Focal Intradural Brain Infections in Children: An Analysis of Management and Outcome

Abstract

Introduction: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. Materials and Methods: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. Results: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. Conclusions: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Cerebellar abscess caused by Listeria monocytogenes in a liver transplant patient

“…This correlates with the clinical presentation in our patient who had headache and vomiting as presenting symptoms. Symptoms of raised intracranial pressure are more common in patients with ITA than in those with supratentorial abscess, and patients with ITA tend to present more with raised intracranial pressure .…”

“…According to Madhugiri et al. , although fever, headache, vomiting, and altered sensorium are the presenting symptoms of intracranial abscesses (ICA), only 34% of patients with infratentorial abscess (ITA) presented with altered sensorium. This correlates with the clinical presentation in our patient who had headache and vomiting as presenting symptoms.…”

Craniectomía descompresiva para empiema por Aggregatibacter aphrophilus: revisión de la literatura y presentación de caso

“…Epidemiológicamente, se encuentran la mayoría de series y reportes de caso en países en vías de desarrollo, sobre todo en India y en Sudáfrica con una importante predominancia en hombres jóvenes (7,8). Además, se han encontrado factores predisponentes y asociados como: VIH, estado postrasplante, tratamiento de enfermedades neoplásicas o enfermedades autoinmunes (12). En el ámbito clínico se ha descrito que una de las principales causas de formación de empiemas subdurales es la presencia de infecciones contiguas que se diseminan y alcanzan el encéfalo.…”

“…Para el abordaje de los empiemas supratentoriales se plantea la discusión y el tema central de la mayoría de los estudios y series de casos: ¿qué resulta más efectivo: la craniectomía o la craneotomía en comparación con el trepano? (2,6,12). La literatura ha comparado ambos abordajes.…”

“…(1,2,10). La evaluación del manejo quirúrgico corresponde a determinar la efectividad de las principales técnicas usadas actualmente: la realización de un trepano por el que se drena el pus y se irriga el empiema y el uso de una craniectomía o craneotomía, a fin de liberar mayor espacio para el edema del encéfalo (2,9,12).…”