Long term results of neurosurgical treatment of subdural fluid collections
in infants after purulent meningitis
Odległe wyniki leczenia neurochirurgicznego wylewów podtwardówkowych u niemowląt
po przebytym ropnym zapaleniu opon mózgowo-rdzeniowych
Augustyn Folwaczny
1, Andrzej Życiński
2, Jan Baron
3, Piotr Bażowski
2, Józef Dzielicki
4,
Tomasz Legaszewski
5, Wojciech Pieniążek
1, Anna Kuroś-Wikło
6, Stanisław Furgał
1, Edyta Machura
1,
Franciszek Halkiewicz
1, Bogusław Mazurek
71 Chair and Department of Paediatrics in Zabrze 2 Chair and Clinic of Neurosurgery
3 Chair and Department of Radiology and Nuclear Medicine 4 Chair and Department of Paediatric`s Surgery in Zabrze 5 First Chair and Department of Radiology in Zabrze 6 Chair and Clinic of Anesthesiology and Intensive Care 7 Department of Paediatric Cardiology
Medical University of Silesia, Katowice
ABSTRACT
Despite efficient vaccination schedules, great progress in intensive care and potent antimicrobial therapies the bacterial meningitis is still life-threatening condition. Aim of the study: Assessment of remote neurosurgical – treatment results of sub-dural fluid collections in infants after bacterial meningitis. Mate-rial: 40 infants (12 girls and 28 boys) aged 3 weeks to 10 month of life. All the children had a history of purulent meningitis in: 14 (35%) with concomitant septicemia – and meningo- encepha-litis in 7 (17,5%). In all patients subdural fluid collections were diagnosed. Multiple decompressing subdural punctures were performed in 27 (67,5%) of patients. Bilateral burr-hole trepa-nation was performed in two stages in 28 (70%) of patients, unilateral in 10 (25%) and craniotomy in 2 (5%). Results: After 13-31 year observations, the results of neurosurgical treatment are as follows: normal psychomotor development in 33 (82,5%) of children, mental retardation in 3 (7,5%), serious psychomotor retardation in 2 (5%), epilepsy in (3) 7,5%, partial hearing loss in (6) 15%, unilateral visual impairment in 3 (7,5%). Two of patients completed university education, two bachelor’s degree, four are university students, five completed college, seven attend college, eight completed vocational school, five attended sec-ondary school. The remaining five disabled patients completed or attend individual education. Conclusions: Long term results of neurosurgical treatment in our patients, who are the most severe cases treated in region inhabited by 6,5 mln population, seem to be satisfactory.
Key words: bacterial meningitis, subdural fluid collections, burr hole trepanation, craniotomy.
STRESZCZENIE
Bakteryjne zapalenia opon mózgowo-rdzeniowych mimo wpro-wadzenia skutecznych programów szczepień ochronnych, dużych postępów w intensywnej terapii, szerokich możliwości zastosowania odpowiedniej antybiotykoterapii, nadal pozo-stają poważnym, zagrażającym życiu schorzeniem. Cel pracy: Ocena odległych wyników leczenia neurochirurgicznego wyle-wów podtwardówkowych u niemowląt po przebytym ropnym zapaleniu opon mózgowo-rdzeniowych. Materiał i metoda: 40 niemowląt (12 dziewczynek i 28 chłopców) w wieku od 3 tygo-dni do 10 miesiąca życia. Wszystkie dzieci przebyły zapalenie opon mózgowo-rdzeniowych, w tym 14 (35%) z towarzyszącą posocznicą oraz 7 (17,5%) zapalenie opon mózgowo-rdzenio-wych i mózgu. U wszystkich niemowląt stwierdzono wylewy podtwardówkowe. Wielokrotne nakłucia odbarczające pod-twardówkowe w oddziałach macierzystych województwa śląskiego i opolskiego wykonywano u 27 (67,5%) dzieci. Tre-panację otworkową obustronną wykonywano dwuetapowo u 28 (70%) dzieci, jednostronną u 10 (25%) dzieci. Kraniotomię wykonano u 2 dzieci. Wyniki: Odległe wyniki leczenia po obser-wacji 13 – 31-letniej przedstawiają się następująco: 33 (82,5%) dzieci wykazuje prawidłowy rozwój psychomotoryczny, troje (7,5%) dzieci – upośledzenie umysłowe, 2(5%) dzieci upośle-dzenie psychomotoryczne dużego stopnia, u trojga (7,5%) dzieci stwierdzono padaczkę, u sześciorga (15%) niedosłuch, u trojga (7,5%) niedowidzenie jednostronne. Dwoje dzieci ukończyło szkołę wyższą, dwoje studium pomaturalne, czworo uczęszcza do szkoły wyższej, pięcioro ukończyło szkołę średnią, siedmioro uczęszcza do szkoły średniej, ośmioro ukończyło szkołę zawo-dową, pięcioro uczęszcza do gimnazjum, pozostałe pięcioro z upośledzeniem umysłowym ukończyło lub kontynuuje naucza-nie indywidualne. Wniosek: Mimo że materiał obejmował naj-cięższe przypadki leczone na terenie obszaru zamieszkanego przez około 6,5 mln ludności, odległy wynik postępowania tera-peutycznego wydaje się dobry.
Desp��e eff�c�e�� vacc��a��o� schedules, grea� progress �� ���e�s�ve care a�d po�e�� a���m�crob�al �herap�es, bac�er�al me���g���s ��M� �s s��ll l�fe-�hrea�e���g co�d���o� [1-5].
I� Europe �he ��c�de�ce of �he d�sease ra�ges from 2 – 6 cases per 100000 [1]. O�se� of �M occurs mos� of�e� �� �he f�rs� �wo years of l�fe [1]. Mor�al��y �� me���gococ-cal �M �� ch�ldre� reaches 1 – 4% [1], a�d accord��g �o l��era�ure, �he da�a �s markedly h�gher whe� me���gococcal sepsis occurs.
I� p�eumococcal �M �he mor�al��y ra�ges from 6 �o 20% w��h h�gher ��c�de�ce of compl�ca��o�s a�d �eurolo-g�cal def�c��s [1]. 15% ou� of 482 ch�ldre� prese��ed by �el�ola a�d al. d�ed [6]. �rese��ly, �� Europe, as a resul� of eff�c�e�� vacc��a��o� program, �M caused by Haemoph�-lus ��flue��ae � occurs ma��ly �� �o�-vacc��ees [1]. Mor-�al��y w��h�� �h�s group amou��s �o 3%. I� pre�erms remo�e co�seque�ces occur �� up �o 50% of pa��e��s [7]. H�gher ��c�de�ce of �eurolog�cal compl�ca��o�s a�d dea�hs �s observed �� mal�our�shed ch�ldre� w��h body mass def�c�� [8]. Immed�a�e emp�r�cal a���m�crob�al �herapy a�d s�ab�l�-�a��o� of v��al fu�c��o�s �s par��cularly �mpor�a�� �� severe course of �he d�sease. Dur��g �rea�me�� pa��e�� should be u�der �eurolog�cal, lary�golog�c a�d op�halmolog�c co�-�rol a�d �ra�sfo��a�ellar U� or CT/NMR should be perfor-med [1,2,5,9]. Neurorad�ology reveals �ha� subdural flu�d collec��o�s occur �� 30-40 % of �M [10]. O�ly 10-20% of cases demo�s�ra�e ��creased ���racra��al pressure [11]. Lo�g-s�a�d��g exper�e�ce revealed �ha� flu�d collec��o�s caused by �M or �rauma requ�re more of�e� a� opera��ve �rea�me�� due �o adhes�o�s a�d capsule forma��o� [11,12].
AIM Of THE STUDY
The a�m was �o assess remo�e resul�s of �eurosurg�cal �re-atment of fluid collections in infants after purulent menin-g���s.
MATERIAL
40 ��fa��s �12 g�rls a�d 28 boys� aged 3 weeks �o 10 mo��hs of l�fe were �rea�ed �� �eurolog�cal u��� a� I Cha�r a�d Depar�me�� of �ed�a�r�cs, ��les�a� Med�cal Academy �� Zabr�e be�wee� 1979 a�d 1997. All of �hem had a h�s�ory of purule�� me���g���s w��h co�com��a�� sep��caem�a �� 14 �35%� a�d e�cephal���s �� 7 �17,5%�. Ch�ldre� were �rea-�ed �� �rea-�ed�a�r�c Depar�me��s of ��les�a� Med�cal Academy, Cou��y a�d C��y Hosp��als ma��ly �� ��les�a� a�d Opole Vo�vodsh�ps.
I� 22 �55%� cases �����al cl���cal s�a�us of ch�ldre� was severe or ex�remely severe. O�ly �wo ch�ldre� �5%� were prev�ously cured �� Zabr�e. E��ology of �M �s prese��ed �� �able I.
Table I. Etiology of meningitis in assessed patients
Ethiology Number of patients %
Neisseria meningitidis 11 27,5 Haemophilus influenzae 5 12,5 Salmonella 3 7,5 Streptococcus pneumoniae 2 5 Staphylococcus aureus 1 2,5 Staphylococcus epidermidis 1 2,5 Unknown 17 42,5
Recurre�� se��ures were observed �� 8 �20%� of ch�l-dre�, w��h u��la�eral local��a��o� �� �wo.
I� o�e boy �C.K., f�le �umber 2016/88� af�er surv�v��g me���goe�cephal���s he had a� �he age of 6 mo��hs, a r�gh� – s�ded hem�pleg�a occurred. Dur��g surgery abou� 190 ml of bloody flu�d was evacua�ed u�der h�gh pressure. The bra�� pulsa�ed well, a�d �� had a �e�de�cy �o expa�d. R�gh� flacc�d pares�s s�opped comple�ely several mo��hs af�er o� opera��o�. �rese��ly, �he phys�cally a�d me��ally f�� you�g ma� �s a 3-rd year u��vers��y s�ude��.
Mul��ple decompress��g subdural pu�c�ures �� ma�er-�al wards were performed �� 27 �67,5%� ch�ldre�. I� 15 �37,5%� cerebrosp��al flu�d cy�os�s, assessed dur��g �he f�rs� pu�c�ure, ra�ged from u�cou��able mass �o 16/3, pro-�e�� co�ce��ra��o� ra�ged from 3379 mg/dl �o 200 mg/dl. I� rema����g12 �30%� ch�ldre� cerebrosp��al flu�d was bloody or xa��ochrom�c w��h �umerous �o u�cou��able lysed ery�hrocy�es �� smear a�d pro�e�� co�ce��ra��o�s ra�ged from 5550 mg% �o 264 mg/dl.
Cerebral CT sca�s were performed �� 37 �92,5%� ch�l-dre�, w��h co�com��a�� U� exam��a��o� �� seve�, a�d MRI �� o�e pa��e��. I� �wo ch�ldre� o�ly U� exam��a��o� �5%� was performed, a�d �� o�e, �� 1979, cerebral a�g�ography �2,5%�.
Bilateral burr hole trepanation was performed in two s�ages �� 28 �70%� ch�ldre�, a�d u��la�eral �� 10 �25%�. Cra��o�omy was do�e �� �wo pa��e��s. Dur��g 68 �repa-�a��o�s be�wee� 20 – 200 ml �mea� 62 ml� of flu�d was evacua�ed.
O�e ch�ld, a boy �M.T., f�le 688/80�, who a� �he age of f�ve mo��hs we�� dow� w��h �M �salmonella typhi
murium B� accompa��ed w��h DIC. Dur��g h�s s�ay a�
I��e�s�ve Care U��� mul��ple subdural pu�c�ures were per-formed. �ubseque��ly, w�de lef� – s�de cra��o�omy was do�e w��h evacua��o� of purule�� 3-4cm flu�d collec��o�. A� �he seco�d s�age of surgery 40 ml of �o�-purule�� flu�d
Słowa kluczowe: zapalenia opon mózgowo-rdzeniowych, wylewy podtwardówkowe, trepanacje otworkowe, kranioto-mia
was evacua�ed from �he reg�o� above r�gh� hem�sphere. A� prese�� pa��e�� �s 29 years old �he�gh� 188 cm, body mass 79 kg – f�g 1a,b,c,d,e�. U�for�u�a�ely, CT sca�s from 1980
had d�sappeared. He has comple�ed �pec�al �r�mary �chool for me��ally re�arded. He walks a�d speaks sa��sfac�or�ly, ca� read a�d cou��, helps w��h housework.
Fig.1 Silhouette of patient M.T. aged 26 (meningitis at 5 mths) – a,b; profile picture with craniotomy scar -c; up-to date CT scan with staples and moderate enlarging of subdural space in the frontal region – d,e.
I� a�o�her ch�ld �I.M., f�le 845/89�, �� whom purule�� p�eumococcal me���goe�cephal���s was d�ag�osed a� �he age of �hree weeks, mul��ple decompress��g pu�c�ures a�d 0,9% sal��e lavages of lef� s�de were performed. He was opera�ed o� �w�ce, a� �he age of e�gh� a�d s�x�ee� mo��hs, w��h �he evacua��o� of 150 ml a�d 80 ml of e�capsula�ed purule�� flu�d subseque��ly. I� �h�s pa��e�� a� �he age of
seve� mo��hs 150 ml of xa��hochrom�c flu�d was evacua-�ed from �he r�gh� subdural space. F�g 2a prese��s cerebral CT sca� a� �he age of f�ve mo��hs, a�d 2d- 13,5 mo��hs la�er. A� prese�� �he pa��e�� �s 21 years old. He walks a�d speaks qu��e well. He comple�ed ��d�v�dual, home educa-��o�. �ecause of ep�lepsy, he �s chro��cally �rea�ed w��h valproa�e.
Fig.2. Patient I.M. at the age of 5 months with large fluid collections at the frontal, occipital and parietal region – a.; 1,5 month later a marked reduction of fluid collections with contrast enhancement of , what can be interpreted as pericerebral absecsses – b; next CT scan performed eight months later revealed regression of the size of abscesses with residual changes – c; four months later CT revealed fluid collections at frontal and right occipital regions – d.
a. 14.07.89 b. 01.09.89
I� a ch�ld K.�. �f�le �umber 98/97�, a pre�erm w��h b�r�h we�gh� of 1650 g, �� �he �h�rd week of l�fe s�aphylococcal sepsis (S. epidermidis� a�d me���g���s were d�ag�osed. I� f�f�h mo��h of l�fe a 100 ml of xa��hochrom�c flu�d was evacua�ed from r�gh� subdural space �hygrohaema�oma�. I� eleve��h mo��h of l�fe 20 ml of bloody flu�d was evacua-�ed from �he same reg�o�. �ecause of ��creas��g ���er�al hydrocephaly ve��r�culo – a�r�al shu�� modo �ude�� 12 mm was �mpla��ed �� �h�r�ee��h mo��h of l�fe. A� prese��, �he boy �s mo�or�cally f��, has IQ below average, b�la�eral hypoacus�s. He has ��d�v�dual �ra����g program a� school.
O�e ch�ld ��.�., f�le No 1857/92�, a boy who a� �he age of 6 mo��hs suffered from bac�er�al severe e�cephalo – me���g���s �Haemophilus Influenzae� w��h card�oresp�-ra�ory fa�lure symp�oms. Af�er 2 mo��hs a subdural flu�d collec��o� was loca�ed over r�gh� hem�sphere a�d co�s�s�-��g of 40 ml hema�oma a�d 60 ml hygroma. A� �he age of 10 mo��hs, collec��o� of 200 ml bloody a�d xa��hochrom�c flu�d was evacua�ed from lef� subdural space �f�g.3a CT before �eurosurg�cal �rea�me��, f�g. 3� co��rol CT sca� af�er 6,5 mo��hs, f�g. 3 c,d af�er �e� years�. A� prese��, �he boy a��e�ds seco�dary school w��h good progress. He has
Fig. 3. Patient B.P. At the age of 8 months with bilateral pericerebral hygro – hematomas - before neurosurgical treatment – a; control CT scan after 6,5 months with residual subdural hematoma at the region of left frontal lobe – b; control CT scant ten years after – c,d.
a. 6.11.92 b. 28.05.93
�o pa�holog�cal f��d��gs �� �eurolog�cal exam��a��o�. I� o�e g�rl �U.Ż., f�le No 114/88�, a pre�erm �b�r�h we�gh� 1450g�, a� �he 8 mo��h of age me���gococcal me���g���s was d�ag�osed. A� �he age of 12 mo��hs a cap-sula�ed, r�gh� s�ded �hree-layer, 20 + 15 + 20 ml subdural xa��ochrom�c flu�d collec��o� was evacua�ed. Rece��ly she has comple�ed �ech��cal college.
Remo�e resul�s of �rea�me�� af�er 13-31 -year follow-up are prese��ed �� �ab. II.
Table II. Results of treatment in 13-31 years follow-up Remote treatment results Number of patients % Normal psychomotor development 33 82,5 Mental retardation 3 7,5 Severe psychomotor retardation 2 5 Epilepsy 3 7,5
Partial hearing loss 6 15
Unilateral visual impairment 3 7,5 I� pa��e��s w��h me��al re�arda��o� �M.T., f�le No 688/80 a�d I.M., f�le No 845/89� salmo�ellous, a�d p�eumococ-cal �M was d�ag�osed, a�d pre�erm pa��e�� �K.�., f�le No 98/97� w��h Staphylococcus epidermidis neonatal bacterial me���g���d�s. �a��e��s w��h severe psychomo�or re�arda��o� �G.�, f�le No 1977/93, a�d �.�., f�le No 1867/94� had u�k-�ow� or s�aphylococcal ��. aureus� e��ology subseque��ly. I� 3 pa��e��s w��h seco�dary ep�lepsy, e��ology �� o�e case of �M rema��ed u�k�ow�, a�d �� 2 ch�ldre� p�eumococ-cal ��fec��o� was d�ag�osed. I� 6 pa��e��s w��h hear��g �mpa�rme�� me���gococcal e��ology was es�abl�shed, �� 4, salmo�ellos�s �� 1, a�d �� 1 pa��e�� e��ology rema��ed u�k�ow� [18, 21-23]. I� 5 cases hear��g �mpa�rme�� was b�la�eral, a�d �� 1 – u��la�eral. I� �he group of 40 opera�ed o� pa��e��s �wo �5%� d�ed from �o�-�eurolog�cal causes.
DISCUSSION
Lo�g – �erm compl�ca��o�s of bac�er�al me���g���s are: seco�dary ep�lepsy, me��al re�arda��o�, cerebral palsy, a�a-lyser fu�c��o� d�sorders, les�o�s of cra��al �erves, se�sual �mpa�rme��, charac�eropa�h�es, headaches a�d educa��o�al problems [2,3,5,12,13]. Neurolog�cal co�seque�ces are s�g-��f�ca��ly more of�e� �� case of severe course of �he d�sease �� acu�e phase [14]. Major subdural flu�d collec��o�s are accompa��ed by recurre�� fever, vom����g, focal symp�oms a�d se��ures. If �he subdural flu�d collec��o� �s expa�s�ve or �s b�gger �� s��e, subdural pu�c�ure a�d dra��age �s �ecessary [9,12,15]. I� case of subdural empyemas �rea�me�� �s always opera��ve, some��mes w��h several days’-of dra��age a�d local a���b�o��cs [16-19]. 27 �67,5%� ou� of our 40 pa��e��s af�er �M had mul��ple decompress��g subdural pu�c�ures because of l�fe �hrea�e���g co�d���o�. ��la�eral burr-hole �re-pa�a��o� was performed �� �wo s�ages �� 28 �70%� ch�ldre�, u��la�eral �� 10 �25%� a�d cra��o�omy �� 2 �5%�.
O� �he bas�s of 13–31-year observa��o� �� 33 pa��e��s
�ormal psychomo�or developme�� was fou�d. Educa��o� of our pa��e��s �s prese��ed �� �able III. I� �he group of 461 ch�ldre� accord��g �o de Louvo�s a�d al. [ 20], af�er �M – 7,8 % of pa��e��s a��e�d spec�al educa��o� school. The r�sk of �eurolog�cal compl�ca��o�s ra�ges from 10 – >30% [18, 21, 22]. Desp��e ou�s�a�d��g progress �� �rea�me�� �� rece�� years, �h�s perce��age d�d �o� decrease markedly [16, 22]. Early adm���s�ra��o� of dexame�haso�e �� Haemoph�lus ��flue��ae � a�d p�eumococcal ��fec��o�s �mproved f��al �rea�me�� resul�, bu� �� o�hers �s doub�ful [17].
Table III. Education in 13-31years follow-up
Education Number of patients %
University - graduated 2 5
University - student 4 10
Post-college licency - graduated 2 5
College - graduated 5 12,5
College - student 7 17,5
Vocational school - graduated 8 20
Gymnasium - attending 5 12,5
Individual education program 5 12,5
Immed�a�ely af�er �he acu�e phase of �M 30 – 40% of pa��e��s prese�� �eurolog�cal symp�oms. Ma�y d�sorders co�cer���g cra��al �erves, hear��g, v�s�o�, mo�or ac��v��y a�d behav�or resolve w��h�� a few weeks or mo��hs [24-26].
�er�ous ���ell�ge�ce �mpa�rme�� �IQ < 70� appear �� 5 – 10% of pa��e��s [26,27], �� �ex� 5% IQ ra�ges from 70 – 80, a�d �� 10% m��or school problems are observed.
I� our s�udy group 5 �12,5%� pa��e��s are me��ally re�arded. Recurre�� se��ures were observed �� 8 �20%� of our pa��e��s. I� 889 pa��e��s w��h �M repor�ed from ped�a-�r�c ce��ers �� Fra�ce [28] se��ures were observed �� 13,6% of pa��e��s. Ep�lepsy occurs �� 4-7 % of ch�ldre� af�er �M [24,26,27].
I� occurs usually w��h�� �he f�rs� f�ve years, bu� �� could occur eve� 15 years af�er �M. I� our pa��e��s ep�lepsy occu-red �� 3 �7,5%� cases. Hear��g �mpa�rme�� was d�ag�osed �� 6 �15%� of our pa��e��s. Accord��g �o l��era�ure repor�s hear��g loss �>25 d�� occurs �� 7 – 10% [2,7,18,23], a�d �� p�eumococcal ��fec��o�s eve� abou� 19% [16]. Accord��g �o �he mos� ac�ual research of �el�ola a�d al. [29] adm�-��s�ra��o� of dexame�haso�e or glycerol does �o� pro�ec� from hear��g �mpa�rme�� �� �M. U��la�eral eyes�gh� �mpa-�rme�� was observed �� 3 �7,5%� of pa��e��s. O�her au�hors repor� 2 – 4% ��c�de�ce [3,30,31].
Va� Cale�bergh a�d al. [31] appl�ed lo�g-�erm ex�er-�al dra��age of subdural hemorrhages �� 31 ��fa��s. Th�s cl���cally effec��ve �herapy was burde�ed w��h low com-pl�ca��o� ra�e. V��cho� a�d al. [32] �� 29 pa��e��s recru��ed from �he area ��hab��ed by popula��o� of 4 m�ll�o�, w��h subdural flu�d collec��o�s af�er �M �rea�ed �eurosurg�cally a�d observed for 26 years had fou�d �ormal psychomo�or developme�� �� 69%, severe compl�ca��o�s �� 10% a�d
ep�-lepsy �� 39%. To�al resolv��g of g�a�� subdural empyemas was ach�eved �� 10 mo��hs old g�rl af�er �eedle pu�c�ures a�d 0,9% sal��e lavage [4]. �aechl� a�d al. [33] descr�bed 8 mo��h old boy w��h ep�dural empyema of pos�er�or cave, �� whom hyperbar�c �herapy w��h 100% oxyge� was
adm�-��s�ered. Th�s me�hod �s usually used as add���o�al �herapy �� pa��e��s w��h cerebral empyemas, �umors a�d ��farc��o�s [34]. �ummar����g, remo�e resul�s of �rea�me�� adm���s�e-red �� our pa��e��s are good, desp��e assess��g �he mos� ser�ous cases recru��ed from 6,5 m�ll�o� popula��o� area.
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Correspondence:
Augustyn Folwaczny, I Katedra i Klinika Pediatrii w Zabrzu ŚUM w Katowicach, 41- 800 Zabrze, ul. 3-go Maja 13 – 15 e-mail: wpieniazek@interia.pl
