Intracranial invasive group A streptococcus: a neurosurgical emergency in children.

OBJECTIVE: Invasive group A streptococcus (iGAS) infections are associated with a high rate of morbidity and mortality. CNS involvement is rare, with iGAS accounting for only 0.2%-1% of all childhood bacterial meningitis. In 2022, a significant increase in scarlet fever and iGAS was reported globally with a displacement of serotype, causing a predominance of the emm1.0 subtype. Here, the authors report on iGAS-related suppurative intracranial complications requiring neurosurgical intervention and prolonged antibiotic therapy. METHODS: The authors performed a retrospective chart review of consecutive cases of confirmed GAS in pediatric neurosurgical patients. RESULTS: Five children with a median age of 9 years were treated for intracranial complications of GAS infection over a 2-month period between November 2022 and December 2022. All patients had preceding illnesses, including chicken pox and upper respiratory tract infections. Infections included subdural empyema with associated encephalitis (n = 2), extradural empyema (n = 1), intracranial abscess (n = 1), and diffuse global meningoencephalitis (n = 1). Streptococcus pyogenes was cultured from 4 children, and 2 were of the emm1.0 subtype. Antimicrobial therapy in all patients included a third-generation cephalosporin but varied in adjunctive therapy, often including a toxin synthesis inhibitor antibiotic such as clindamycin. Neurological outcomes varied; 3 patients returned to near neurological baseline, 1 had significant residual neurological deficits, and 1 patient died. CONCLUSIONS: Despite the worldwide increased incidence, intracranial complications remain rarely reported resulting in a lack of awareness of iGAS-related intracranial disease. Awareness of intracranial complications of iGAS and prompt referral to a pediatric neurology/neurosurgical center is crucial to optimize neurological outcomes.

Spontaneous lumbar intraspinal subdural abscess: a case report.

BACKGROUND: Subdural spinous abscess is a rare pathology that carries significant morbidity if not diagnosed and treated early; of the cases reported in the literature, very few are genuinely spontaneous in nature. CASE PRESENTATION: Here we demonstrate the case of an otherwise entirely fit and well 56-year-old White, British female presenting with low back pain, bilateral sciatica and sensate urinary retention; lumbar subdural spinous abscess was diagnosed on urgent magnetic resonance imaging and the patient was successfully managed with surgical evacuation and prolonged antibiotic therapy. The patient made a full neurological recovery and was followed-up in the outpatient setting 12 weeks following her initial surgery; she was pain free with normal inflammatory markers and a normal neurological examination. There have been no further consultations and a telephone call at 20 weeks confirmed that she remains well. CONCLUSIONS: This is the second case reported in the literature of a genuinely spontaneous subdural spinous abscess, which was successfully managed with surgical evacuation following prompt diagnosis. This highlights the need to ensure infective pathologies are kept at the back of one's mind even in the most unlikely circumstances, and that excellent outcomes can be achieved with early surgical intervention.

Surgical management of interhemispheric subdural empyemas: Review of the literature and report of 12 cases.

BACKGROUND: Subdural empyemas (SDEs) are rare intracranial infections mostly secondary to sinusitis. Incidence of SDEs is 5-25%. Interhemispheric SDEs are even rarer, which makes their diagnosis and treatment difficult. Aggressive surgical interventions and wide-spectrum antibiotics are needed for treatment. In this retrospective clinical study, we intended to evaluate the results of surgical management supported by antibiotics in patients with interhemispheric SDE. METHODS: Clinical and radiological features, medical and surgical management and outcomes of 12 patients treated for interhemi-spheric SDE have been evaluated. RESULTS: 12 patients were treated for interhemispheric SDE between 2005 and 2019. Ten (84%) were male, two (16%) were female. Mean age was 19 (7-38). Most common complaint was headache (100%). Five patients were diagnosed with frontal sinusitis prior SDE. Initially, three patients (27%) underwent burr hole aspiration and ten patients (83%) underwent craniotomy. In one patient both were done in the same session. Six patients were reoperated (50%). Weekly magnetic resonance imaging and blood tests were used for follow-up. All patients received antibiotics for at least 6 weeks. There was no mortality. Mean follow-up period was 10 months. CONCLUSION: Interhemispheric SDEs are rare, challenging intracranial infections that have been related to high morbidity and mor-tality rates in the past. Both antibiotics and surgical interventions play role in treatment. Careful choice of surgical approach and repeated surgeries if necessary, accompanied by appropriate antibiotic regimen, leads to good prognosis reducing morbidity and mortality.

Review of management practices of sinogenic intracranial abscesses in children.

OBJECTIVE: This study aimed to evaluate the management practices and outcomes in children with sinogenic intracranial suppuration. METHOD: This was a retrospective cohort study in a single paediatric tertiary unit that included patients younger than 18 years with radiologically confirmed intracranial abscess, including subdural empyema and epidural or intraparenchymal abscess secondary to sinusitis. Main outcomes studied were rate of return to the operating theatre, length of hospital stay, death in less than 90 days and neurological disability at 6 months. RESULTS: A cohort of 39 consecutive patients presenting between 2000 and 2020 were eligible for inclusion. Subdural empyema was the most common intracranial complication followed by extradural abscess and intraparenchymal abscess. Mean length of hospital stay was 42 days. Sixteen patients were managed with combined ENT and neurosurgical interventions, 15 patients underwent ENT procedures alone and 4 patients had only neurosurgical drainage. Four patients initially underwent non-operative management. The rates of return to the operating theatre, neurological deficits and 90-day mortality were 19, 9 and 3, respectively, and were comparable across the 4 treatment arms. In the univariate logistic regression, only the size of an intracranial abscess was found be associated with an increased likelihood of return to the operating theatre, whereas combined ENT and neurosurgical intervention did not result in improved outcomes. CONCLUSION: Sinogenic intracranial abscesses are associated with significant morbidity and mortality. The size of an intracranial abscess has a strong association with a need for a revision surgery.

Subdural empyema in immunocompetent pediatric patients with recent SARS-CoV-2 positivity: case report.

Subdural empyema refers to the collection of purulent material in the subdural space and the most source of it is bacterial meningitis in infants while sinusitis and otitis media in older children. It has been very recently reported that coronaviruses (CoV) exhibit neurotropic properties and may also cause neurological diseases. CoV-related complications as hypercoagulability with thrombosis and associated inflammation, catastrophic cerebral venous sinus thrombose sand bacterial-fungal superinfections have been well documented in adult patients. Hereby, we describe 15-year-old and 12-year-old female children with subdural empyema after SARS-CoV2. The patients presented limitation of eye in the outward gaze, impaired speech, drowsiness, fever, vomiting and they also were tested positive for COVID-19. MRI indicated subdural empyema and surgical interventions were needed to relieve intracranial pressure and drain pus after receiving broad spectrum antibiotics treatments. The microbiological analysis of abscess material revealed Streptococcus constellatus which is extremely rare in an immunocompetent child and the patients received appropriate IV antibiotic therapy. Eventually, patients became neurologically intact. Pediatric patients with CoV infections should be closely monitored for neurological symptoms. Further research and more data on the correlation between CoV infections would provide better recognition and treatment options in an efficient manner in children.

Risk Factors and Surgical Treatment Options for Intracranial Infections.

AIM: To present our experience on intracranial infections, and to determine the possible locations as well as the risk factors for surgical treatment. MATERIAL AND METHODS: Over 13 years, 103 patients with intracranial infection underwent surgical evacuation. Seventy-one (68.9%) patients were men, and the mean age was 38.57 years. For intracranial infections, direct and indirect microbiological identification methods were used. The clinical and radiological data of patients were retrospectively analyzed and compared statistically based on the type of infection, location, history of previous surgery, comorbid diseases, and demographic features of the patients. RESULTS: Forty-six (44.7%) patients had intraparenchymal abscess, 25 (24.3%) had subdural empyema, and 32 (31.0%) had epidural empyema. Emergent surgical evacuation was performed in 60 (58.25%) patients. Microbiological agents were not isolated in 26 (25%) patients, while multiple microorganisms were isolated in 17 (16.5%) patients. Intraparenchymal abscesses are more common in the frontal lobe and cerebellum, while subdural empyemas are located more frequently in the frontoparietal region. There was no significant difference between intracranial infection and age, gender, history of surgery, and preoperative antibiotic use. However, a statistically significant relationship between intracranial infection, history of previous surgery, and the patient?s comorbid disease was found. Specifically, intraparenchymal abscesses were more frequently detected in immunocompromised patients, and subdural empyemas were common in patients with previous tumor surgery. CONCLUSION: Brain abscesses commonly develop in the frontal lobe and cerebellum. Patients who underwent previous cranial surgery and patients with comorbid diseases are more prone to intracranial infections. Large abscesses with significant edema are best candidates for emergent surgical evacuation.

Lawsonella clevelandensis causing spinal subdural empyema.

Lawsonella clevelandensis is a recently described species and genus of bacterium in the Corynebacterineae suborder which is Gram-stain positive, partially acid-fast and anaerobic. Very few cases of human infection due to this organism are described and here we seek to add to the limited medical literature. We report the case of a 2-year-old girl who presented with an infected spinal dermoid cyst secondary to Lawsonella clevelandensis which required surgical drainage and a long course of antibiotics. We encountered diagnostic and therapeutic difficulties because this is a fastidious organism which was difficult to culture and ultimately required molecular detection and identification. To the best of our knowledge, this is only the seventh reported case of Lawsonella clevelandensis causing human infection worldwide and the first in the UK. This is the first reported case of Lawsonella clevelandensis infection in a child and the second reported case of this organism causing spinal infection.

Towards improved outcome in children treated surgically for spontaneous intracranial suppuration in South Wales.

INTRODUCTION: Spontaneous central nervous system (CNS) infections in children are rare. Treatment involves surgical intervention and antibiotic therapy. We describe a single centre experience of managing this condition in South Wales. METHODS: We performed a retrospective review of surgically managed cases in our unit for patients under 18 years of age between 2008 and 2018. Data were collected regarding aetiology, location, microbiology examination, treatment and outcomes. RESULTS: Twenty-six patients were identified of which 25 case notes were available. Fifteen were male and 10 were female. Median age was 12 years (age range 0.3-17 years). Seven patients (28%) had a burr-hole aspiration and 18 (72%) underwent craniotomy. A second procedure was performed in 10 (40%) and a third procedure in two (8%). Fourteen (56%) had a brain abscess, 10 (40%) had subdural empyema (one was bilateral) and one (4%) had an extradural empyema. Fifteen (60%) had a raised WCC (>11.5 × 109/L) and 22 (88%) had a CRP of >10 mg/L at presentation. Three (12%) patients had a normal WCC and CRP at presentation. Overall, 12 (48%) were secondary to sinus infection, with the most common organism being Streptococcus. Seven (28%) were due to otitis media or mastoiditis, six (24%) had no cause identified. The mean number of CT/MRI scans was 6.7 (range 3-13). The mean follow-up period was 16.7 months (range 1-117 months). At last follow up, 19 (76%) had a GOS of 5, five (20%) had a GOS of 4 and one (12%) had GOS of 3. There were no deaths. CONCLUSIONS: In Wales, outcomes have improved over time in keeping with other paediatric neurosurgical units in England. Increased availability of imaging resources in our hospital and use of neuro-navigation for all cases in our unit as well as earlier identification of sepsis, communication with microbiologists with dedicated ward rounds and, enhanced identification of causative organisms and contemporary anti-microbials have also contributed towards the improved management of this condition.

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.

Oral sequential therapy in the treatment of post-surgical epidural abscess and subdural empyema.

PURPOSE: The management of post-surgical subdural empyema and subdural abscess is not standardised. The objective was to analyse the efficacy and safety of oral sequential therapy (OST). METHODS: Retrospective observational study in a tertiary hospital in Vigo (Spain). We included adult patients with subdural abscess or epidural empyema with microbiological isolation. Clinical and demographic variables, isolated microorganisms and treatment regimens were included, as well as mortality and adverse effects during the follow-up period. RESULTS: Thirty patients were reviewed, two died due to causes other than infection. Six-month recurrence rate was 2/28 and all other patients (26/28) had clinical cure at the end of the treatment. The commonest isolated microorganisms were Gram-positive, especially Staphylococcus aureus. The most widely used oral antibiotic was trimethoprim-sulfamethoxazole (80%). No side effects related to oral treatment were observed. CONCLUSION: After adequate source control, OST can be a safe practice in the management of post-surgical epidural abscess and subdural empyema.

Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children.

OBJECTIVE: Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention. METHODS: A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted. RESULTS: 65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%. CONCLUSION: Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.

Sinogenic Intracranial Suppuration in Children: Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate temporal trends in the management of sinogenic intracranial suppuration and its outcomes in children. DATA SOURCES: A systematic search of databases was performed (Medline, Embase, Cochrane, ClinicalTrials.gov). REVIEW METHODS: Studies in children (age <18 years) with sinogenic subdural empyema, extradural abscess, and intraparenchymal abscess were included. Data on treatment strategies were extracted. Primary outcome was death <90 days. Secondary outcomes were return to theater, neurologic disability at 6 months, and length of stay. Random effects meta-analysis and meta-regression were performed to investigate the effect of time and endoscopic sinus surgery (ESS) on these outcomes. RESULTS: A total of 32 retrospective observational studies involving 533 patients recruited across a 45-year period (1975-2020) were included. The pooled estimates for 90-day mortality, permanent neurologic disability, and return to theater were 2.3% (95% CI, 1.1%-3.6%; I2 = 0, P > .99), 21.3% (95% CI, 15.3%-27.3%; I2 = 75.2%, P < .001), and 37.3% (95% CI, 29.5%-45%; I2 = 71.2%, P < .001), respectively, with no significant differences found across the study period. The pooled estimate for ESS was 58.4% (95% CI, 44.2%-72.6%; I2 = 97.1%, P < .001) with a significantly increasing trend in its use in the more recent years. ESS was not associated with improved mortality, reduced need for revision surgery, or neurologic disability. CONCLUSION: The outcomes of sinogenic intracranial complications have not changed over the last 45 years, and ESS was not associated with improved patient outcomes. Further high-quality studies are required to determine the most appropriate treatment modalities to improve the burden of morbidity associated with sinogenic intracranial suppuration in children.

The Case for Early Antibiotic Commencement and Source Control in Paediatric Subdural Empyema: A Single-Centre Retrospective Case Series.

BACKGROUND: Subdural empyema is a neurosurgical emergency requiring prompt diagnosis and treatment. There is a debate between the benefits and risks of starting early antibiotics prior to surgical drainage as this is purported to reduce the rate of microbiological diagnosis. Here, we describe our experience of treating this potentially life-threatening condition, advocating for the early commencement of antibiotics and importance of source control in its treatment. METHODS: Retrospective review of a prospectively collected electronic departmental database included all patients who were admitted to our unit with a diagnosis of subdural empyema over an 11-year period (2008-2018). Basic demographic data were collected. Further data pertaining to mode of presentation, surgical approach, causative organism, post-operative antibiotic regime, anti-seizure medications, length of hospital stay, further surgery, and neurological outcomes were extracted. RESULTS: Thirty-six children underwent 44 operations for subdural empyema at our institution during the study period. Median age was 11.0 (range 0.2-15.8); 47.2% (17/36) were female. Over time, there was decreasing use of burr holes and increasing use of craniectomy as the index surgery. Using a combination of extended culture and polymerase chain reaction, a microbiological diagnosis was achieved in all 36 cases; the commonest causative microorganism was of the Streptococcus anginosus group of bacteria. Seven patients underwent repeat surgery, and 4 patients underwent a concurrent ENT procedure. No risk factors were significant in predicting the likelihood of re-operation (location of subdural empyema, age, index surgery type, inflammatory markers, concurrent ENT procedure, and microorganism) although it was notable that none of the patients undergoing a concurrent ENT procedure underwent repeat surgery (p = 0.29). Median length of stay was 12 days (range 3-74), and there were no inpatient or procedure-related mortalities. Clinical outcomes were good with 94.4% (34/36) categorized as modified Rankin Scale 0-3 at discharge and there were 2 cranioplasty-related complications. CONCLUSIONS: We observed an evolution of practice from limited surgical approaches towards more extensive index surgery over the study period. Given that a microorganism was isolated in all cases using a comprehensive approach, initiation of antibiotic therapy should not be delayed on presentation. Concurrent ENT surgery may be an important factor in providing aggressive source control thereby reducing the need for repeat surgery.

Efficacy of endoscopic sinus surgery alone versus in combination with neurosurgical intervention for the treatment of pediatric subdural empyema.

OBJECTIVES: To compare treatment outcomes for sinogenic subdural empyema (SE) between those managed with initial endoscopic sinus surgery (ESS) alone versus those treated with a combination of ESS and craniotomy over the last decade at our institution. To better characterize subdural empyema with regard to presentation, causative pathogens, and treatment course. METHODS: Retrospective single-center chart review to identify and evaluate pediatric SE patients between 2009 and 2019. Patients meeting inclusion criteria were classified in one of two groups: those who initially underwent ESS or frontal trephination without concurrent neurosurgical procedure and those who underwent craniotomy or burr hole in addition to a sinus procedure. Presenting characteristics and treatment outcomes were compared between the two groups. RESULTS: Eighteen patients met inclusion criteria. The ESS alone and the ESS + craniotomy subgroups each had 9 patients with similar baseline characteristics. The ESS + craniotomy group was more likely to present with neurological symptoms (p = 0.039) and have multiple intracranial fluid collections (p = 0.046). 74.1% of patients presented to the Emergency Department (ED) or to their primary medical doctor and were treated with outpatient management prior to hospitalization with definitive surgical management. The most common presenting symptoms were fever, headache and nausea/vomiting. There were no differences between treatment groups in rate of return to the operating room (OR) (p = 1.00), length of stay (LOS) (p = 0.553), or adverse neurological outcomes (p = 0.456). 44.4% of patients in the ESS alone group eventually required neurosurgical intervention. CONCLUSIONS: Surgical SE patients often present to medical professionals in the primary care setting or ED and are managed with outpatient treatment before admission with definitive treatment. In this small retrospective cohort patients who underwent sinus intervention alone had similar rates of return to OR, LOS and adverse neurological outcomes use as those who underwent a sinus procedure in coordination with a neurosurgical intervention. There may be a group of patients with SE who may be managed with endoscopic procedures alone and further studies should seek to determine the characteristics of this population.

Subdural false twins: concomitant appearance of subdural haematoma and spontaneous subdural empyema.

A 55-year-old man was taken to the emergency department due to right arm weakness for the past 3 days and fever (39.5°C). There was no impaired consciousness, no history of trauma and meningeal signs were absent on physical examination. Blood analysis and inflammatory markers were not evocative of a systemic infection. A cranial CT scan was requested, revealing hypodense bilateral hemispheric subdural collections, suggestive of chronic subdural haematomas. He was submitted to surgical drainage by burr holes, which confirmed the chronic subdural collection on the left side. Unexpectedly, after dural opening on the right side, a subdural purulent collection was found, which was later confirmed as an empyema due to Escherichia coli infection. A second surgical drainage was performed by craniotomy due to recurrence of the right subdural collection. Spontaneously appearing subdural empyemas due to E. coli are extremely rare and their treatment is not always straightforward. The reported case is an example of an apparently straightforward and frequent pathology that turned out to be a challenging case, requiring a multidisciplinary approach.

Pediatric Spinal Subdural Abscesses: A Report of Three Consecutive Patients.

BACKGROUND: Despite technological advances in medical treatment, the prognosis of the rarely reported spinal subdural abscesses (SSAs) has remained a serious entity largely unaffected, especially when they are diagnosed late. In this study, the authors aimed to present the surgical outcomes of 3 consecutive pediatric patients with SSA. MATERIALS AND METHODS: We retrospectively reviewed the medical records of pediatric patients with spinal lesions who underwent surgery at 2 neurosurgical centers spanning 7 years, from 2012 to 2019. All pediatric patients who were diagnosed with SSA (n = 3) were selected as the core sample for this study. RESULTS: Three pediatric patients (2 females and 1 male) with SSA were surgically treated. Holocord SSA was observed in 1 patient. The mean age was 7.1 ± 7.7 years. The most common presenting symptoms were gait disturbance and weakness of lower extremities (100%). The mean preoperative course was 5.7 ± 4.0 weeks. The causative pathogens were Escherichia coli (E. coli) and M. tuberculosis. In the 2nd case, the pathogen was non-tuberculosis mycobacterium in the extramedullary abscess. In the 44th postoperative month, she underwent surgery for intramedullary abscess. The causative pathogen was E. coli. Except for 1 male adolescent who presented with severe clinical status (paraplegic), the improvement was observed in all patients at their last follow-up after 50.3 ± 43.5 months of average. CONCLUSIONS: Drainage followed by appropriate antibiotics is the optimal treatment for SSAs. Early diagnosis and urgent surgical treatment are essential for a good prognosis. All surgically treated SSA patients with neurological deficits were rehabilitated with physical therapy postoperatively.

Immediate replacement of bone flap after craniotomy for empyema in children.

PURPOSE: Optimal management of the bone flap after craniotomy for intracranial infection has not been well defined in the pediatric population. This study reviewed the outcomes of a single Canadian center where immediate replacement of the bone flap was standard practice. METHODS: This is a retrospective study of all patients who underwent craniotomies for evacuation of epidural or subdural empyema at a single center from 1982 to 2018. Patients were identified using the prospective surgical database maintained by the Division of Pediatric Neurosurgery at BC Children's Hospital. Primary outcome was treatment failure, defined as reoperation at the site of initial surgery for removal of an infected bone flap or repeat drainage of empyema under the replaced bone flap. Secondary outcome was any reoperation for recurrent infection at any site. RESULTS: Twenty-four patients met the inclusion criteria with a minimum of 3-month follow-up from the index intervention. Treatment failure occurred in four patients (17%), all of whom required repeat surgery for further drainage of pus underlying the bone flap. Mean time to repeat surgery was 13 days. Any reoperation for recurrent infection at any site occurred in three patients. Seven out of 24 patients required a second surgery to evacuate empyema (29.2%). Age, sex, epidural or subdural location, osteomyelitis, and bone flap wash were not associated with the primary outcome of treatment failure. CONCLUSION: Immediate replacement of the bone flap in the surgical management of pediatric subdural or epidural empyema is reasonable. Replacing the flap at the time of first surgery avoids the morbidity and costs of a subsequent reconstructive operation.

Suppurative Intracranial Complications of Pediatric Sinusitis: A Single-Center Experience.

BACKGROUND: Suppurative intracranial complications of sinusitis are rare events in children and can lead to harmful neurologic sequelae and significant morbidity. We sought to review the presentation and management of patients admitted at our hospital with these conditions. METHODS: This was a retrospective study of pediatric patients admitted to a quaternary children's hospital from 2007 to 2019 for operative management of sinusitis with intracranial extension. Clinical characteristics, including surgical and microbiological data, were collected and analyzed. RESULTS: Fifty-four patients were included; the median age was 11.0 years, and there was a male predominance. Eighty-nine percent of patients had prior healthcare visits for the current episode of sinusitis; 46% of patients had an abnormal neurologic exam on admission. Epidural abscess and subdural empyema were the most common complications, and subdural empyema was associated with repeat surgical intervention. The dominant pathogens were Streptococcus anginosus group organisms (74%). The majority of patients completed treatment parenterally, with a median duration of therapy of 35 days. Neurological sequelae, including epilepsy or ongoing focal deficits, occurred in 22% of patients. History of seizure or an abnormal neurological exam at admission were associated with neurological sequelae. CONCLUSIONS: Clinicians should consider intracranial complications of sinusitis in patients with symptoms of sinusitis for >1 week. Patients should undergo urgent neuroimaging, as neurosurgical intervention is essential for these patients. Subdural empyema was associated with repeat neurosurgical intervention. Neurological sequelae occurred in 22% of patients, and new onset seizure or an abnormal neurological exam at admission were associated with neurological sequelae.

Endoscopic Evacuation of a Panhemispheric Subdural Empyema.

BACKGROUND: Subdural empyema (SDE) is a well-known entity in pediatric populations and is associated with a high rate of morbidity and mortality. Large scale evacuation of empyema, although effective, places the bone flap at risk of failure when replaced. CASE DESCRIPTION: We report the case of a 19-year-old man with a history of a shunted left middle fossa cyst presenting with a panhemispheric SDE after removal of his cystoperitoneal shunt by an outside facility. Extensive evacuation was performed via the patients prior parietal shunt incision after expansion of the preexisting burr hole. Cultures grew methicillin-sensitive Staphylococcus aureus and Propionibacterium acnes, and he was treated with long-term antibiotics. The patient had a complete recovery with persistent empyema resolution on 6-month follow-up. CONCLUSIONS: Endoscopic-assisted burr hole evacuation of large panhemispheric and loculated SDE is feasible, effective, and safe. The primary advantage over conventional open evacuations is that it negates the need for a bone flap and its potential complications related to a secondary infection.

Combined microsurgical fluorescence for optimizing resection in refractory empyema and cerebritis.

PURPOSE: Due to the generalization of new microsurgical equipment, intraoperative fluorescence techniques have extended in neurosurgical practice, mainly in neurovascular and neuro-oncology patients. The aim of identifying pathological tissue and also differentiating from the normal brain helps neurosurgeons to approach other kinds of intracranial entities such as infections. METHODS: It is described in the case of an 11-year-old patient who underwent a subdural empyema by performing a craniotomy and evacuation of the purulent collection. After a non-optimal evolution, a frontobasal meningoencephalitis was assessed with cerebral involvement and associated intracranial hypertension. Indocyanine green (ICG) was used in reintervention for demonstrating a great damage of cortical vascularization around the infected area as well as fluorescein (FL), which identified a large area of avascularized tissue. RESULTS: Both techniques allowed a selective excision of the affected brain parenchyma while preserving viable parenchymal areas. Radiological evolution and clinical outcome were good. CONCLUSIONS: The identification of vascular patterns in brain lesions and the recognition of viable or necrotized tissues are suitable for a selective resection of the parenchyma, minimizing morbidity. Clinical outcome is related to a safe and effective management of inflammatory and infectious processes.