Unusual intracranial suppuration: illustrative cases

BACKGROUND Intracranial suppuration (ICS) is a rare complication that can arise from various disease processes and is composed of brain abscess, extradural empyema, and subdural empyema. Although significant progress has been achieved with antibiotics, neuroimaging, and neurosurgical technique, ICS remains a serious neurosurgical emergency. An uncommon presentation of ICS is sterile ICS, which has yet to be fully elucidated by clinicians. The authors present 2 cases of unusual sterile ICS: a sterile subdural empyema and a sterile brain abscess. OBSERVATIONS Both patients underwent surgical treatment consisting of craniotomy to evacuate the pus collection. The blood cultures from both the patients, the collected empyema, and the thick capsule from the brain abscess were sterile. However, the necrotic brain tissue surrounding the abscess contained inflammatory cells. The authors’ review of the literature emphasizes the rarity of sterile ICS and substantiates the necessity for additional studies to explore this field. LESSONS Sterile ICS is a disease entity that warrants further investigation to determine appropriate treatment to improve patient outcomes. This study highlights the paucity of data available regarding sterile ICS and supports the need for future studies to uncover the etiology of sterile ICS to better guide management of this condition.

Evaluation of treatment approaches for sinogenic intracranial abscess in children

Objectives: To evaluate the management practices and outcomes in children with sinogenic intracranial suppuration. Design: Retrospective cohort study. Setting: A single paediatric tertiary unit. Participants: Patients younger than 18 years with radiologically confirmed intracranial abscess including subdural empyema (SDE), epidural (EDA) or intraparenchymal (IPA) abscess secondary to sinusitis. Main outcome measures: The rates of return to theatre, the length of hospital stay (LOS), death <90 days and neurological disability (ND) at 6 months. Results: A cohort of 39 consecutive patients (41% male, mean age 11.5) presenting between 2000-2020 were eligible for inclusion. SDE was the most common intracranial complication (n=25, 64%) followed by EDA (n=12, 31%) and IPA (n=7, 18%). The mean LOS was 42 days (SD 16). Sixteen patients (41%) were managed with combined ENT and neurosurgical interventions, 15 (38.5%) underwent ENT procedure alone and 4 (10.3%) had neurosurgical only drainage. Four patients initially underwent non-operative management. The rates of return to theatre, ND and 90-day mortality were 19 (48.7%), 9 (23.1%) and 3 (7.7%) respectively and were comparable across the four treatment arms. In the univariate logistic regression, only the size of an intracranial abscess (10mm) was found be associated with an increased likelihood of return to theatre (odds radio 7, confidence interval 1.09-45.1), while combined ENT and neurosurgical intervention did not result in improved outcomes. Conclusion: Sinogenic intracranial abscesses are associated with a significant morbidity and mortality. The size of an intracranial abscess has a strong association with a need for a revision surgery.

Sinogenic Intracranial Suppuration in Children: Systematic Review and Meta-analysis

Objective To evaluate temporal trends in the management of sinogenic intracranial suppuration and its outcomes in children. Data Sources A systematic search of databases was performed (Medline, Embase, Cochrane, ClinicalTrials.gov). Review Methods Studies in children (age <18 years) with sinogenic subdural empyema, extradural abscess, and intraparenchymal abscess were included. Data on treatment strategies were extracted. Primary outcome was death <90 days. Secondary outcomes were return to theater, neurologic disability at 6 months, and length of stay. Random effects meta-analysis and meta-regression were performed to investigate the effect of time and endoscopic sinus surgery (ESS) on these outcomes. Results A total of 32 retrospective observational studies involving 533 patients recruited across a 45-year period (1975-2020) were included. The pooled estimates for 90-day mortality, permanent neurologic disability, and return to theater were 2.3% (95% CI, 1.1%-3.6%; I2 = 0, P > .99), 21.3% (95% CI, 15.3%-27.3%; I2 = 75.2%, P < .001), and 37.3% (95% CI, 29.5%-45%; I2 = 71.2%, P < .001), respectively, with no significant differences found across the study period. The pooled estimate for ESS was 58.4% (95% CI, 44.2%-72.6%; I2 = 97.1%, P < .001) with a significantly increasing trend in its use in the more recent years. ESS was not associated with improved mortality, reduced need for revision surgery, or neurologic disability. Conclusion The outcomes of sinogenic intracranial complications have not changed over the last 45 years, and ESS was not associated with improved patient outcomes. Further high-quality studies are required to determine the most appropriate treatment modalities to improve the burden of morbidity associated with sinogenic intracranial suppuration in children.

Demography, types, outcome and relationship of surgically treated intracranial suppuration complicating chronic suppurative otitis media and bacterial rhinosinusitis

ABSTRACT Introduction: Surgically treated intracranial suppurations (ICS) are uncommon, life-threatening neurosurgical emergencies. They can result from complication of chronic suppurative otitis media (CSOM) and bacterial rhinosinusitis (BRS). The objective of this study was to know the frequency of BRS and CSOM and relate it to its rare complication of surgically treated ICS while also describing the demography, type and outcome of ICS that resulted from BRS and CSOM. Materials and Methods: All patients that presented to the Otorhinolaryngological department and Neurosurgical unit of the same institution with clinical and radiological features of CSOM, BRS, and ICS were prospectively studied over a 5-year period. Patients were followed up for a minimum of 3 months. Results: Two thousand, two hundred and seventy-nine patients presented during the 5-year study period. Of all these patients, 1511 had CSOM (66.3%) and 768 (33.7%) presented with features of BRS. Eleven (0.73%) had ICS complicating their CSOM while 8 (1.04%) cases of surgically treated ICS followed BRS. Bacterial rhinosinusitis was not more likely to lead to ICS (P = 0.4348). The Odds ratio (OR) of a child ≤ 18 years of age with CSOM developing ICS was 5.24 (95% Confidence interval 1.13-24.34; P = 0.0345), while it was 7.60 (95% Confidence interval 1.52-37.97; P = 0.0134) for children with BRS. Conclusions: The most common type of ICS complicating CSOM and BRS was brain abscess and subdural empyema, respectively. Children are more prone to develop surgical ICS following CSOM and BRS. The proportion of males that had ICS was higher in both CSOM and BRS patients. Optimal outcome is achieved in patients that presented with GCS of 13 and above.