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Intracranial
subdural empyema along with brain abscess are serious debilitating conditions
with increased risk in patients undergone cranial surgery and to those with
immunosuppression, extremes of age, malnourishment. Here we present a case with
the subtlest neurological deficits and its progression with time. We shall
review our goals and attitude in treating this patient.
INTRODUCTION
Intracranial subdural empyema (ISDE) is a
condition characterized by localized collection of pus in between the arachnoid
and dura mater. It almost never crosses the meningeal boundaries such as the
falx or the tentorium. This condition is rare due to the modernization of
armaments in microbial warfare. Better fitted techniques and hospital attitude
to disposables and sterility has brought done the incidence of ISDE further
down. Non-traumatic chronic subdural hematomas to develop ISDE have been
reported in only 27 documented cases around the world. A pre-existing subdural
hematoma transforming into an ISDE is attributed to hematogenous spread of
infective potentials. It is extremely difficult to narrow out the possible
spectrum of organisms more probable to cause this particular condition [1,2].
In this report we present an adult case that
developed ISDE along with a solitary brain abscess following chronic subdural
hematoma.
CASE REPORT
T This lady of 70 years was admitted
under our care following a prolonged period of care outside our facility. She
was previously admitted with a history of slipping and hitting her head 2 years
back and was admitted with signs of moderate head injury. Following evaluation,
she was diagnosed as a case of left sided subdural hematoma. The size of the
hematoma and the progression of the patient demanded a conservative approach in
this patient. Later she was discharged in good health. But 6 months into the
incident she developed convulsions starting on one side of her body and lasted
for 2-3 min, this followed with right sided hemiparesis which progressed
slowly. The patient was admitted again with an increase in the size of the
subdural hematoma (Figure 1).
A unilateral burr hole over the parietal
prominence was made and the hematoma drained. The operation note stated of
motor-oil fluid to be evacuated and the inner membrane was left intact.
Immediate post-operative recovery was well and the patient was discharged 15
days later. The patient had been away from regular follow-ups. But nine months
into her recovery she started having intermittent low-grade fever with chills
and rigors. She lost considerable amount of weight and was apathetic. Her care
givers notice a slow development of swelling over the previous scar for the
burr hole. The swelling slowly gave away and discharged frank pus. She was
taken back and admitted and started on empirical antibiotics. On radiology she
was found to have a subdural collection with enhanced walls juxta to the
parietal bone. Burr hole drainage using the same incision mark was done and
cultures sent, which were negative for growth.
Patient on this round was on total 3 weeks of
antibiotics. Three weeks following discharge she again developed the same
condition with swelling and discharge from the wound with an even worse
hemiparesis. Repeat CT scan was done and was show to have reformation of pus (Figure 2). On evaluation for markers
of inflammation and microbiology no signs of sepsis were proved. To note
especially serial microbiological cultures were all negative. Craniectomy of
the osteomyelitic parietal bone was done and frank pus from both the epidural,
subdural compartments were drained and sent for cultures.
The intra-axial abscess was drained using a
brain cannula and thoroughly washed. Locally necrotic parts of the brain were
removed and were through washed using normal saline and Hydrogen Peroxide. A
12F Penrose drain was kept epidurally and was closed ensuring hemostasis.
Patient was followed up and continued on broad spectrum empirical antibiotic
coverage, including anaerobes; as the cultures failed to yield any growth. The
patient objectively improved as hemiparesis was reduced and fever subsided, but
CBC and CRP were inconclusive. Three weeks into in house intravenous
antimicrobial therapy the patient again started to develop fever, hemiparesis,
and the swelling over the craniectomy defect. Radiological evaluation using CT
scan showed the formation of a large extra-axial subdural hypodense crescentic
collection of pus and intra-axial solitary abscess with thickened walls within
the left parietal lobe (Figure 3).
Re-exploration and drainage was again
performed and the samples sent for culture. As usual the cultures failed to
point out any responsible micro-organisms. Additional three weeks of
intravenous antimicrobials was given and patient was put on a high energy diet,
along with supplements. She received three whole blood transfusions in her two
months of care in this hospital. Patient subjectively and objectively improved
and was put on oral antibiotics following 6 weeks of intensive intravenous
antimicrobial therapy. After satisfactory improvements in the general condition
of the patient she was discharged with advice along a further 6 months course
of oral antimicrobials and scheduled follow-up visits every 15 days (Figure 4).
DISCUSSION
Due to the relatively low incidence of
subdural hematomas being infected there was only 27 reported cases on literature
review [2]. The mortality rate from ISDE has dropped to levels below 10% from
40% due to advances in the fields of medicine [3]. The only challenge in this
condition is that the clinicians is faced with the odd of a very invasive and
stubborn infection without the classical clinical signs that should have been
related to it [1,4]. The same pattern was seen in our patient, she had no signs
of meningism or overt septicemia or sepsis. In one study it is of opinion that
patients with ISDE have subtle symptoms and signs only 15% presents with
headache and 35% with fever [3]. These refractory cases’ management has to be
tailored to the clinical settings in that particular situation. Our patient
particularly had no yield on any of the cultures given out. This prompted us to
use empirical antimicrobials with meningitic concentrations for the utmost
efficacy. On the note of interventions, burr hole and craniotomy are both
appropriate as surgical procedures for this particular setting [2]. But in our
case we have had poor results with both burr hole and craniectomy, both being
required multiple times.
CONCLUSION
In our opinion, these cases need more
attention due to the misleading fact of subtle warning signs to an overt and
deadly disease. Lesions reappearing after an initial burr hole drainage should
be prompted to be converted to a formal craniectomy and planning for
cranioplasty at a later setting.
1. French
H, Schaefer N, Keijzers G, Barison D, Olson S (2014) Intracranial subdural
empyema: A 10 year case series. Ochsner J 14: 188-194.
2. Yamamoto
S, Asahi T, Akioka N, Kashiwazaki D, Kuwayama N, et al. (2015) Chronic subdural
hematoma infected by Propionibacterium
acnes: A case report. Case Rep Neurol 7: 6-14.
3. Doan
N, Patel M, Nguyen HS, Mountoure A, Shabani S, et al. (2016) Intracranial
subdural empyema mimicking a recurrent chronic subdural hematoma. J Surg Case
Rep 2016: rjw158.
4. Brouwer
MC, Coutinho JM, van de Beek D (2014) Clinical characteristics and outcome of
brain abscess: Systematic review and meta-analysis. Neurology 82: 806-813.
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