Presenting complaint: Inability to talk, left sided weakness of 4 days duration
Patient has been complaining of recurrent head and ear aches for the past five years . This was frequently associated with yellowish nasal discharge . He was suddenly taken ill and became febrile and couldn’t move the left half of the body which prompted the parents to visit the regional hospital . He was seen and admitted for an initial diagnosis of cerebral abscess and a cause of antibiotics started . During the time of admission he had second episodes of focal seizures which were managed with rectal diazepam.
He has had a normal childhood with no history of chronic illness or hospital admissions for serious illness.
He was referred to Komfo Anokye Teaching hospital paediatric emergency for further management
Ill looking, febrile Temp 38.4 deg C
Respiratory system: Resp rate:44cpm with flaring of alae nasae . AN entry reduced at lung bases . Transmitted sounds were also heard . SP 02: 96%
Pulse rate: 128cpm , capillary refill time lets their 3 seconds . B P: 80 / 64 mm Hg
Central nervous system:
GCS:10/15 (M5 E4 V1) , pupils reacted equally to light
left upper and lower limbs:Tone and reflexes were reduced ,power was zero
Right upper and lower limbs Tone and reflexes were normal,power was 3
Speech was completely impaired
Initial Diagnosis: left hemiplegia secondary to intracranial abscess
1.Head CT scan: subdural fluid collection continent with abscess in the Right fronto parietal region. The wt maxillary sinus was poorly pneumatised and fluid filled
2. Full blood count: WBC -43.33 Neutrophils- 92% Hb-11.7g/ dl Plt- 41
3. BUN3.12 Creat-19µmol / L Na- 135 K- 3.5 Cl- 106
Patient was reviewed by the neurosurgery team and a decision was taken to perform a craniotomy to drain the abscess.
Under general anaesthesia and in supine position patient’s head was draped imposing the Right parietal region . 4cm scalp incision was used to raise a soft tissue flap. A burr hole was drilled to expose the dura . A cruciate incision was made to drain the abscess . A size 24 Foley’s catheter was used to irrigate the subdural space after which the drain was left insitu connected to a drainage bag . The scalp wound was closed with interrupted sutures. Pua was sent for Gram stain ,culture and sensitivity
Post operative period
Patient was put on IV phenytoin to control seizures,supp Paracetamol for fever control and l V tavanic acid to treat the infection. He was also fed via nasogastric tube.
Patient improved remarkably from the 3rd day post operative period . Speech appreciably Improved. He could make out faces of relatives and call them by names. He was able to swallow feeds which nessecitated removal of nasogastric tube
Subdural empyema is a serious intracranial infection where pus collects between the dura and the arachnoid. Mortality was close to 100% before the advent of penicillins. The aggressive use of antibiotics coupled with ealy detection using MRI has caused the mortality to fall drastically. It however still remains life threatening for patients for who diagnosis is missed or delayed . Bacterial infections of the frontal m, maxilllary and ethmoid sinuses still remains the commonest routes of spread to the brain in older children whilst bacterial meningitis still remain the common means neonates and infants get subdural empyema.
The patients usually with high grade fever ,seizures , altered level of consciousness and varying neurological deficits as a result of mass effect of the abscess causing raised intracranial pressure. Patient may present with a short history of sinus , ear, mastoid infection. Cortical infarction may result from thromboses cortical veins and carvenous sinus . This may result from repeated scalp venous puncture ,leading to osteomyelits of the calvaria and subsequent spread of septic emboli to the brain. Leading causative organisms are anaerobes, aerobic streptococci, staphylococci, Haemophilus influenzae,Streptococcus pneumoniae, and other gram-negative bacilli.
Paranasal sinusitis –Staphylococcus aureus, alpha-hemolytic streptococci, anaerobic streptococci, Bacteroides species, Enterobacteriaceae
Middle ear infection, mastoiditis – Alpha-hemolytic streptococci, Pseudomonas aeruginosa, Bacteroides species, S aureus
Meningitis :(infant or child) –S pneumoniae,H influenzae,Escherichia coli,Neisseria meningitidis
Neonates – Enterobacteriaceae, group B streptococci, Listeria monocytogenes
Trauma, postsurgical infection –S aureus,Staphylococcus epidermidis, Enterobacteriaceae
Pulmonary spread –S pneumoniae,Klebsiella pneumoniae
The clinician may see signs of raised intracranial pressure such as dilated pupil on the ipsilateral side of the lesion, hemiparesis , palses of cranial nerve 3,4 and 6. Nasal discharge , maxillary sinus , frontal sinus tenderness may be elicited. Stupor , Nuchal rigidity rigidity points to meningeal irritation as a result of meningitis .
Contrast CT scans of the head would clearly show hypodense collections commonly foun in the frontal region.
Treatment : Subdural empyema is ia neurosurgical emergency. Craniotomy is done to evacuate the abscess. Antibiotics therapy, antiseixure prophylaxis antipyretics and daily maintenece of iV fluids are also given. The otolarynngologist, maxillofacial surgeons may be involved to perform mastoidectomy , antral washout as may be necessary.
Patient is rehabilited after surgery to aid in the recovery of neurological deficits. This may involve the occupational and speech therapists
Credits : Dr(s) J.B Addae , Adu -Gyamfi who performed the surgery , supervised by Dr Frank Nketiah