Introduction: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. Materials and Methods: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. Results: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. Conclusions: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Keywords:
Abscess, Burr hole, Subdural empyema, Craniotomy, Hydrocephalus
1.
Pandey P, Umesh S, Bhat DI, Srinivas D, Abraham R, Pillai S, Balasubramaniam A, Devi I, Sampath S, Chandramouli BA: Cerebellar abscesses in children: excision or aspiration? J Neurosurg Pediatr 2008;1:31–34.
2.
Venkatesh MS, Pandey P, Devi BI, Khanapure K, Satish S, Sampath S, Chandramouli BA, Sastry KV: Pediatric infratentorial subdural empyema: analysis of 14 cases. J Neurosurg 2006:105(5 suppl):370–377.
3.
Banerjee AD, Pandey P, Devi I, Sampath S, Chandramouli BA: Pediatric supratentorial subdural empyemas: a retrospective analysis of 65 cases. Pediatr Neurosurg 2009:45:11–18.
4.
Brydon HL, Hardwidge C: The management of cerebellar abscess since the introduction of CT scanning. Br J Neurosurg 1994:8:447–455.
5.
Nadvi SS, Parboosing R, van Dellen JR: Cerebellar abscess: the significance of cerebrospinal fluid diversion. Neurosurgery 1997:41:61–67.
6.
Unnikrishnan M, Chandy MJ, Abraham J: Posterior fossa abscesses: a review of 33 cases. J Assoc Physicians India 1989:37:376–378.
7.
Macewen W: Pyogenic Infective Diseases of the Brain and Spinal Cord. New York, Macmillan & Co., 1893.
8.
Arseni C, Ciurea AV: Cerebellar abscesses: a report on 119 cases. Zentralbl Neurochir 1982:43:359–370.
9.
Bradley PJ, Manning KP, Shaw MD: Brain abscesses secondary to otitis media. J Laryngol Otol 1984:98:1185–1191.
10.
Morgan H, Wood MW: Cerebellar abscesses: review of seventeen cases. Surg Neurol 1975:3:93–96.
11.
Yang S: Brain abscess: a review of 400 cases. J Neurosurg 1981:55:794–799.
12.
Pennybacker J: Cerebellar abscess: treatment by excision with the aid of antibiotics. J Neurol Neurosurg Psychiatry 1948:11:1–12.
13.
Krayenbuhl H, Weber G: Therapy and diagnosis of acute brain abscesses and thrombophlebitides. Acta Neurochir (Wien) 1952:2:281–295.
14.
Agrawal D, Suri A, Mahapatra AK: Primary excision of pediatric posterior fossa abscesses – towards zero mortality? A series of nine cases and review. Pediatr Neurosurg 2003:38:63–67.
15.
Ch’ai WH, Ho CF: Cerebellar abscess: the advisability of treatment by tapping. Endokrinologie 1965:9:403–413.
16.
Schreiber F: Cerebellar abscesses of otitic origin in nine children: eight recoveries after cannulation. Ann Surg 1941:30–335.
17.
Borovich B, Johnson E, Spagnuolo E: Infratentorial subdural empyema: clinical and computerized tomography findings: report of three cases. J Neurosurg 1990:72:299–301.
18.
Jennett B, Bond M: Assessment of outcome after severe brain damage: a practical scale. Lancet 1975:1:480–484.
19.
Kojima A, Yamaguchi N, Okui S: Supra- and infratentorial subdural empyema secondary to septicemia in a patient with liver abscess – case report. Neurol Med Chir (Tokyo) 2004:44:90–93.
20.
Morgan DW, Williams B: Posterior fossa subdural empyema. Brain 1985:108:983–992.
21.
Nathoo N, Nadvi SS, van Dellen JR: Infratentorial empyema: analysis of 22 cases. Neurosurgery 1997:41:1263–1269.
22.
Polyzoidis KS, Vranos G, Exarchakos G, Argyropoulou MI, Korantzopoulos P, Skevas A: Subdural empyema and cerebellar abscess due to chronic otitis media. Int J Clin Pract 2004:58:214–217.
23.
Toth S, Szabo S, Kollar J, Sikula J: Subtentorial subdural empyema: case report. Surg Neurol 1992:37:208–210.
24.
Halvin ML, Ratcheson RA: Subdural empyema; in Kaye AH, Black PM (ed): Operative Neurosurgery. London, Harcourt, 2000, pp 1667–1678.
25.
Renaudin JW: Cranial epidural abscess and subdural empyema; in Wilkins RH, Rengachary SS (eds): Neurosurgery, ed 2. New York, McGraw-Hill, 1996, pp 3313–3316.
26.
Atiq M, Ahmed US, Allana SS, Chishti KN: Brain abscess in children. Ind J Pediatr 2006:73:401–404.
27.
Brook I: Microbiology and management of brain abscess in children. J Ped Neurol 2004:2:125–130.
28.
Gómez J, García-Vázquez E, Martínez Pérez M, Martínez Lage J, González Tortosa J, Pérez Espejo MA, Ruiz J, Herrero JA, Canteras M, Valdés M: Brain abscess. Evaluation of prognostic factors: does the use of antibiotic prescribing protocols improve outcome? Ann Med Interna 2008:25:331–334.
29.
Song L, Guo F, Zhang W, Sun H, Long J, Wang S, Bao J: Clinical features and outcome analysis of 90 cases with brain abscess in central China. Neurol Sci 2008:29:425–430.
30.
Mut M, Hazer B, Narin F, Akalan N, Ozgen T: Aspiration or capsule excision? Analysis of treatment results for brain abscess at single institute. Turk Neurosurg 2009:19:36–41.
31.
Nathoo N, Nadvi SS, van Dellen JR, et al: Intracranial subdural empyemas in the era of computed tomography: a review of 699 cases. Neurosurgery 1999:44:529–536.
32.
Pathak A, Sharma BS, Mathuriya SN, et al: Controversies in the management of subdural empyema: a study of 41 cases with review of the literature. Acta Neurochir (Wien) 1990:102:25–32.
33.
Pattisapu JV, Parent AD: Subdural empyemas in the children. Pediatr Neurosci 1987:13:251–254.
34.
Smith HP, Hendrick EB: Subdural empyema and epidural abscess in children. J Neurosurg 1983:58:392–397.
35.
Yilmaz N, Kiymaz N, Yilmaz C, et al: Surgical treatment outcome of subdural empyema: a clinical study. Pediatr Neurosurg 2006;42:293–298.
36.
Nathoo N, Nadvi SS, Gouws E: Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients. Neurosurgery 2001;49:872–878.
37.
Yoshikawa TT, Chow AW, Guze LB: Role of anaerobic bacteria in subdural empyema: report of 4 cases and review of 327 cases from the English literature. Am J Med 1975;58:999–1003.
38.
Bannister G, Williams B, Smith S: Treatment of subdural empyema. J Neurosurg 1981;55:82–88.
39.
Hoyt DS, Samuel RF: Otolaryngologic management of patients with subdural empyema. Laryngoscope 1991;101:20–24.
40.
Kurien M, Job A, Mathew J, Chandy M: Otogenic intracranial abscess: concurrent craniotomy and mastoidectomy – changing trends in a developing country. Arch Otolaryngol Head Neck Surg 1998;124:1353–1356.
41.
Gupta S, Vachharajani S, Kulkarni AV, Taylor MD, Dirks P, Drake JM, Rutka JT: Neurosurgical management of extraaxial central nervous system infections in children. J Neurosurg Pediatr 2011;7:441–451.
© 2011 S. Karger AG, Basel
2011
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