Pediatric emergency medicine trisk 1007

the patient can be afebrile. The treatment of brain abscess is the same as
that of any other abscess: incision and drainage. This procedure is
diagnostic as well. Needle aspiration combined with the administration of
broad-spectrum antibiotics will clear approximately 80% to 85% of
abscesses. The remainder will require craniotomy for complete cure. If
infection extends to the craniotomy flap; then reoperation, bone flap
removal, and drainage of the abscess should be carried out for definitive
therapy.
Subdural Empyema. Subdural empyema is rare after craniotomy but may
follow burr hole drainage of a chronic subdural hematoma. This entity is
also marked by neurologic deterioration, with the development of focal
signs of hemiparesis, seizures, or both. These neurologic findings are
related to mass effect from edema that unlike subdural hematomas, is out of
proportion to the volume of fluid in the subdural space. It can also be
further complicated by venous thrombosis and infarction. Diagnosis by CT
scan may be difficult, and a high index of suspicion is required. However, a
parafalcine subdural collection, which can be seen on CT scan, is
pathognomonic for subdural abscess. Treatment with drainage and broadspectrum antibiotics is the gold standard. Drainage may be accomplished by
reoperation or burr holes, and many surgeons recommend placing subdural
catheters for irrigation of this space with antibiotic solutions such as
concentrated bacitracin.
Infarctions
Arterial Infarcts. Arterial infarct is a rare complication after craniotomy but
may occur if there has been substantial intraoperative manipulation of
cerebral vessels. Clinically, the patient will usually exhibit focal neurologic
deficits. If a large area or bilateral areas of the brain are involved, the
patient may experience a global decrease in level of consciousness and
more extensive neurologic deficits.
Cerebellar infarction, specifically, incurs a higher risk of obstructive
hydrocephalus due to occlusion of the fourth ventricle. Symptoms and signs
related to cerebellar dysfunction, such as dizziness, vertigo, nausea,

vomiting, truncal ataxia, nystagmus, and dysarthria, appear first. Next, the


patient may suffer from the progression of hydrocephalus with symptoms of
headaches, agitation, and obtundation. The development of cranial nerve
dysfunction necessitates neurosurgical intervention for decompression of
the posterior fossa with potential removal of hemorrhage.
Venous Infarcts. Venous infarcts are generally seen after craniotomy,
especially if the venous sinuses are involved in the surgical field. Repair of
dural sinus lacerations or prolonged compression of a sinus by an extrinsic
force places the patient at risk of venous sinus thrombosis and infarction.
Presenting symptoms include headache, nausea, vomiting, and seizures,
often resembling those caused by pseudotumor cerebri. Cerebral venous
thrombosis and/or dural sinus thrombosis can lead to venous infarction.
This infarction may present as hemorrhage and often involves the
subcortical white matter. CT scan reveals hemorrhage that may traverse the
typical arteriovascular boundaries. The component of hemorrhage or
significant mass effect resulting from cerebral edema becomes a
neurosurgical emergency. Evacuation of the clot may be necessary, as may
decompressive craniectomy.
Suggested Readings and Key References
Blumstein H, Schardt S. Utility of radiography in suspected ventricular
shunt malfunction. J Emerg Med 2009;36(1):50–54.
Brown RD Jr, Weibers DO, Forbes GS. Unruptured intracranial aneurysms
and arteriovenous malformations: frequency of intracranial hemorrhage
and relationship of lesions. J Neurosurg 1990;73(6):859–863.
Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of
severe traumatic brain injury, fourth edition. Neurosurgery 2017;80(1):6–
15.
Chandrasenan J, Klezl Z, Bommireddy R, et al. Spondylodiscitis in

children. J Bone Joint Surg Br 2011;93(8):1122–1125.
Chi JH, Fullerton HJ, Gupta N. Time trends and demographics of deaths
from congenital hydrocephalus in the United States: national center for
health Statistics data, 1979 to 1998. J Neurosurg 2005;103(2 Suppl):113–
118.


Cruz J, Minoja G, Okuchi K, et al. Successful use of the new high-dose
mannitol treatment in patients with Glasgow coma scale scores of 3 and
bilateral abnormal papillary widening: a randomized trial. J Neurosurg
2004;100(3):376–383.
Dayer R, Alzahrani MM, Saran N, et al. Spinal infections in children: a
multicentre retrospective study. Bone Joint J 100-B(4):542–548.
Diringer MN, Videen TO, Yundt K, et al. Regional cerebrovascular and
metabolic effects of hyperventilation after severe traumatic brain injury. J
Neurosurg 2002;96(1):103–108.
Domenicucci M, Mancarella C, Santoro Get al. Spinal epidural hematomas:
personal experience and literature review of more than 1000 cases. J
Neurosurg Spine 2017;27(2):198–208.
Garton HJL, Kestle JR, Drake JM. Predicting shunt failure on the basis of
clinical symptoms and signs in children. J Neurosurg 2001;94(2):202–
210.
Gleeson H, Wiltshire E, Briody J, et al. Childhood chronic recurrent
multifocal osteomyelitis: pamidronate therapy decreases pain and
improves vertebral shape. J Rheumatol 2008;35(4):707–712.
Gore PA, Maan H, Chang S, et al. Normobaric oxygen therapy strategies in
the treatment of postcraniotomy pneumocephalus. J Neurosurg
2008;108(5):926–29.
Goyal P, Mangla R, Gupta Set al. Pediatric congenital cerebrovascular
anomalies. J Neuroimaging 2019;29(2):165–181.

Hadjipavlou AG, Korovessis PG, Kakavelakis KN. Spine infection: medical
versus surgical treatment options. In: Vaccaro AR, Eck JC, eds.
Controversies in Spine Surgery . New York: Thieme; 2010:250–260.
Hasbun R, Wootton SH, Rosenthal N, et al. Epidemiology of meningitis and
encephalitis in infants and children in the United States, 2011–2014.
Pediatr Infect Dis J 2019;38(1):37–41.
Hofmann SR, Kapplusch F, Girschick HJ, et al. Chronic recurrent
multifocal osteomyelitis (CRMO): presentation, pathogenesis, and
treatment. Current Osteoporosis Reports 2017;15(6):542–554.
Hoit DA, Schirmer CM, Weller SJ, et al. Angiographic detection of carotid
and vertebral arterial injury in the high-energy blunt trauma patient. J
Spinal Disord Tech 2008;21(4):259–266.


Hospach T, Langendoerfer M, von Kalle T, et al. Spinal involvement in
chronic recurrent multifocal osteomyelitis (CRMO) in childhood and
effect of pamidronate. Eur J Pediatr 2010;169(9):1105–1111.
Iskandar BJ, McLaughlin C, Mapstone TB, et al. Pitfalls in the diagnosis of
ventricular shunt dysfunction: radiology reports and ventricular size.
Pediatrics 1998;101(6):1031–1036.
Jansson A, Renner ED, Ramser J, et al. Classification of non-bacterial
osteitis: retrospective study of clinical, immunological and genetic
aspects in 89 patients. Rheumatology (Oxford) 2007;46(1):154–160.
Kahle KT, Kulkarni AV, Limbrick DD Jr, et al. Hydrocephalus in children.
Lancet 2016;387(10020):788–799.
Kim TY, Stewart G, Voth M, et al. Signs and symptoms of cerebrospinal
fluid shunt malfunction in the pediatric emergency department. Pediatr
Emerg Care 2006;22(1):28–34.
Koroknay-Pál P, Lehto H, Niemelä M, et al. Long-term outcome of 114
children with cerebral aneurysms: clinical article. J Neurosurg Pediatr

2012;9(6):636–645.
Kumar R, Singhi S, Singhi P, et al. Randomized controlled trial comparing
cerebral perfusion pressure-targeted therapy versus intracranial pressuretargeted therapy for raised intracranial pressure due to acute CNS
infections in children. Crit Care Med 2014;42(8):1775–1787.
Labauge P, Brunereau L, Laberge S, et al. Prospective follow-up of 33
asymptomatic patients with familial cerebral cavernous malformations.
Neurology 2001;57(10):1825–1828.
Lasjaunias P, Wuppalapati S, Alvarez H, et al. Intracranial aneurysms in
children aged under 15 years: review of 59 consecutive children with 75
aneurysms. Childs Nerv Syst 2005;21(6):437–450.
Lee JY, Ebel H, Ernestus RI, et al. Various surgical treatments of chronic
subdural hematoma and outcome in 172 patients: is membranectomy
necessary? Surg Neurol 2004;61(6):527–528.
Lehnert BE, Rahbar H, Relyea-Chew A, et al. Detection of ventricular
shunt malfunction in the ED: relative utility of radiography, CT, and
nuclear imaging. Emerg Radiol 2011;18(4):299–305.
Mater A, Shroff M, Al-Farsi S, et al. Test characterstics of neuroimaging in
the emergency department evaluation of children for cerebrospinal fluid
shunt malfunction. CJEM 2008;10(2):131–135.