Tiirkis1i Neiirosiirgery 6: 25 - 27, 1996 Kiizeyli: Pyocep/ia/iis

Ventricular Empyema And Pyocephalus:A Case Report

KA YHAN KUZEYLI, FADiL AKTÜRK, ERTUGRUL ÇAKIR, SÜLEYMAN BAYKAL,

MURAT KARAKUS, SONER DURU

Karadeniz Teehnieal University Medical Faeulty Department of Neurosurgery Trabzon, Türkiye

Abstract: Intraeranial infeetions are among the complieations ofspina! dysraphism cases. Ventrieular empyema and pyoeephaliisare those kinds of infeetions and are quite rare problems withlimited reports in the literature.

INTRODUCTION

In central nervous system (CNS) infections !ike;meningitis, ventricu!itis, cerebritis, cerebral abscessand ventricular empyema; one way of spread of themicroorgan~sms is, spinal defects !ikemeningomyelocele or dermal sinuses (2).

. Ventriculitis frequently presents withmeningitis or as a result of a cerebral abscess openinginto the ventricles and also may present as a shuntcompIication.

Ventricular empyema and pyocephalus,progressive phases of ventricu!itis are rarely seentoday because of the progress in medical and surgicaltreatment O).

CASE REPORT

A 4- month old male infant was seen with

hyperthermia, lethargy, paraplegia and increasedhead circumference. Physical examination revealedan increase in head circumference, a full andnonpulsatile anterior fontanel and an infected25x35x35mm. thoracolumbar myeloschisis. Therewas no cerebrospinal fluid (CSF) leakage from themyeloschisis. CBC was: WBC 14500/mm3, Hgb 9,5g/di and thrombocytes were normaL.In his neurologicalexamination; general condition was bad, neonatalreflexes were absent and the patient was paraplegic.

CT scan of the brain revealed bifrontal

In this report, we present the evolution and management of apyoeephalus case and disCllss the pertinent literatiireKey words: Computed tomography, magnetie resonanceimaging, myelosehisis, pyocephalus , ventrIculilr empyemil.

hypodense multifocal regions, minimal ring- shapedcontrast enhancement and asymmetry of bothoccipital horns. The density of the intraventricularregion was ca1culated as pus. The third ventricle wasof CSF density. Periventricular oedema and aporencephalic region were also detected in the leftoccipital region (Fig 1).

Magnetic resonance imaging ( MRI ) taken thesame day showed that the occipital horns of lateralventricles were isolated and their borders showed

homogeneous, well defined, ring-shaped contrastenhancement. The bilateral frontal horns were not

detectable and these regions were completely hypointense (Fig 2). With these findings, an initialdiagnosis of ventricular empyema was made.Bilateral ventricular taps were performed, duringwhich 45 cc. pus was drained from the right side and35 cc. from the left side. CT scan taken af ter

yen tricular ta ps revea led in tra yen tricularpneumocephalus (Fig 3).

Acinetobacterium lwoffi was detected in the

culture antibiogram from the pus. The patient wastreated with a low dose anti oedema and specificantibiotics, and followed up with periodic CT scans.The patient's myeloschisis was treated with antisepticand scatrising medications and healed completely.

Three months later a dynamic CT study wasperformed to distinguish porencephalic cysts fromventricular dilatation and to show the CSF dynamics.

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Tiirkisli Neiirosiirgery 6: 25 - 27, 1996

First, contrast material was given into the left frontalhom of the lateral ventriele. it was observed that the

contrast material was passing to the frontal hom ofthe right lateral ventriele and to the third ventriele;but none was observed in either of the occipital homs.A second tap was made from the right posteriorparieta!. Contrast material was observed in theoccipital ham of the right lateral ventriele and cystsaround it alsa filled (Fig 4). Therefore; two mediumpressure ventriculoperitoneal shunts (one ventricu!ar

Fig. 1: CT senii sliowiiig bifroiilal Iiypodeiise lIliiltifocal regioiis aiidmiiiimal riiig sliaped caiilmsl eiihaiieemeiil of bolli occipila/IWrils. Also, o poreiieeplialic region mid periveiilricii/aroedeiiia were delecled iii Ilie left occipilal region.

Fig. 2: Coiilmsl eiilimieed MRI sliowiiig isolaled oeeipilal lioms of

Ilie Iatemi veiitrides aiid Iwmogeiieviis, well margiiialrd, riiigsliaped eoiilmsl eiilimieemeiit of Ilie borders of Ilie iliirdveiitride. Bilateml froiilal IiOrllS !Dere not deleclable.

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Kiizeyli: Pyoeeplialiis

Fig. 3: CT seaii lakeii afier veiilriciilar tappiiig sliowiiig airiii laleml veliirides.

Fig. 4: Dyiiamie CT stiidy inade for ciisliiigiiisliiiig porciiccp//(//ieeysls froiii veiilrieiilar dilatalioiis. Tlie Iwo air biibblesare relaled willi Ilie lefl [roiilal aiid riglil posleriorparietal lappiiigs.

end into the !eft frontal ham and the other into the

right accipita! ham) were instal1ed and connectedwith a "Y" connectar (Fig 5,6).

When the patient was discharged, he was active,coping with his environment, the fantane! waspulsating and head circumference was not increasingquick!y.

DISCUSSION

Tiirkish Neiirosiirgery 6: 25 - 27, 1996

Fig. 5-6:Posloperalive CT seliiis showiliS Ihe veiilriciilar eiids

of Ihe shiiiils; aiie iii Ihe lefl frol/llIl IlIld tlie olher

iii Ilie righl oeeipiliil ham of Ilie LLL lera 1 veiilricles.

In CNS infections secondary to spinaldysraphism cases; micro-organisms (2,3) reach theintracranial region by haematogeneous ways orsubarachnoid CSF routes because of a contaminated

spinal defect or CSF leakage (4). Infection starts withacute meningitis and the resultant ventriculitis maybe seen frequently in the newbom (2, 3, 5).Ventriculitis causes obstruction by foraminalattachments (5). Then, ventricles become isola tedfrom the surroundings, and becomes completely fillwith pus. This is called ventricular empyema. Aftera while, empyema organises and a certaingliomesenchymal reaction develops in thesurraunding cerebral tissue. This event ends with

Kiizcyli: Pyoeepliiiliis

fusion of the anterior horns of the ventricles which is

not seen macroscopically (Fig 2). This condition istermed pyocephalus intemus (4).

The time course between ventriculitis and

pyocephalus may be related with the patient'simmune system, pathogenicity of microorganisms,early diagnosis; sufficient and apprapriate antibioticsand ventricular drainage 0,4). In our case; becausethe patient had no radiological evaluation ( CT orMR!) before he was seen by us, radiologica!evaluation of the stages between ventriculitis andpyocephalus could not be made.

Although ventricular drainage and antibiotictreatment are the principles of ventriculitis treatment(6), ventricular tapping to drain the infection,parenteral antibiotics and control CT seans arenecessary in ventricular empyema cases.

After the treatment of ventriculitis, ventricu!arempyema or pyocepha!us; multiple porencephaliccysts with obstructive and / or communicatedhydrocephalus may develop. In this situationventriculography can be very helpful in showing theventriculoventricular and cysto-ventricularcommunications . In conclusion, 1) Spinal defectsmust be kept sterile. In CNS infections treated withantibiotics and extraventricular drainage, antibioticsmust be used in sufficient doses and for a sufficient

period of time, and the patient must be followed upwith periodic CT seans 2) Ventricular empyema andpyocephalus are important but rare complicationswhich can be seen after inefficient or insufficient

antibiotic treatment and in patients who are nottreated with extra ventricular drainage.Correspondence : Kayhan KUZEYLI

KTÜ Tip FakültesiNörosirurji A.B.D.61187/ Trabzon.

REFERENCES

1. Chapman ME,Sellar R],Whittle IR:A valtlable CT finding incerebral abscess.Clinical Radiology 45:195-197,1992

2. Durack DT,Perfect JR:Bacterial infections,inNeurosurgery.Wilkins RH,Rengechary SS, Mc Graw HillBook CompanyNew York V:3,1985,ppl921-1928

3. Esiri MM,Oppenheimer DR: Pyogenic infections andgranuiomas,in Diagnostic Neuropathology,Chp 9,BlackwellScientific Publications.Oxford.1989,pp 130-138

4. Hori A,Ikeda K:Pyocephalus in a case of encephalocele andArnold Chiari anomaly:InteractlOns between malforinatioiisand inflammatioii.Brain Dev 7:434-437,1985

5. Kaplan K:Braiii Abscess,in Iiifectioiis of the Central NervousSystem. The Medical Cliiiics of North America.WB SaundersCompany.Philadelphia 1985,69(2):pp345-360

6. Raimoiidi AJ:lnfections,in Pediatric Neurosurgery.TheoriticalPrinciples Art of Surgical Techniques.Chpl2 Springer­Verlag.New York,pp331-340

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