Intracranial Epidural

Abscess in the Setting of

Sinusitis

Peter Morgenstern, MS4

M.B.

32 RHM c/o headache + retro-orbital pain x 3d

Denies fevers, chills, nausea, vomiting, photophobia, neck stiffness, vision changes, nasal drainage

PMH – Samter’s Triad Asthma

PSxH – Multiple nasal polypectomies (2005, 2007, 2009)

M.B.

Denies smoking, minimal alcohol use

Meds: Ventolin inhaler, fluticasone, flovent

Allergies: Aspirin, Ibuprofen

Exam Afebrile Well-appearing, uncomfortable 2/2 HA HEENT: frontal and maxillary sinus tenderness Neuro: intact

M.B.

140 101 11 105

3.6 26.3 0.9

15.2 15.4 209 41.1

PT 13.5

PTT 21.0

INR 1.1

Imaging – Pre-op

CNS Abscess

Epidural

Spinal

Intracranial

Subdural

Intraparenchymal

Intracranial Epidural Abscess

Predisposing factors Sinusitis Neurosurgical Procedure Trauma

Numerous causative organisms

Incidence decreasing

Morbidity/Mortality decreasing

Hlavin et al. 1994

Presentation and Diagnosis

Fever, headache, nausea/Vomiting

Confusion, agitation, seizures, hemiparesis, cranial neuropathies

Periorbital cellulitis or frontal edema (45%)1

CT and MRI

Other studies

Pradilla et al. 2009

Management

Hastings 1907

Surgical Drainage – ENT and Neurosurgical

Trans-ethmoidal drainage1

Removal of infected bone, possible CSF diversion ENT in the acute setting2

Medical Antibiotics Possible AEDs, corticosteroids, hyperosmolar fluids Hyperbaric oxygen therapy3

Role for conservative approach4

Management

1. Patron et al. 20102. Delgaudio et al. 20103. Heran et al. 20034. Baechli et al. 2008

Outcomes

Historically poor

Favorable in most cases today

Positive predictors young age, - encephalopathy, neuro deficit, comorbidities

Negative predictors – herniation, delayed neuroimaging, delayed diagnosis

M.B.

M.B.

Urgent bifrontal craniotomy

Broad-spectrum antibiotics after OR culture

Vancomycin, Gentamycin, Metronidazole

Consult with ENT and ID

Modify antibiotic coverage based on culture

Imaging – Post-op

M.B.

Uncomplicated post-op course

Notable improvement in symptoms

Discharged on POD #7

4-6 week course of IV vancomycin and ceftriaxone pending cultures

Culture: pan-sensitive coagulase negative staphylococcus

Conclusions

Maintain high clinical suspicion

Image early

Collaborative approach

Aggressive drainage + antibiotic therapy

Are more rigorous studies needed?

Thank You

References Baechli H, Schmutz J and Mayr JM. Hyperbaric Oxygen Therapy for the treatment of an epidural abscess in the posterior fossa of an 8-month-old infant.

Pediatr Neurosurg 2008; 44: 239-242.

Enoch DA, Gillham MI, Macfarlane R, Antoun N, Sule O. A troublesome head-butt. Lancet Infect Dis 2007; 7: 694.

Erman T, Demirhindi H, Göçer AI, Tuna M, Ildan F and Boyar B. Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis. Surg Neurol 2005; 63(2): 107-12.

Hastings H. A Report of Two Cases of Epidural Abscess of Otitic Origin. California State Journal of Medicine 1907; 5(10): 257-260.

Heran NS, Steinbok P, Cochrane DD. Conservative neurosurgical management of intracranial epidural abscesses in children. Neurosurgery 2003; 53(4): 893-7.

Hlavin ML, Kaminski HJ, Fenstermaker RA and White RJ. Intracranial suppuration: a modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery 1994; 34: 974-981.

Johnson DL, Markle BM, Wiedermann BL, Hanahan L. Treatment of intracranial abscesses associated with sinusitis in children and adolescents. J Pediatr 1988; 113: 15-23.

Kim JE, Kountakis SE. "The prevalence of Samter's triad in patients undergoing functional endoscopic sinus surgery". Ear, Nose, Throat J 2007; 86(7): 396–9.

Kombogiorgas D. and Solanki G. The Pott puffy tumor revisited: neuosurgical implications of this unforgotten entity. J Neurosurg (2 Suppl Pediatr) 2006; 105: 143-149.

Patron V, Orsel S, Caire F, Aubry K, Jegoux F. Transethmoidal drainage of frontal brain abscesses. Surg Innov 201. Epub ahead of print.

Pradilla G, Ardila GP, Hsu W and Rigamonti D. Epidural Abscesses of the CNS. Lancet Neurol 2009; 8: 292-300.

Samter’s Triad Asthma

Widal 1922, Samter and Beers 1968 Aspirin Sensitivity Asthma Nasal/ethmoidal polyposis Onset: 20s-30s Possible cross-reaction with NSAIDS Pathophysiology: arachadonic acid cascade

malfunction

Kim et al. 2007

Pott Puffy Tumor

Percival Pott - 1760

Sub-periosteal abscess

Often secondary to frontal sinusitis

May extend epidurally