Intracranial subdural empyemas and epidural abscesses in children

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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.

ABBREVIATIONS EA = epidural abscess; SE = subdural empyema.

Article Information

Correspondence Paul A. Grabb: Children’s Mercy Hospital, Kansas City, MO.

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.



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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.





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