Infantil infected chronic subdural
hematoma
Case presentation
Helene Hurth, MS6
Innsbruck Medical University
M.M.
• H&P: 5 m.o. male: fever, irritability for 3 days, intermittent emesis
poor hygiene, macrocephaly
no 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 abuse
3y/o healthy sibling
M.M.
Preoperative MRI
Bilateral chronic
subdural hematoma
Le: 25 mm
Ri: 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 mm
Ri: 7-8 mm
Resolution of
midline 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: epidural
abscess, 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
Etiology
early, 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
N=20
N=29
M. Tanikawa, Acta Neurochirurgica 2001
Surgical treatment: CSDH
• Outcome, reoperation, hospital stay
• Hematoma recurrance: thick membranes
-> residualhematoma
-> rebleeding
MRI (T2*) imaging
to 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