Neurnradiologg
Neuroradiology 11,169-173 (1976)
@ by Springer-Verlag 1976
Focal Angiographic Abnormalities with Subdural Empyema D. M. Kaufman and N. E. Leeds Departments of Neurology and Radiology, Section of Neuroradiology, Montefiore Hospital and Medical Center, Albert Einstein College of Medicine, Bronx, N. Y., USA
Summary. Thirteen patients with subdural empyema underwent arteriography preoperatively and three were restudied postoperatively. Arterial vascular changes were found in nine cases and consisted of localized or diffuse arterial irregularities. In two cases the arterial changes resolved with effective therapy. These arterial changes are similar in appearance and response to therapy to those noted with meningitis; however, in this series they were shown to have occurred in seven cases with subdural empyema but without associated meningitis. Therefore, subdural empyema alone may cause localized or diffuse arterial irregularities.
Key words: Subdural emlpyema, Meningitis, Arterial irregularities.
Introduction A subdural empyema is an infection situated between the dura mater and the arachnoid. Purulent fluid is usually located over one or both cerebral hemispheres but it may extend to the interhemispheric fissure (parafalcine space) or be confined solely to this loca-
Table 1. Summary of neuroradiological arteriographic findings
Preoperative extracerebral avascular subdural area
Preoperative vascular changes
F F F
Frontoparietal Frontoparietal Bilateral frontal and parafalcine
None None Diffuse arterial constrictions early filling veins
14
M
Frontoparietal
15 16 26 2
M M M M
Subfrontal Frontotemperoparietal Frontoparietal Bilateral frontoparietal
1 4
F M
Parietal Temperoparietal
Meningitis 66 Otitis media 37 Bacteremia 62
M F M
Temperoparietal Temperoparietal Bilateral frontoparietal and parafalcine
Constriction of supraclinoid carotid and proximal anterior cerebral arteries Localized arterial constrictions Diffuse arterial irregularities Diffuse arterial irregularities Localized arterial irregularities with delayed filling Multiple arterial constrictions Localized irregular arterial constrictions None None Multifocal constrictions of distal middle cerebral artery with irregularity and absent vessels
Case
Etiology
Age
Sex
1 2 3
Sinusitis Sinusitis Sinusitis
5 12 13
4
Sinusitis
5 6 7 8 9 10
Sinusitis Sinusitis Sinusitis Postoperative Infection* Meningitis Meningitis
11 12 13
* Placement of ventricular-artrial shunt
Postoperative vascular changes
Diffuse arterial constrictions with recurrence of empyema Absence of spasm
Absence of irregularities
170
D.M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
fig. 1. Case 4. A 14 year old boy with sinusitis developed rapid onset of periorbital edema, fever, lethargy, hemiparesis and aphasia. There was no nuchal rigidity. The CSF contained 360 mononuclear and 40 polymorphonuclear cells/mm 3 and 100 mg% glucose and 51 mg% protein. No organisms were cultured from the CSF. The left carotid arteriogram illustrates constrictions of the supraclinoid internal carotid and anterior cerebral arteries. In addition, there is a shift of the anterior cerebral artery from left to right (arrows)
Fig. 2. Case 4. Nine days after evacuation of the subdural empyema a repeat arteriogram demonstrates the reversibility of the arterial constrictions. The arterial lumen appears normal and there is no shift of the anterior cerebral arteries
D. M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
a
171
b
Fig. 3. Case 8. A 2 year old boy was treated for pseudotumor cerebri five months prior to admission. On the day of admission he experienced high fever and status epilepticus. The CSF contained 22 mononuclear and 78 polymorphonuclear cells/ram 3 and 102 rag% glucose and 101 mg% protein. No organisms were cultured from the CSF a) Early arterial phase, direct right carotid angiography with magnification. The frontal subdural mass is recognized since the callosomarginal brances of the anterior cerebral artery do not reach the inner table of the skull b) Late arterial phase. Two irregularly filling middle cerebral arteries in the parietal region are recognized (arrows) c) Intermediate phase. There is delayed emptying of the two involved arteries (arrows)
tion. Supratentorial subdural empyema results most commonly from spread of contiguous infections (sinusitis and otitis media), meningitis and open head wounds [1-6]. Without therapy venous thrombosis and intraparenchymal brain abscess may develop [1, 2, 6]. Cerebral arteriography is the diagnostic procedure of choice [4-6]. The present report concerns the analysis of the cerebral arteriograms in thirteen patients with subdural empyema. The purpose of the paper is to emphasize the frequency and diagnostic significance of
irregularities of the arterial walls with subdural empyema. The paper will also illustrate that the vascular changes may be reversible. The clinical information and general diagnostic tests of these cases are described elsewhere [6].
Materials and Methods
Thirteen patients with subdural empyema underwent arteriography at this hospital in the last ten years. The
172
D. M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
etiology, location, and neuroradiological angiographic findings associated with the empyemas are summarized in Table 1. In all 13 cases arteriography was performed preoperatively and in three cases (Cases 3, 4 and 13) arteriography was repeated postoperatively.
Fig. 4. Case 13. A 61 year old man who had undergone resection of a pulmonary abscess 18 months prior to admission had suffered with chronic bronchitis. He presented with a ten day history of left orbital and otitic pain with subsequent development of right hemiparesis and seizures. The CSF was not examined preoperatively. The arteriogram shows diffuse arterial constrictions with possible small vessel occlusions (arrows)
Results
Arteriography revealed that in all cases the subdural empyema was in the supratentorial compartment. In three cases there were bilateral collections of purulent material. Two of these also had parafalcine collections. In the remaining cases the empyema was unilateral but tended to spread diffusely. The etiology of the subdural empyema was paranasal sinusitis in seven cases, bacterial meningitis in three, and, in one case each, otitis media, ventricularatrial shunt infection and hematogenous spread from chronic pulmonary infection. Nine of the thirteen patients had arterial wall irregularity. Two types of luminal alterations were noted: (1) diffuse irregularities and constrictions, (2) multifocal or segmental constrictions (Figs. 1-5). Diffuse arterial alterations occurred in five cases while localized changes were present adjacent to the empyema in four cases. When cerebral arteriography was performed postoperatively in Cases 3, 4 and 13, the arterial constriction and irregularities were found to have resolved in Cases 4 and 13 (Figs. 1, 2, 4, 5); however, when cerebral arteriography was repeated one month postoperatively in Case 3 because of recurrence of signs and symptoms, the subdural collection was found to have reaccumulated and persistent arterial irregularity was observable. Discussion
The arteriographic features previously described in patients with subdural empyema have included "pool-
Fig. 5. Case 13. Six days following removal of the empyema the diffuse arterial wall involvement is no longer apparent
D. M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
ing" of contrast material in the dural wall, extravasations of contrast material along the arteries, irregularities of the arched cortex at the margin, and arterial narrowing and vascular irregularity [7-9]. Vascular changes aid in differentiating subdural empyema from hematoma. In our series diffuse and multifocal arterial changes were demonstrated in nine cases. In two cases these abnormalities resolved with appropriate surgical drainage and antibiotic therapy. The arterial irregularities with subdural empyema are similar to those observed in other intracranial infections [10, 11] and meningitis in particular [12, 13]. Recently, Gado [12] has demonstrated cerebral arterial narrowing and occlusion in two cases of H. influenza meningitis. He noted reversal of the changes when arteriography was repeated after one month in one case and at seven weeks in the other. With the exception of Cases 9, 10 and 11, where the empyema followed meningitis, we believe that in this series the vascular changes are due solely to the subdural empyema rather than a concomitant purulent meningitis. In all cases the clinical presentation was inconsistent with meningitis and indicative of an intracranial mass lesion. Antibiotic therapy was ineffective without surgical drainage of the empyema. Finally, in those cases where the spinal fluid was examined, there was no evidence of meningitis. In two of our patients (Cases 4 and 13) reversal of the changes occurred, as in meningitis, but this was noted at an earlier time (9 and 6 days, respectively) after treatment began. These transient arterial changes in subdural empyema and bacterial meningitis seem analagous. In both conditions the purulent material which bathes the leptomeningeal arteries probably acts as a vascular irritant that causes constriction.
173
References L Kubik, C. S., Adams, R. D.: Subdural empyema. Brain 66, 18 (1943) 2. Courville, C. B.: Subdural empyema secondary to purulent frontal sinusitis: a clinicopathologic study of forty-two cases verified at autopsy. Arch~ Otolaryng. (Chicago) 39, 211 (1944) 3. Hitchcock, E., Andreadis, A.: Subdural empyemas: a review of 29 cases. J. Neurol. Neurosurg. Psychiat. 27, 422-434 (1964) 4. Bhandari, Y. S., Sarkari, N. B. S.: Subdural empyema: a review of 37 cases. J. Neurosurgery 32, 35-39 (1970) 5. Farmer, T. W., Wise, G. R.: Subdural empyema in infants, children and adults. Neurology 23, 254-261 (1973) 6. Kaufman, D. M., Miller, M., Steigbigel,N.: Subdural empyema: Analysis of 17 recent cases and review of the literature. Medicine 54, 485-498 (1975) 7. Ferris, E., Ciembroniewicz, J~: Subdural empyema: report of a case demonstrating the unusual angiographic triad. Am. J. Roentgen. 92, 838-843 (1964) 8. Raimondi, A. J.: Pediatric Neuroradiology p. 665. Philadelphia: Saunders 1972 9. Torres, H., Yarzagary, L., West, C.: Subdural empyema, angiographic and clinical considerations. Neurochirurgia 13, 201-210 (1970) 10. Davis, D. O., Taveras, J. M.: Radiological aspects of inflammatory conditions affecting the central nervous system. Clin. Neurosurg. 14, 192-210 (1966) 11. Leeds, N. E., Goldberg, H. I.: Angiographic manifestations in cerebral inflammatory disease. Radiology 98, 595-604 (1971) 12. Gado, M., Axley, J., Appleton, D., Prensky, A.: Angiography in the acute and post-treatment phases of Hemophilus Influenza Meningitis. Radiology 110, 439-440 (1974) 13. James, A., Hodges, F., Jordan, C., Mathews, E., Heller, R.: Angiography and cisternography in acute miningitis. Radiology 103, 601-606 (1972)
Receive& March 8, 1976 Dr. N Leeds Department of Radiology Montefiore Hospital 111 East 210th Street Bronx, New York 10467, USA
Neuroradiology 11,169-173 (1976)
@ by Springer-Verlag 1976
Focal Angiographic Abnormalities with Subdural Empyema D. M. Kaufman and N. E. Leeds Departments of Neurology and Radiology, Section of Neuroradiology, Montefiore Hospital and Medical Center, Albert Einstein College of Medicine, Bronx, N. Y., USA
Summary. Thirteen patients with subdural empyema underwent arteriography preoperatively and three were restudied postoperatively. Arterial vascular changes were found in nine cases and consisted of localized or diffuse arterial irregularities. In two cases the arterial changes resolved with effective therapy. These arterial changes are similar in appearance and response to therapy to those noted with meningitis; however, in this series they were shown to have occurred in seven cases with subdural empyema but without associated meningitis. Therefore, subdural empyema alone may cause localized or diffuse arterial irregularities.
Key words: Subdural emlpyema, Meningitis, Arterial irregularities.
Introduction A subdural empyema is an infection situated between the dura mater and the arachnoid. Purulent fluid is usually located over one or both cerebral hemispheres but it may extend to the interhemispheric fissure (parafalcine space) or be confined solely to this loca-
Table 1. Summary of neuroradiological arteriographic findings
Preoperative extracerebral avascular subdural area
Preoperative vascular changes
F F F
Frontoparietal Frontoparietal Bilateral frontal and parafalcine
None None Diffuse arterial constrictions early filling veins
14
M
Frontoparietal
15 16 26 2
M M M M
Subfrontal Frontotemperoparietal Frontoparietal Bilateral frontoparietal
1 4
F M
Parietal Temperoparietal
Meningitis 66 Otitis media 37 Bacteremia 62
M F M
Temperoparietal Temperoparietal Bilateral frontoparietal and parafalcine
Constriction of supraclinoid carotid and proximal anterior cerebral arteries Localized arterial constrictions Diffuse arterial irregularities Diffuse arterial irregularities Localized arterial irregularities with delayed filling Multiple arterial constrictions Localized irregular arterial constrictions None None Multifocal constrictions of distal middle cerebral artery with irregularity and absent vessels
Case
Etiology
Age
Sex
1 2 3
Sinusitis Sinusitis Sinusitis
5 12 13
4
Sinusitis
5 6 7 8 9 10
Sinusitis Sinusitis Sinusitis Postoperative Infection* Meningitis Meningitis
11 12 13
* Placement of ventricular-artrial shunt
Postoperative vascular changes
Diffuse arterial constrictions with recurrence of empyema Absence of spasm
Absence of irregularities
170
D.M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
fig. 1. Case 4. A 14 year old boy with sinusitis developed rapid onset of periorbital edema, fever, lethargy, hemiparesis and aphasia. There was no nuchal rigidity. The CSF contained 360 mononuclear and 40 polymorphonuclear cells/mm 3 and 100 mg% glucose and 51 mg% protein. No organisms were cultured from the CSF. The left carotid arteriogram illustrates constrictions of the supraclinoid internal carotid and anterior cerebral arteries. In addition, there is a shift of the anterior cerebral artery from left to right (arrows)
Fig. 2. Case 4. Nine days after evacuation of the subdural empyema a repeat arteriogram demonstrates the reversibility of the arterial constrictions. The arterial lumen appears normal and there is no shift of the anterior cerebral arteries
D. M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
a
171
b
Fig. 3. Case 8. A 2 year old boy was treated for pseudotumor cerebri five months prior to admission. On the day of admission he experienced high fever and status epilepticus. The CSF contained 22 mononuclear and 78 polymorphonuclear cells/ram 3 and 102 rag% glucose and 101 mg% protein. No organisms were cultured from the CSF a) Early arterial phase, direct right carotid angiography with magnification. The frontal subdural mass is recognized since the callosomarginal brances of the anterior cerebral artery do not reach the inner table of the skull b) Late arterial phase. Two irregularly filling middle cerebral arteries in the parietal region are recognized (arrows) c) Intermediate phase. There is delayed emptying of the two involved arteries (arrows)
tion. Supratentorial subdural empyema results most commonly from spread of contiguous infections (sinusitis and otitis media), meningitis and open head wounds [1-6]. Without therapy venous thrombosis and intraparenchymal brain abscess may develop [1, 2, 6]. Cerebral arteriography is the diagnostic procedure of choice [4-6]. The present report concerns the analysis of the cerebral arteriograms in thirteen patients with subdural empyema. The purpose of the paper is to emphasize the frequency and diagnostic significance of
irregularities of the arterial walls with subdural empyema. The paper will also illustrate that the vascular changes may be reversible. The clinical information and general diagnostic tests of these cases are described elsewhere [6].
Materials and Methods
Thirteen patients with subdural empyema underwent arteriography at this hospital in the last ten years. The
172
D. M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
etiology, location, and neuroradiological angiographic findings associated with the empyemas are summarized in Table 1. In all 13 cases arteriography was performed preoperatively and in three cases (Cases 3, 4 and 13) arteriography was repeated postoperatively.
Fig. 4. Case 13. A 61 year old man who had undergone resection of a pulmonary abscess 18 months prior to admission had suffered with chronic bronchitis. He presented with a ten day history of left orbital and otitic pain with subsequent development of right hemiparesis and seizures. The CSF was not examined preoperatively. The arteriogram shows diffuse arterial constrictions with possible small vessel occlusions (arrows)
Results
Arteriography revealed that in all cases the subdural empyema was in the supratentorial compartment. In three cases there were bilateral collections of purulent material. Two of these also had parafalcine collections. In the remaining cases the empyema was unilateral but tended to spread diffusely. The etiology of the subdural empyema was paranasal sinusitis in seven cases, bacterial meningitis in three, and, in one case each, otitis media, ventricularatrial shunt infection and hematogenous spread from chronic pulmonary infection. Nine of the thirteen patients had arterial wall irregularity. Two types of luminal alterations were noted: (1) diffuse irregularities and constrictions, (2) multifocal or segmental constrictions (Figs. 1-5). Diffuse arterial alterations occurred in five cases while localized changes were present adjacent to the empyema in four cases. When cerebral arteriography was performed postoperatively in Cases 3, 4 and 13, the arterial constriction and irregularities were found to have resolved in Cases 4 and 13 (Figs. 1, 2, 4, 5); however, when cerebral arteriography was repeated one month postoperatively in Case 3 because of recurrence of signs and symptoms, the subdural collection was found to have reaccumulated and persistent arterial irregularity was observable. Discussion
The arteriographic features previously described in patients with subdural empyema have included "pool-
Fig. 5. Case 13. Six days following removal of the empyema the diffuse arterial wall involvement is no longer apparent
D. M. Kaufman and N. E. Leeds: Focal Angiographic Abnormalities with Subdural Empyema
ing" of contrast material in the dural wall, extravasations of contrast material along the arteries, irregularities of the arched cortex at the margin, and arterial narrowing and vascular irregularity [7-9]. Vascular changes aid in differentiating subdural empyema from hematoma. In our series diffuse and multifocal arterial changes were demonstrated in nine cases. In two cases these abnormalities resolved with appropriate surgical drainage and antibiotic therapy. The arterial irregularities with subdural empyema are similar to those observed in other intracranial infections [10, 11] and meningitis in particular [12, 13]. Recently, Gado [12] has demonstrated cerebral arterial narrowing and occlusion in two cases of H. influenza meningitis. He noted reversal of the changes when arteriography was repeated after one month in one case and at seven weeks in the other. With the exception of Cases 9, 10 and 11, where the empyema followed meningitis, we believe that in this series the vascular changes are due solely to the subdural empyema rather than a concomitant purulent meningitis. In all cases the clinical presentation was inconsistent with meningitis and indicative of an intracranial mass lesion. Antibiotic therapy was ineffective without surgical drainage of the empyema. Finally, in those cases where the spinal fluid was examined, there was no evidence of meningitis. In two of our patients (Cases 4 and 13) reversal of the changes occurred, as in meningitis, but this was noted at an earlier time (9 and 6 days, respectively) after treatment began. These transient arterial changes in subdural empyema and bacterial meningitis seem analagous. In both conditions the purulent material which bathes the leptomeningeal arteries probably acts as a vascular irritant that causes constriction.
173
References L Kubik, C. S., Adams, R. D.: Subdural empyema. Brain 66, 18 (1943) 2. Courville, C. B.: Subdural empyema secondary to purulent frontal sinusitis: a clinicopathologic study of forty-two cases verified at autopsy. Arch~ Otolaryng. (Chicago) 39, 211 (1944) 3. Hitchcock, E., Andreadis, A.: Subdural empyemas: a review of 29 cases. J. Neurol. Neurosurg. Psychiat. 27, 422-434 (1964) 4. Bhandari, Y. S., Sarkari, N. B. S.: Subdural empyema: a review of 37 cases. J. Neurosurgery 32, 35-39 (1970) 5. Farmer, T. W., Wise, G. R.: Subdural empyema in infants, children and adults. Neurology 23, 254-261 (1973) 6. Kaufman, D. M., Miller, M., Steigbigel,N.: Subdural empyema: Analysis of 17 recent cases and review of the literature. Medicine 54, 485-498 (1975) 7. Ferris, E., Ciembroniewicz, J~: Subdural empyema: report of a case demonstrating the unusual angiographic triad. Am. J. Roentgen. 92, 838-843 (1964) 8. Raimondi, A. J.: Pediatric Neuroradiology p. 665. Philadelphia: Saunders 1972 9. Torres, H., Yarzagary, L., West, C.: Subdural empyema, angiographic and clinical considerations. Neurochirurgia 13, 201-210 (1970) 10. Davis, D. O., Taveras, J. M.: Radiological aspects of inflammatory conditions affecting the central nervous system. Clin. Neurosurg. 14, 192-210 (1966) 11. Leeds, N. E., Goldberg, H. I.: Angiographic manifestations in cerebral inflammatory disease. Radiology 98, 595-604 (1971) 12. Gado, M., Axley, J., Appleton, D., Prensky, A.: Angiography in the acute and post-treatment phases of Hemophilus Influenza Meningitis. Radiology 110, 439-440 (1974) 13. James, A., Hodges, F., Jordan, C., Mathews, E., Heller, R.: Angiography and cisternography in acute miningitis. Radiology 103, 601-606 (1972)
Receive& March 8, 1976 Dr. N Leeds Department of Radiology Montefiore Hospital 111 East 210th Street Bronx, New York 10467, USA
