Case report: evaluation of intracranial compliance in a child with subdural empyema

Case presentation: A 12-year-old female patient presents a 5-day history of fever and severe frontal and occipital headache associated with vomiting, nocturnal awakenings, vertigo, and phonophobia. She evolved with dysarthria, decreased level of consciousness, left hemiparesis followed by systemic arterial hypertension, bradycardia and 8 episodes of focal seizures. On neurological examination, she was alert, lucid, oriented, and without focal points. An ophthalmoscopic examination revealed the, she had papilledema in both eyes. Cranial resonance (MR) showed suggestive signs of acute inflammatory maxillary and left frontal sinus disease related to subdural empyema with suggestive signs of intracranial hypertension (IH). The assessment of intracranial compliance (IC) with a non-invasive device, Brain4care, was performed in the lying and sitting position, with a mean p2/p1 ratio of 1.43 and 1.39, respectively. After the diagnosis, the patient was submitted to empyema drainage and antibiotic therapy. On the 13th postoperative day, with an improvement of the clinical condition, a new IC monitoring was made and revealed a p2/p1 lying down ratio of 1.01 and a sitting position of 1.07.

Discussion: IH is a secondary condition due to the loss of brain compensatory mechanisms related to different etiologies. In the clinical case, the presence of empyema caused classic signs of IH found on MR: the empty sella turcica sign, optic nerve tortuosity, changes in optic nerve intensity, and changes in the visualization of the adeno/neurohypophysis. Besides that, neuroimaging findings are not always as characteristic. Ophthalmological examination revealed papilledema, but absence of papilledema does not rule out IH. Most of the exams used for the diagnosis of IH reveal indirect data and because of that invasive exams are often used to prove the brain alterations, one of the reasons that justify the creation of a non-invasive device to monitor IC. Brain4care monitoring was consistent with the exams and patient's evaluation, showing acute changes in IC. And, sequentially demonstrated compliance improvement that was concomitant with clinical and imaging tests.

Final comments: Due to the life-threatening risk, IH and its causes could be accurately and quickly investigated and diagnosed. Thus, brain4care seems to be an easy-to-handle, non-invasive device that can measure IC, which can assist the treatment and clinical follow-up of the patients.

 

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Artikel online veröffentlicht:
18. September 2023