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|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 2 | Page : 207-209
A case of subdural empyema following chronic subdural hematoma drainage
Aysegul Ozdemir Ovalioglu1, Ozlem Altuntas Aydin2
1 Department of Neurosurgery, Haseki Education and Research Hospital, Istanbul, Turkey
2 Department of Infectious Diseases, Haseki Education and Research Hospital, Istanbul, Turkey
|Date of Submission||14-Mar-2013|
|Date of Decision||14-Mar-2013|
|Date of Acceptance||22-Mar-2013|
|Date of Web Publication||29-Apr-2013|
Aysegul Ozdemir Ovalioglu
Department of Neurosurgery, Haseki Education and Research Hospital, Istanbul
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ovalioglu AO, Aydin OA. A case of subdural empyema following chronic subdural hematoma drainage. Neurol India 2013;61:207-9
One of the surgery-related complications of burr-hole craniostomy is subdural empyema (SDE). If not recognized and treated early, SDE may be complicated by cerebral abscess, cortical venous thrombosis, or localized cerebritis and may lead to death.  We report one such case.
A 54-year-old male presented with 20 hour duration of headache, fever, and progressive deterioration of consciousness. He had undergone two burr-holes craniostomy and closed system drainages two times in a month for right fronto-parietal chronic subdural hematoma (CSDH). He presented to emergency department 10 days after the last surgery. There was history of closed head trauma 4 months ago and no skull fracture. Neurological examination revealed a Glasgow Coma Scale score of 10 (E3, V2, M5) and left side hemiparesis (3/5). Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated subdural collection in the same localization of the prior SDH [Figure 1] and [Figure 2]. With a possible diagnosis of SDE, he underwent emergent surgery under local anesthesia using the same burr holes to evacuate the subdural collection. At operation, a very thick capsule was seen around the lesion. A yellowish purulent material was drained with puncturing of the capsule. The empyema cavity was irrigated with sterile saline solution until the returning fluid was clear, and drains were placed in the subdural space for 2 days. Postoperatively he was alert and the hemiparesis resolved rapidly on postoperative day-1. Culture of the subdural fluid identified methicillin-resistant Staphylococcus epidermidis. He was treated with intravenous vancomycin and meropenem for 6 weeks. He was on prophylactic antiepileptic treatment since the first subdural hematoma drainage. He recovered fully and repeat MRI at 6 weeks follow-up did not show any recurrence of pus collection [Figure 3]. He has been followed up in the outpatient clinic for 2 years.
In adults, SDE is common due to contiguous spread of infection from paranasal sinuses, ear, head trauma (compound depressed fracture), and rarely following neurosurgical procedure.  The incidence of empyema after a neurosurgical procedure is very rare [Table 1]. ,,, Of the 43 patients operated for CSDH at our institute in the same year, 4 patient required recurrent surgery. Only this was the infected case.
Diagnosis of SDE is based on a strong clinical suspicion and the clinical features include fever, altered mental state, focal neurological deficits, and seizures with a fulminant and rapid downhill course.  In this patient, the initial impression in the emergency department was subdural hematoma reaccumulation, however, presence of fever and altered mental status were suggestive of infective pathology.
|Figure 1: Axial computed tomography scan revealing a thick layer of subdural collection in the right frontoparietal region|
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|Figure 2: Coronal T2-weighted magnetic resonance image showing hyperintense subdural empyema in the right frontoparietal region|
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|Figure 3: Axial T1-weighted magnetic resonance image with contrast agent demonstrating improvement after surgical drainage followed with 6 week antibiotherapy|
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CT typically demonstrates a crescent-shaped extra-axial fluid collection that can be either iso- or hyper-attenuating compared with the cerebro spinal fluid. Classically, there is also enhancement of the inner membrane with contrast administration.  MRI has become the imaging modality of choice. Increased signal intensity is usually seen on T1-weighted and fluid-attenuated inversion recovery (FLAIR) MRI sequences because of the increased protein concentration of an empyema relative to cerebro spinal fluid. A fluid collection surrounded by a contrast-enhancing rim is often the feature.  These changes, however, are not specific and are not always present, especially early in the disease process.
Early diagnosis and aggressive treatment is essential to avoid complications and death. Surgery- or trauma-related SDE carry a worse prognosis and a high mortality. Surgical drainage is mandatory as the antimicrobial agents alone fail to sterilize the empyema. The goals of surgical therapy are to achieve adequate decompression of the brain and to evacuate the empyema completely. ,,, The choice of surgical procedures remains controversial. Drainage by craniotomy is associated with better outcome and lower mortality as it ensures maximal drainage of the loculated pus and also allows inspection of adjacent structures, and removal of the bone flap if necessary. However, some reports advocate drainage via burr-holes. ,
Presence of hematoma capsule carries the risk of development of an infectious focus.  In this patient CSDH was traumatic as he had history of closed head trauma. On both the occasions closed system drainage were performed and the drain was not left for more than 48 hours. He was given prophylactic antibiotics on both the occasions. Probably, recurrent surgeries had increased the risk of infection in this patient. Our patient highlights the need for high index of suspicion for SDE in patients with CSDH who had closed system drainage when the present with fever and fresh neurological deficits and altered mental status.
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[Figure 1], [Figure 2], [Figure 3]
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