Infantil infected chronic subdural hematoma

Case presentationHelene Hurth, MS6

Innsbruck Medical University

M.M.• H&P: 5 m.o. male: fever, irritability for 3 days, intermittent emesis

poor hygiene, macrocephalyno h/o trauma, no LOC

alert, moves all extremities, PERRL, EOMI, bulging fontanelle,

Temp: 40,6°C (105,1°F), BP 82/67mmHg, HR 180, RR 34, SpO2 99% no ecchymosis/lacerations/abrations/deformities/crepitus

• Lab: CRP 40,3 mg/dl, WBC 14,8• PMH:term born, methamphetamine pos at birth

PICU at 1 month for RSV, apnea spells• SH: father retains full custody

open CWS case – mother: substance abuse3y/o healthy sibling

M.M.

Preoperative MRI

Bilateral chronicsubdural hematoma

Le: 25 mmRi: 15 mm

Enhancement of membranes

3mm rightward midline shift

M.M.

• Subdural tab via AF after admission: 4+ GNR in gram stain – E.coli

• Burr hole drainage w/ bilateral drains the next morning

• Abx: Ceftriaxone, Meropenem

Postoperative MRI

Le: 12 mmRi: 7-8 mm

Resolution ofmidline shift

Septations

OP

• Craniotomy w/ resection of membranes on day 5 after borr hole drainage due to remaining fever and up trending inflammatory markers

Childhood extraaxial CNS infections

• Age peaks: >11y (50%) & <1y (>20%)

• Duration of symptoms based on underlying cause

• Fever, headache, altered consciousness, focal deficits, full AF, poor feeding, seizures

S. Gupta, J Neurosurg Pediatrics 2011

Childhood extraaxial CNS infections• Postsinusitis: (frontal) SDE, epidural abscess, Pott‘s puffy tumor; +-

cerebritis

• Postmeningitis: diffuse hemispheric/infratentorial SDE

• Postoperative: epiduralabscess, SDE, osteomyelitis at OP-site

• Otogenic -> mastoiditis: SDE, epidural abscess

S. Gupta, J Neurosurg Pediatrics 2011

Childhood extraaxial CNS infections

• Treatment: Initial wide craniotomy + abx• Complications: recurrent seizures, venous sinus/

cortical vein thrombosis• Outcome: preoperative presentation

Etiologyearly, aggressive surgical treatment

S. Gupta, J Neurosurg Pediatrics 2011

Infected CSDH

• Rare • Strept spp, Staph aureus, H. influenzae, E. coli,

Salmonella spp • Hematogenous • Satisfactory outcome • Antibiotic treatment• Drainage vs craniotomy

Surgical treatment: CSDH

• Pre-OP T2*-MRI, randomly BH or SC• Burr holes: equivalent, lower mortality/morbidity/hospital stay• Small craniotomy w/ resection of outer and intrahematomal

membranes: superior if intrahematomal membranes present

M. Tanikawa, Acta Neurochirurgica 2001

N=20 N=29

Surgical treatment: CSDH• Outcome, reoperation, hospital stay• Hematoma recurrance: thick membranes

-> residualhematoma-> rebleeding

MRI (T2*) imagingto predict need for craniotomy

M. Tanikawa, Acta Neurochirurgica 2001

Case Tanikawa et al.

Summary

• Neurosurgery often required in extraaxial CNS infections

• Early diagnosis!• Consider infected CSDH with signs of bacteremia