Intracranial subdural empyema and its management. A review of the literature with comment

Intracranial subdural empyema is a rare form of suppuration in Europe and North America, and is a potentially dangerous but treatable disease. The clinician must be aware that this complication requires prompt diagnosis and urgent neurosurgical intervention. The etiology, pathology, bacteriology, clinical features, diagnostic procedures and the different surgical approaches to this disease are reviewed. It seems that there is no single best surgical approach for treating subdural empyema, however, multiple burr holes drainage and craniotomy remain the most frequently used approaches.

Interhemispheric subdural empyema--case report

We report a case of interhemispheric subdural empyema following a meningoencephalitis. Ten days after the beginning of his illness a CT scan showed a left interhemispheric subdural empyema with a low density collection, a faintly enhancing rim, multiple very small cortical abscesses and brain edema. The empyema was successfully treated by the direct introduction of a catheter into the left interhemispheric subdural space via a single posterior frontal parasagittal burr hole, irrigation with saline, aspiration of the empyema, and removal of the catheter at the end of operation.

Brain abscesses from neglected open head injuries: experience with 17 cases over 20 years

We are reviewing our experience with 17 civilian cases with post-traumatic brain abscesses treated in the era of CT scanning over a period of 20 years. The principal cause for this intracranial complication was the neglected compound depressed fracture. One was a newborn infant with left parietal abscess caused by a vacuum extraction. We have used the following methods of treating the abscesses: single burr hole aspiration in the newborn with an excellent result; repeated aspiration, with debridement of the depressed fracture, in 5 cases (1 death); aspiration with early subsequent excision, via craniotomy, in 7 cases (no death), and primary excision, via craniotomy, in 4 cases (1 death). The early subsequent excision of the abscess, 2 or 3 days after the initial aspiration, has proved in our experience very satisfactory. In cases with bone fragment into the abscess cavity the excision of the abscess is indicated. The cultured pus from the abscess cavity showed mixed flora (streptococci and staphylococci) in 7 cases; staphylococcus aureus in 4; staphylococcus epidermidis in 2, and no growth in 4 cases. Antibiotics play an important role in the treatment of post-traumatic brain abscesses.

Autoimmune thyroid disorders in juvenile chronic arthritis and systemic lupus erythematosus

The appearance of autoimmune thyroiditis in the course of other autoimmune diseases, which do not affect specific organs (systemic lupus erythematosus, Sjögren syndrome, rheumatoid arthritis and others), is more frequent than is usually believed. Nevertheless, it is scarcely studied, especially in children. The purpose of this study was to look for autoimmune lesions of the thyroid gland in children suffering from juvenile chronic arthritis (JCA) and systemic lupus erythematosus (SLE). Twenty seven children having JCA and twelve children with SLE, aged 5 to 18 years, were enrolled into study. In all of them the disease was in an active phase. The serum levels of total thyroid hormones (T3, T4) and TSH, thyroid antibodies (TAB and MAB) and antinuclear antibodies (ANAB) were analyzed using respectively fluoroimmunologic, microhemagglutination and indirect immunofluorescention tests. According to our results, autoimmune thyroiditis was found in 12 out of 27 children with JCA (44.4%); 85.2% of them were euthyroid, 11.1% had a compensated hypothyroidism, and 3.7% had Hashi-toxicosis. From a clinical point of view, very interesting was the combination of JCA, autoimmune thyroiditis and pseudoxanthoma elasticum in a 13-year old girl. Positive thyroglobulin antibodies (1:80-1:5120) were found in 17 out of 27 cases of JCA (63%). The microsomal antibodies were elevated (1:100-1:1600) in 7 out of 27 (25.9%); antinuclear antibodies (1:80-1:640) were detected in 15 out of 27 cases of JCA (55.5%). A simultaneous elevation of all three kinds of antibodies was found in 14.8% of children with JCA, and of TAB and MAB--in 18.5%. Thyroid gland disorders were detected also in children suffering from SLE. Thyroglobulin antibodies were positive (1:80-1:5120) in 7 out of 12 cases. Antinuclear antibodies (1:320-1:2560) were detected in 8 out of 12 cases (66.7%). The serum levels of T3, T4 and TSH were in the reference limits in all children with SLE. The present study suggests that involvement of the thyroid gland is not uncommon in autoimmune disease in Autoimmune thyroiditis can occur in association with other autoimmune diseases, affecting some organs or systems, such as the insulin-dependent diabetes mellitus, pernicious anaemia, thrombocytopenia, vitiligo, as well as some chromosomal aberrations--Turner's syndrome, Noonan's syndrome and Down's disease [1]. The appearance of autoimmune thyroiditis together with other autoimmune diseases which do not affect specific organs (such as systemic lupus erythematosus, Sjögren syndrome) is the reason to classify them in a common subgroup of the autoimmune polyendocrine syndromes--type IIID [2]. The rheumatic diseases are--more frequently than suspected--associated with autoimmune thyroiditis, but this connection is not well studied. The literature offers very scarce information on the problem, especially for the childhood. The purpose of this study was to look for autoimmune lesions of the thyroid gland in children suffering from juvenile chronic arthritis (JCA) and systemic lupus erythematosus (SLE).

Severe craniocerebral injury by an axe with good outcome: case report

We report a young patient who was operated on for a penetrating slow impact craniocerebral injury in the left frontal region caused by an axe. The patient was admitted comatose, with right hemiplegia. The blade of the axe was embedded deeply into his head. A craniectomy was carried out around the axe blade and it was removed easily. The cerebral wound was 6 cm long in horizontal plane and about 7 cm deep. Significant amount of contused and necrotic brain tissue was aspirated. The patient showed an uneventful recovery.

Acute subfrontal epidural hematoma: report of two cases

Two cases of acute subfrontal epidural hematoma are reported. Both were diagnosed by computed tomography scan and successfully removed via a frontal craniotomy.

Surgical treatment of brain abscess

The author reviews the methods of surgical treatment of brain abscess. All methods are grouped into the following six categories: tube drainage, marsupialization, the migration method of Kahn, tapping only, aspiration, and excision. At present, only two methods are used: aspiration and excision. Antibiotics and computed tomographic (CT) scanning play important roles in the surgical treatment of a brain abscess. The use of CT scanning is invaluable in the management of brain abscess for early and exact localization, assessment of the adequacy of operation, and sequential follow-up.

Successful removal of a partial Siamese twin with a carbon dioxide laser

A case of a 'partial Siamese twin' is discussed, and the neurological signs and operative findings are recorded. The operation was performed with the aid of a carbon dioxide laser, which not only facilitated and expedited the procedure but also ensured minimal loss of blood. The wound broke down in part, but complete healing occurred within less than a month. At the time of discharge the baby showed no abnormal neurological signs.

Experience with multiloculated brain abscesses

The author reports his experience with 10 consecutive multiloculated brain abscesses diagnosed by computerized tomography and successfully treated by excision (primary or early secondary) or repeated aspiration.

Computerized tomography and surgical treatment in intracranial suppuration. Report of 30 consecutive unselected cases of brain abscess and subdural empyema

The authors report their experience with 30 cases of intracranial suppuration: 23 with brain abscess and seven with subdural empyema. All of the cases were diagnosed by means of computerized tomography and enhancement with intravenous contrast material. Most of the patients were treated by single or repeated aspiration through burr holes.