NeuroSurgery Conference

ClerkJune 11, 2010

2-3 PM

ASSESSMENT

• Left Fronto-Parietal Subdural Empyema secondary to left frontal sinusitis

DISCUSSION

CNS INFECTIONS

• Meningitis – inflammation of the meninges of the brain or spinal cord

• Encephalitis – inflammation of the brain• Myelitis – inflammation of the spinal cord• Neuritis – inflammation of the peripheral nerves

CNS INFECTIONS

• Brain abscess – focal intracranial suppuration in the brain substances

• Subdural empyema – infection between dura mater and subarachnoid space

• Epidural abscess – focal suppuration between skull and dura mater

CNS INFECTIONS

• Three locations where infection may occur:– Subarachnoid Space– Subdural Space– Epidural Space

ROUTE OF INFECTION• Hematogenous spread

– Direct foci of infection– Parenteral entry

• Direct Extension– Sinusitis– Otitis– Mastoiditis– Dental Infections

• Direct Introduction– Head trauma– Neurosurgical procedure– Lumbar puncture– Spinal anesthesia

CARDINAL MANIFESTATIONS

Fever HeadacheAlteration in

consciousness

Focal neurologic

signs

SUBDURAL EMPYEMA

• Collection of pus between the dura and arachnoid membranes

SUBDURAL EMPYEMA• 15-25% of focal suppurative CNS

infections• SINUSITIS (Frontal Sinuses) –

most common predisposing condition

• Predilection to young males 3:1, 20-30’s

• Complication of trauma or neurosurgery

• Secondary infection

ETIOLOGY

SINUSITIS TRAUMA/NEUROSURGERY

Streptococci – most commonStaphylococci

EnterobacteriaceaeAnaerobic Bacteria

StaphylococciGram(-) baccili

SIGNS AND SYMPTOMS

• Hx of Chronic sinusitis or mastoiditis

Fever HEADACHE Alteration in consciousness

Focal neurologic

signsSeizure

IncreaseICP

Coma

LABORATORY FINDINGS

CSF FINDINGSIncreased pressure

Pleocytosis (50-1000/mm3)

Predominant PMN

Elevated Protein (75-300mg/dL)

Normal Glucose

MRI

MANAGEMENT

• Medical Emergency– 3rd gen cephalosporin, vancomycin

and metronidazole – Minimum of 4 weeks

• Emergent neurosurgical evacuation– definitive step– Burr-hole drainage or craniotomy – Gram’s stain and culture

PROGNOSIS

• Influenced by the ff:• Level of consciousness at

hospitalization• Size• Time of intervention

THANK YOU