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.

After the storm: Extracorporeal membrane oxygenation after hemicraniectomy in a child.

Ventricular arrhythmias following neurological injury have been attributed to sympathetic surge in subarachnoid hemorrhage and traumatic brain injury. Despite associated risks of bleeding and thrombosis, veno-arterial extracorporeal membrane oxygenation (ECMO) in critically ill, clinically unstable postoperative neurosurgical patients can be lifesaving. In the context of neurological injury and the neurosurgical population, the literature available regarding ECMO utilization is limited, especially in children. We report a case of successful ECMO utilization in a child with malignant ventricular tachycardia after decompressive craniectomy for refractory intracranial hypertension following evacuation of extensive subdural empyema.

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.

Different Approaches in Skull Base Surgery Carry Risks for Different Types of Complications.

Complications are not uncommon in the complex field of skull base surgery. The intrinsic relationship of lesions in this region to important neurovascular structures, dura mater, and bone may lead to significant morbidity and mortality. The evolution of endoscopic endonasal surgery has had a significant impact on this field as a less invasive option for treatment of selected lesions, but major morbidity may still occur; moreover, endoscopic approaches have been associated with higher rates of some specific complications, such as cerebrospinal fluid leaks. Based on a presented case report, the authors discuss the management of various complications associated with different approaches for resection of skull base malignancies, including epidural and intradural pneumocephalus, subdural hematoma, and subdural empyema. Important lessons learned by the senior author throughout more than 30 years of his skull base surgery practice are highlighted. The inherent risk of complications in skull base surgery emphasizes the importance of their avoidance, prevention, and learning from one's unfavorable experience so as not to repeat them.

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.

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.

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.

Unusual subdural empyema in a homeless patient diagnosed by molecular approach: a case report.

BACKGROUND: We report a case of subdural empyema in a homeless patient caused by Bartonella quintana. B. quintana is a facultative intracellular bacteria for which bacterial growth is fastidious. The molecular biology approach has been a real help in establishing the diagnosis. CASE REPORT: A 59-years old homeless patient, with a history of chronic alcohol abuse, was brought to the emergency department with a massive subdural empyema. Extensive microbiological evaluation didn't reveal any pathogen in the pus collected before antibiotic treatment. B. quintana was detected in the pus from the empyema using a 16S rRNA-based PCR. Histology of intraoperative samples was consistent with the diagnosis and a serological assay was positive. The patient responded well to a treatment that included craniectomy with drainage of the loculated pus, total removal of the infected capsule and a combination of antibiotics. CONCLUSION: This unique case of B. quintana-related empyema illustrates the risk of secondary infection of subdural hematoma with B. quintana since such infections have recently reemerged, predominantly among the homeless populations. Patients with subdural empyema in at-risk populations should be systematically evaluated for B. quintana with an appropriate diagnostic approach involving molecular biology.

New perspectives in the endoscopic treatment of brain purulent collections: targets, techniques, results in a case series, and overview of the literature.

BACKGROUND: Purulent intracranial infections are threatening conditions. Different surgical approaches have been described, respecting the rationale of evacuating the fluid component of the purulent collection. Emerging evidence supports the use of the endoscope for the treatment of cerebral abscesses and subdural empyemas; especially the peculiarities of flexible endoscopes could potentially offer a more effective and conclusive management as compared with the drainage through catheters. We describe our experience in the treatment of intracranial purulent collections with flexible endoscopy, comparing it with the most recent literature. METHODS: Ten patients affected by intracranial suppuration were treated with endoscopy at our institution. The neurosurgical technique is thoroughly described. The related literature is reviewed, providing a comprehensive overview on the endoscopic treatment of intracranial suppuration so far. RESULTS: All the patients had a good clinical outcome, with no peri-operative complications. The postoperative scans showed significant radiological improvement, with important reduction of the pus volume. In all cases, the microbiological cultures showed positivity. CONCLUSIONS: In our experience, the use of the flexible scope proved feasible and effective in the treatment of intracranial purulent collections. Visual awareness of the internal capsule is not limited to a direct inspection of the fluid pus; it rather allows an active removal of the more solid (and perhaps more microbiologically significant) fibrinoid component, and also assists in final bleeding control and in assessing the extent of the evacuation. The steering capabilities of the fiberscope are particularly suitable for such purposes, allowing sampling the solid internal layer of the pyogenic membrane, and potentially shedding light on the actual clinical significance of this component of the abscess.

Unilateral hearing loss in a 94-year-old patient.

A case report of a 94-year-old, previously well male patient who presented with fever thought to be caused by community acquired pneumonia, new unilateral hearing loss and reduced consciousness. Despite antibiotic treatment he continued to deteriorate. Brain imaging with computer tomography and magnetic resonance imaging revealed a left otomastoiditis with osteomyelitis of the skull base, associated with an adjacent subdural empyema. He was also found to have a venous sinus thrombosis, most likely secondary to otitis media. He was managed with intravenous antibiotics, anticoagulation, grommet insertion and a hearing aid and he made a good recovery. This case reminds us to consider otitis media in older patients who present with hearing loss and fever. Otitis media can lead to serious complications including subdural empyema and osteomyelitis of the skull base.

Treatment-refractory Escherichia coli subdural empyema caused by infection of a chronic subdural hematoma in an infant.

INTRODUCTION: Subdural empyema (SDE) is a neurosurgical emergency that is typically treated with surgical drainage, either by burr hole or by craniotomy. Escherichia coli is an uncommon cause of SDE and is associated with infection of a pre-existing subdural hematoma. CASE REPORT: We report the case of an otherwise healthy, immunocompetent 4-month-old infant girl with an E. coli-infected subdural hematoma. The infection persisted despite aggressive neurosurgical treatment that included drainage of the subdural space through burr holes and, subsequently, a wide craniotomy was performed. Ultimately, after 30 days, the SDE resolved with good neurological outcome. A review of prior literature indicates that infected subdural hematomas (including those caused by E. coli) are typically less aggressive and respond to burr hole drainage. CONCLUSION: We illustrate the fulminant progression of the SDE in the face of neurosurgical treatment. Our experience suggests lowering the threshold for wide craniotomy in these incompletely understood cases.

Predictors of outcome of subdural empyema in children.

OBJECTIVE: The aim of this study was to report the etiology, clinical features, microbiology, surgical outcome, and predictors of outcome of spontaneous subdural empyema (SDE). METHODS: The authors conducted a retrospective study in a tertiary hospital. Children up to 18 years of age, with a diagnosis of SDE with infective etiology, were included in the present cohort. Patients with posttraumatic, postsurgery, and tubercular origin of SDE were excluded from the study. The Glasgow Outcome Scale was used for outcome assessment at the end of 3 months. For analysis purposes, the demographic data, clinical features, radiological data, microbiology, type of surgery, and complication data were categorized, and univariate and multivariable logistic regression analyses were performed to identify the factors associated with outcome. RESULTS: Ninety-eight children were included in the study and the mean age was 10.9 years. Otogenic origin (34.7%) was the most common source of infection, followed by meningitis (14.3%). The mean duration of symptoms was 12 days. Seventy-six children presented with Glasgow Coma Scale (GCS) score > 8 and the supratentorial location was the most common location. Almost 75% of the children underwent craniotomy or craniectomy and the rest had burr-hole evacuation. Beta-hemolytic Streptococcus (10%) was the most common organism isolated. Cerebral venous thrombosis (CVT; 10.2%) was the most frequent complication in this cohort. The other complications were infarction (6.1%), new-onset seizure (4.1%), and bone flap osteomyelitis (4.1%). Thirteen cases had a recurrence of pus collection, which was more common in the craniotomy group than in the burr-hole group. Age (p = 0.02), GCS score ≤ 8 (OR 8.15, p = 0.001), CVT (OR 15.17, p = 0.001), and presence of infarction (OR 7, p = 0.05) were strongly associated with unfavorable outcome. In multivariable logistic regression analysis, only GCS score ≤ 8 (p = 0.01), CVT (p = 0.02), and presence of infarction (p = 0.04) had a significant impact on unfavorable outcome. CONCLUSIONS: Prompt diagnosis and immediate intervention is the goal of management of SDE, especially in children as a delay in diagnosis can result in unconsciousness and secondary complications such as CVT and infarction, which adversely affect outcome.

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

PURPOSE: 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. METHODS: A retrospective analysis of data obtained from clinical records was performed, followed by multivariate regression analysis of patient and treatment-related factors. RESULTS: 113 patients were included with a median age of 53 years 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). CONCLUSIONS: 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 due to Salmonella paratyphi B in an infant: a case report and review of literature.

Intracranial infection due to Salmonella is uncommon in children. Subdural empyema (SDE) is described with Salmonella typhi as a complication of meningitis. We report a 6-month-old infant with SDE secondary to Salmonella paratyphi B who had presented with prolonged fever and enlarging head. A literature review of Salmonella SDE in infants with respect to clinical course and outcome is presented.

Management of spinal infection: a review of the literature.

Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2-7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient's general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.

Interhemispheric and Infratentorial Subdural Empyema with Preseptal Cellulitis as Complications of Sinusitis: A Case Report.

Intracranial complications of paranasal sinusitis have become rare due to the use of antibiotics nowadays. However, several cases have been reported due the ability of paranasal sinusitis to cause serious complications. Once the infection spreads over the cranial structure, it could infect the orbits, underlying bones, meninges, adjacent veins, and brain. Subdural empyema is a rare but potentially life-threatening complication following paranasal sinusitis and should be considered as a neurological emergency. The location where subdural empyema may appear is a challenge in diagnosis and treatment. We report the case of a 17-year-old boy who presented in a state of somnolence due to interhemispheric and infratentorial subdural empyema with preseptal cellulitis secondary to pansinusitis. Early diagnosis and aggressive antibiotic treatment combined with neurosurgical operation were mandatorily implemented. The case was managed using a multidisciplinary approach including the ENT, eye, and nutrition departments. The boy achieved clinical improvement, with impairment of eye movement as the only persistent symptom before discharge. Daily supervision at the primary health care center with continuous antibiotic treatment was recommended to the patient. Pertinent literature with controversies in the management of subdural empyema will be briefly discussed in this case report.

Causes of pneumocephalus and when to be concerned about it.

Intracranial gas is commonly detected on neuroimaging. The recognition of this finding can at first blush be unsettling. Being able to localize this gas to a specific compartment: intraarterial, intravenous, intraparenchymal, subdural, epidural, subarachnoid and intraventricular, is the first step in determining the importance of the gas. Determination of the route of entry: through the skull, extension from a paranasal sinus or the mastoid air cells, via the spine, or trans-vascular, is the other important factor in determining potential consequences. Understanding these parameters allows for a confident determination of etiology. More importantly, it generally provides guidance as to what must be done: either to disregard (e.g., subarachnoid gas following lumbar puncture and intravenous gas following IV placement), obtain follow-up (e.g., postoperative gas), or administer emergent treatment (e.g., intraarterial gas and epidural abscess). In this review, we use gas location and route of entry to classify the various causes of pneumocephalus and provide examples of each of these etiologies.

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

BACKGROUND: There have been various reports concerning Helicobacter cinaedi infections. However, few reports have examined central nervous system infections. CASE PRESENTATION: A 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. CONCLUSIONS: H. 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.

Aspiration of parafalcine empyemas with flexible scope.

PURPOSE: Subdural empyemas are considered neurosurgical emergencies, and the parafalcine location is particularly insidious. We revised the experience of general surgeons who are used to manage chronic pleural purulent collections with video-assisted thoracoscopy. METHODS: With a similar technique, we successfully aspirated a parafalcine empyema using a flexible scope avoiding a more invasive craniotomy. A review of the treatment options of empyematous collections is also provided, focusing particularly on the hazardous parafalcine location. RESULTS: The management of subdural empyemas poses different decision-making problems compared to common brain abscesses, urging a more rapid and holistic surgical treatment with minimally invasive approach. Endoscopic aspiration of parafalcine empyema was followed by complete recovery in our patient. CONCLUSIONS: Flexible endoscopy is a promising method to obtain complete pus removal even from loculated collections through a bur hole, avoiding large craniotomies and consequent potential complications.