Case 20: History of headaches
Thursday, May 26th, 2011Author: Dr Morium Akthar – Paediatric StR
A 12 year old boy presents to the paediatric ED with a one month’s history of headaches. Two weeks ago his GP had treated him for sinusitis with oral amoxicillin which had temporarily eased his headache. He now has a one day history of fever and change in behaviour.
OE he has fluctuating GCS between 10-13 but no focal neurological changes and was very lethargic and aggressive and un co-operative when he woke up. He is given empirical meningitis cover of IV Ceftriaxone.
A CT scan was performed and is shown below:
1. What is the CT diagnosis?
Click to see the answerThis CT shows a subdural empyema collection. Cranial CT scan is the standard technique for quick diagnosis. On CT scan, subdural empyema shows as a hypodense area over the hemisphere or along the falx; the margins are better delineated with the infusion of contrast material.
2. How do children commonly develop this condition?
Click to see the answerIn infants and young children, subdural empyema most often occurs as a complication of meningitis In older children and adults, it occurs as a complication of paranasal sinusitis, otitis media, or mastoiditis. This often occurs within 2 weeks of a sinusitis episode, with the infection spreading intracranially through thrombophlebitis in the venous sinuses.
3. What are the common organisms?
Click to see the answerParanasal sinusitis -Staphylococcus aureus, alpha-hemolytic streptococci, anaerobic streptococci, Bacteroides species, Enterobacteriaceae
Otitis media, mastoiditis – Alpha-hemolytic streptococci, Pseudomonas aeruginosa, Bacteroides species, S aureus
Meningitis (infant or child) -S pneumoniae, H influenzae, Escherichia coli, Neisseria meningitidis
4. What is your management after seeing the CT scan?
Click to see the answerThis child requires intubation and ventilation as they may drop their conscious level. They now need discussion with a paediatric neurosurgical centre for consideration of surgical drainage. Antibiotic treatment alone may be adequate for very small collections (<1.5cm) however the potential for rapid spread means surgery is more common.
The main option is craniotomy and wide exposure and exploration with evacuation of the purulent collection. Stereotactic burr hole placement with drainage and irrigation is also a possibility. It is important to remember that the primary focus of infection may also need surgical input, with an ENT surgeon commonly asked to examine and debride the infection from the paranasal sinuses.