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Non-contrast-enhancing subdural empyema: illustrative case.
Alexander D Rebchuk1, Stephano J Chang1, Donald E G Griesdale2,3,4
11Division of Neurosurgery, Department of Surgery.
Journal of Neurosurgery. Case Lessons
|September 11, 2022
Summary
Subdural empyema (SDE) can be fatal if untreated. This case highlights that SDE may lack typical imaging signs like ring enhancement, necessitating surgical exploration in high-suspicion patients.
Area of Science:
- Neurology
- Neurosurgery
- Infectious Diseases
Background:
- Subdural empyema (SDE) is a critical intracranial infection.
- Prompt surgical and antibiotic treatment is vital for survival.
- Classic imaging shows a contrast-enhancing ring around a subdural collection.
Purpose of the Study:
- To report a case of SDE presenting without contrast enhancement.
- To emphasize the importance of clinical suspicion in diagnosis.
- To discuss diagnostic and therapeutic implications.
Main Methods:
- Case report of a 41-year-old male with SDE symptoms.
- Multiple CT scans over 48 hours showed no contrast enhancement.
- Craniotomy was performed due to high clinical suspicion.
Main Results:
- Frank pus was found during craniotomy.
- Streptococcus pyogenes was identified as the causative agent.
- The patient's SDE was confirmed despite atypical imaging.
Conclusions:
- SDE can manifest without the classic ring enhancement on contrast-enhanced imaging.
- Exploratory surgery (burr holes or craniotomy) is crucial for diagnosis and source control in critically ill patients with suspected SDE.
- Clinical judgment remains paramount when imaging findings are inconclusive.
