infantil infected chronic subdural hematoma case presentation helene hurth, ms6 innsbruck medical...
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Infantil infected chronic subdural hematoma
Case presentationHelene Hurth, MS6
Innsbruck Medical University
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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
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M.M.
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Preoperative MRI
Bilateral chronicsubdural hematoma
Le: 25 mmRi: 15 mm
Enhancement of membranes
3mm rightward midline shift
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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
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Postoperative MRI
Le: 12 mmRi: 7-8 mm
Resolution ofmidline shift
Septations
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OP
• Craniotomy w/ resection of membranes on day 5 after borr hole drainage due to remaining fever and up trending inflammatory markers
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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
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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
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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
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Infected CSDH
• Rare • Strept spp, Staph aureus, H. influenzae, E. coli,
Salmonella spp • Hematogenous • Satisfactory outcome • Antibiotic treatment• Drainage vs craniotomy
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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
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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
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Case Tanikawa et al.
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Summary
• Neurosurgery often required in extraaxial CNS infections
• Early diagnosis!• Consider infected CSDH with signs of bacteremia