Intracranial subdural empyemas and epidural abscesses in children

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OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS EA = epidural abscess; SE = subdural empyema.

Article Information

Correspondence Paul A. Grabb: Children’s Mercy Hospital, Kansas City, MO. pagrabb@cmh.edu.

INCLUDE WHEN CITING Published online March 22, 2019; DOI: 10.3171/2019.1.PEDS18434.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 9. Cranial T1-weighted MR image with contrast, coronal view (left), obtained at the time of diagnosis in a 10-year-old girl with frontal temporal SEs. Corresponding CT with contrast, coronal view (right), obtained 3 weeks after the initial craniotomy, showing the formation of a large abscess remote from the sites of prior infection.

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    Examples of SEs dictated as EAs on imaging reports. Case 7. Cranial T2-weighted MR image, axial view (A), and T1-weighted MR image, axial view (B), obtained in an 8-year-old boy with fever, sinusitis, and seizures. The left frontal collection was epidural (asterisks); the remaining collections were SEs. Case 9. Head CT with contrast (C) obtained in 10-year-old girl with lethargy and dysphasia, which was dictated as not showing intracranial infection, although retrospectively we determined a left extraaxial collection (asterisk) was likely present. Cranial T1-weighted MR image with contrast, axial view (D), shows left frontal SE, originally interpreted as EA. The interhemispheric collection (asterisk) was correctly described as subdural.

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    Case 11. An 11-year-old boy presented with fever, periorbital swelling, lethargy, and irritability. An orbital CT with contrast (A) showed partial opacification of the frontal sinus but was interpreted as showing no intracranial infection, although retrospectively (B) anterior extraaxial hypodensity was likely present (white arrow). The same child presented 48 hours later with worsening symptoms, and head CT without contrast (C) clearly showed a collection (white arrow). Sagittal MRI (D) performed immediately thereafter confirmed both EA and SE.

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    Case 10. An 11-year-old boy with sinusitis presented with seizure and fever. CT without contrast was interpreted as normal (left). The same evening, an MR image with contrast (right) was obtained, showing a left-sided SE (asterisks).

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    Examples of EA only cases. Case 1. Cranial axial T2-weighted MR image (A) and axial T1-weighted MR image with contrast (B) obtained in a 4-year-old girl who had presented with sinusitis and headache. Case 2. Cranial axial T2-weighted (C) and sagittal T1-weighted (D) MR images with contrast obtained in a 13-year-old boy who presented with sinusitis and headache. Both were treated successfully with single burr hole drainage.

References

  • 1

    Agrawal ATimothy JPandit LShetty LShetty JP: A review of subdural empyema and its management. Infect Dis Clin Pract 15:1491532007

  • 2

    Bambakidis NCCohen AR: Intracranial complications of frontal sinusitis in children: Pott’s puffy tumor revisited. Pediatr Neurosurg 35:82892001

  • 3

    Banerjee ADPandey PDevi BISampath SChandramouli BA: Pediatric supratentorial subdural empyemas: a retrospective analysis of 65 cases. Pediatr Neurosurg 45:11182009

  • 4

    Bannister GWilliams BSmith S: Treatment of subdural empyema. J Neurosurg 55:82881981

  • 5

    Bayonne EKania RTran PHuy BHerman P: Intracranial complications of rhinosinusitis. A review, typical imaging data and algorithm of management. Rhinology 47:59652009

  • 6

    Bruner DILittlejohn LPritchard A: Subdural empyema presenting with seizure, confusion, and focal weakness. West J Emerg Med 13:5095112012

  • 7

    Courville CB: Subdural empyema secondary to purulent frontal sinusitis: a clinicopathologic study of forty-two cases verified at autopsy. Arch Otolaryngol 39:2112301944

  • 8

    Dill SRCobbs CGMcDonald CK: Subdural empyema: analysis of 32 cases and review. Clin Infect Dis 20:3723861995

  • 9

    Eggart MDGreene CFannin ESRoberts OA: A 14-year review of socioeconomics and sociodemographics relating to intracerebral abscess, subdural empyema, and epidural abscess in southeastern Louisiana. Neurosurgery 79:2652692016

  • 10

    Garin AThierry BLeboulanger NBlauwblomme TGrevent DBlanot S: Pediatric sinogenic epidural and subdural empyema: The role of endoscopic sinus surgery. Int J Pediatr Otorhinolaryngol 79:175217602015

  • 11

    Germiller JAMonin DLSparano AMTom LWC: Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg 132:9699762006

  • 12

    Giannoni CSulek MFriedman EM: Intracranial complications of sinusitis: a pediatric series. Am J Rhinol 12:1731781998

  • 13

    Gupta SVachhrajani SKulkarni AVTaylor MDDirks PDrake JM: Neurosurgical management of extraaxial central nervous system infections in children. J Neurosurg Pediatr 7:4414512011

  • 14

    Hendaus MA: Subdural empyema in children. Glob J Health Sci 5:54592013

  • 15

    Hicks CWWeber JGReid JRMoodley M: Identifying and managing intracranial complications of sinusitis in children: a retrospective series. Pediatr Infect Dis J 30:2222262011

  • 16

    Kanamalla USIbarra RAJinkins JR: Imaging of cranial meningitis and ventriculitis. Neuroimaging Clin N Am 10:3093312000

  • 17

    Legrand MRoujeau TMeyer PCarli POrliaguet GBlanot S: Paediatric intracranial empyema: differences according to age. Eur J Pediatr 168:123512412009

  • 18

    Leys DDestee APetit HWarot P: Management of subdural intracranial empyemas should not always require surgery. J Neurol Neurosurg Psychiatry 49:6356391986

  • 19

    Liu ZHChen NYTu PHLee STWu CT: The treatment and outcome of postmeningitic subdural empyema in infants. J Neurosurg Pediatr 6:38422010

  • 20

    Lovett MEShah ZSMoore-Clingenpeel MSribnick EOstendorf AChung MG: Intensive care resources required to care for critically ill children with focal intracranial infections. J Neurosurg Pediatr 22:4534612018

  • 21

    Madhugiri VSSastri BVSSrikantha UBanerjee ADSomanna SDevi BI: Focal intradural brain infections in children: an analysis of management and outcome. Pediatr Neurosurg 47:1131242011

  • 22

    Mauser HWVan Houwelingen HCTulleken CAF: Factors affecting the outcome in subdural empyema. J Neurol Neurosurg Psychiatry 50:113611411987

  • 23

    McIntyre PBLavercombe PSKemp RJMcCormack JG: Subdural and epidural empyema: diagnostic and therapeutic problems. Med J Aust 154:6536571991

  • 24

    Meeks RB IIISchmidt JH III: The difficult diagnosis of subdural empyema: report of three cases and review of the literature. W V Med J 92:87881996

  • 25

    Muzumdar DBiyani NDeopujari C: Subdural empyema in children. Childs Nerv Syst 34:188118872018

  • 26

    Nathoo NNadvi SSGouws Evan Dellen JR: Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients. Neurosurgery 49:8728782001

  • 27

    Niklewski FPetridis AKAl Hourani JBlaeser KNtoulias GBitter A: Pediatric parafalcine empyemas. J Surg Case Rep 2013:1–32013

  • 28

    Osman Farah JKandasamy JMay PBuxton NMallucci C: Subdural empyema secondary to sinus infection in children. Childs Nerv Syst 25:1992052009

  • 29

    Patel APMasterson LDeutsch CJScoffings DJFish BM: Management and outcomes in children with sinogenic intracranial abscesses. Int J Pediatr Otorhinolaryngol 79:8688732015

  • 30

    Pathak ASharma BSMathuriya SNKhosla VKKhandelwal NKak VK: Controversies in the management of subdural empyema. A study of 41 cases with review of literature. Acta Neurochir (Wien) 102:25321990

  • 31

    Pattisapu JVParent AD: Subdural empyemas in children. Pediatr Neurosci 13:2512541987

  • 32

    Piatt JH Jr: Intracranial suppuration complicating sinusitis among children: an epidemiological and clinical study. J Neurosurg Pediatr 7:5675742011

  • 33

    Quraishi HZevallos JP: Subdural empyema as a complication of sinusitis in the pediatric population. Int J Pediatr Otorhinolaryngol 70:158115862006

  • 34

    Ray SRiordan ATawil MMallucci CJauhari PSolomon T: Subdural empyema caused by Neisseria meningitidis: a case report and review of the literature. Pediatr Infect Dis J 35:115611592016

  • 35

    Sade RPolat G: Rare and serious complications of sinusitis in pediatric patients: epidural abscess. J Craniofac Surg 28:e144e1452017

  • 36

    Salomão JFCervante TPBellas ARBoechat MCPone SMPone MVS: Neurosurgical implications of Pott’s puffy tumor in children and adolescents. Childs Nerv Syst 30:152715342014

  • 37

    Smith HPHendrick EB: Subdural empyema and epidural abscess in children. J Neurosurg 58:3923971983

  • 38

    Wu TJChiu NCHuang FY: Subdural empyema in children—20-year experience in a medical center. J Microbiol Immunol Infect 41:62672008

  • 39

    Yilmaz NKiymaz NYilmaz CBay AYuca SAMumcu C: Surgical treatment outcome of subdural empyema: A clinical study. Pediatr Neurosurg 42:2932982006

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