was placed after clearance of infection. Regular follow-up showed that the patient is doing well.

Cerebral Convexity Subdural Empyema Due to Odontogenic Chronic Sinusitis

Cerebral Convexity Subdural Empyema Due to Odontogenic Chronic Sinusitis

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.