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.
CourvilleCB: Subdural empyema secondary to purulent frontal sinusitis: a clinicopathologic study of forty-two cases verified at autopsy. Arch Otolaryngol39:211–230, 194410.1001/archotol.1944.00680010224003)| false
EggartMD, GreeneC, FanninES, RobertsOA: A 14-year review of socioeconomics and sociodemographics relating to intracerebral abscess, subdural empyema, and epidural abscess in southeastern Louisiana. Neurosurgery79:265–269, 2016
EggartMD, GreeneC, FanninES, RobertsOA: A 14-year review of socioeconomics and sociodemographics relating to intracerebral abscess, subdural empyema, and epidural abscess in southeastern Louisiana. Neurosurgery79:265–269, 20162690980410.1227/NEU.0000000000001225)| false
GarinA, ThierryB, LeboulangerN, BlauwblommeT, GreventD, BlanotS, et al.: Pediatric sinogenic epidural and subdural empyema: The role of endoscopic sinus surgery. Int J Pediatr Otorhinolaryngol79:1752–1760, 2015
GarinA, ThierryB, LeboulangerN, BlauwblommeT, GreventD, BlanotS, : Pediatric sinogenic epidural and subdural empyema: The role of endoscopic sinus surgery. Int J Pediatr Otorhinolaryngol79:1752–1760, 20152630407010.1016/j.ijporl.2015.08.007)| false
GermillerJA, MoninDL, SparanoAM, TomLWC: Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg132:969–976, 20061698297310.1001/archotol.132.9.969)| false
LovettME, ShahZS, Moore-ClingenpeelM, SribnickE, OstendorfA, ChungMG, et al.: Intensive care resources required to care for critically ill children with focal intracranial infections. J Neurosurg Pediatr22:453–461, 2018
LovettME, ShahZS, Moore-ClingenpeelM, SribnickE, OstendorfA, ChungMG, : Intensive care resources required to care for critically ill children with focal intracranial infections. J Neurosurg Pediatr22:453–461, 201810.3171/2018.4.PEDS1771530004311)| false
PatelAP, MastersonL, DeutschCJ, ScoffingsDJ, FishBM: Management and outcomes in children with sinogenic intracranial abscesses. Int J Pediatr Otorhinolaryngol79:868–873, 201510.1016/j.ijporl.2015.03.02025887135)| false
PathakA, SharmaBS, MathuriyaSN, KhoslaVK, KhandelwalN, KakVK: Controversies in the management of subdural empyema. A study of 41 cases with review of literature. Acta Neurochir (Wien)102:25–32, 199010.1007/BF01402182)| false
RayS, RiordanA, TawilM, MallucciC, JauhariP, SolomonT, : Subdural empyema caused by Neisseria meningitidis: a case report and review of the literature. Pediatr Infect Dis J35:1156–1159, 201610.1097/INF.000000000000125227254039)| false
SalomãoJF, CervanteTP, BellasAR, BoechatMC, PoneSM, PoneMVS, : Neurosurgical implications of Pott’s puffy tumor in children and adolescents. Childs Nerv Syst30:1527–1534, 20142499653510.1007/s00381-014-2480-x)| false