1. Infantil infected chronic subdural hematoma Case presentation Helene Hurth, MS6 Innsbruck Medical University

2. M.M. H&P: 5 m.o. male: fever, irritability for 3 days, intermittent emesis poor hygiene, macrocephaly no 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 abuse 3y/o healthy sibling

3. M.M.

4. Preoperative MRI Bilateral chronic subdural hematoma Le: 25 mm Ri: 15 mm Enhancement of membranes 3mm rightward midline shift

5. 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

6. Postoperative MRI Le: 12 mm Ri: 7-8 mm Resolution of midline shift Septations

7. OP Craniotomy w/ resection of membranes on day 5 after borr hole drainage due to remaining fever and up trending inflammatory markers

8. Childhood extraaxial CNS infections Age peaks: >11y (50%) & 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

9. Childhood extraaxial CNS infections Postsinusitis: (frontal) SDE, epidural abscess, Pott‘s puffy tumor; +- cerebritis Postmeningitis: diffuse hemispheric/infratentorial SDE Postoperative: epidural abscess, SDE, osteomyelitis at OP-site Otogenic -> mastoiditis: SDE, epidural abscess S. Gupta, J Neurosurg Pediatrics 2011

10. Childhood extraaxial CNS infections Treatment: Initial wide craniotomy + abx Complications: recurrent seizures, venous sinus/ cortical vein thrombosis Outcome: preoperative presentation Etiology early, aggressive surgical treatment S. Gupta, J Neurosurg Pediatrics 2011

11. Infected CSDH Rare Strept spp, Staph aureus, H. influenzae, E. coli, Salmonella spp Hematogenous Satisfactory outcome Antibiotic treatment Drainage vs craniotomy

12. 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

13. Surgical treatment: CSDH Outcome, reoperation, hospital stay Hematoma recurrance: thick membranes -> residualhematoma -> rebleeding MRI (T2*) imaging to predict need for craniotomy M. Tanikawa, Acta Neurochirurgica 2001

14. Case Tanikawa et al.

15. Summary Neurosurgery often required in extraaxial CNS infections Early diagnosis! Consider infected CSDH with signs of bacteremia