Subdural Empyema

The outermost layer of protective tissue around the brain and the spinal cord is called dura mater. Bacterial infection and formation of pus underneath this layer is called Subdural Empyema.

Introduction

 

Three thin tissue layers, namely the dura mater, arachnoid mater and pia mater, protect and nourish the brain and spinal cord. “Dura mater” in Latin means “hard mother”. It is the outermost layer and protects the brain. Below the dura is the arachnoid (spiderweb like) mater. It contains blood vessels and supplies nutrition to the brain. The pia mater attaches itself to the brain and spinal cord, covering it.

Infection from other organs like the ear, nose or throat, may disintegrate from their location, travel through the blood vessels to the arachnoid space and from there seeps into the dura mater, forming a collection of pus. This collection is called subdural empyema. Children are more commonly affected than adults.

Complication due to Subdural Empyema

Subdural empyema is a rare, but serious illness. This is because bacteria entering the brain lead to the following complications:

  • Release toxins that directly damage the brain tissue.
  • Forms pus collection that obstructs blood vessels, leading to loss of blood supply to the brain, and formation of blood clots, hence damaging the brain.
  • The brain tissue starts fighting the bacteria by releasing various inflammatory substances, which ultimately cause the brain to retain fluid, leading to brain swelling and increased pressure within the brain.
  • Superficial abscess over the skull.

Because the disease affects the brain in more than one way, the patients may quickly progress to coma and death, if left untreated. This calls for early diagnosis and treatment.

Symptoms

Symptoms of the Subdural Empyema depend on the part of brain affected by the infection. They include:

  • Inability to think clearly or concentrate
  • Headache
  • Nausea
  • Vomiting
  • Speech problems
  • Weakness
  • Seizures

Investigations

These are the standard investigations, of escalation clarity, carried out to assess the existence and status of Subdural Empyema:

  • Ultrasound Sonography

    An Ultrasound Scan is the choice of investigation, particuarly with children who are suspected to have a subdural empyema.

  • Radio Isotope Scan

    A small dose of radioisotope is injected into the patient’s vein and the movement/acumulation of the radioisotope in the head is pictured using a special camera. If there is empyema, it shows up in the picture as a patch of radioisotope.

  • CT Scan

    A CT Scan can also be used to locate a subdural empyema. Sometimes, in order to enhance the CT image, the patient may be given a contrast die before the imaging is done.

  • MRI Imaging

    MRI imaging is used to image the soft tissue, particularly the nerves, etc.

Treatment for Subdural Empyema

Antibiotics is the first line of treatment for a subdural empyema. However, in more severe cases, or when the empyema refuses to respond to antibiotics sufficiently, a surgery may be preferred in order to physically remove the cavity of pus.

Medical Treatment

Bacteria causing infection is identified using blood tests, and appropriate antibiotic therapy is given to kill the offending organism. Medications either heal the lesion completely or help prevent spread to surrounding areas.

Surgical Treatment

There are two main surgical solutions available to treat a Subrual Empyema:

  • Surgeon may perform a Craniotomy (cutting through the skull bone), reach underneath the dura mater, and then remove the empyema.
  • Alternatively, the surgeon can also suck out (aspirate) the pus using a suitable equipment.

Go here for more information on surgical treatment for <he ailment

Treatment Window

If the diagnosis or treatment of subdural empyema is delayed, it can lead to serious neurological complications like paralysis, coma or death.

Ependymoma: Tumor of the Glial Cells in Brain and Spinal Cord

In our brain and spinal cord, there are housekeeping cells called the glial cells. There are 3 types of glial cells. One of them is called ependyma. Cancer of the ependyma is called ependymoma.

Introduction

A type of cells called glial cells do most of the housekeeping work in the brain and spinal cord. Glial cells are divided into three types: Astrocytes, Ependymal cells and Oligodendrocytes. Toxins, radiation exposure, drugs, nutrition imbalance or genetic load can cause alterations in these cells, resulting in uncontrolled growth in the form of a tumor. Tumors originating in the ependymal cells are called endymomas.

Ependymomas are usually slow growing tumors. They are usually found in the fluid-filled hollow spaces in the brain (called ventricles) and the spinal cord. At times, floating in the fluid, the tumor can also spread. Around this tumor, hardening of the tissue or some bleeding may be seen around this type of tumors.

Ependymomas of the brain is common among children. Whereas endymomas of the spinal cord are usually seen in older adults. Some times, these tumors are non-cancerous.

Complication due to Ependymomas

About 10% ependymomas are non-cancerous. They won’t spread to other parts of the body and cause trouble at multiple sites. Even with a tumor that doesn’t spread, its growth can put pressure on adjoining structures and cause complications. Lastly, some of the non-cancerous growth can eventually turn cancerous.

Symptoms of Ependymomas

Symptoms of an ependymoma depends on its location in the brain or spinal cord. Common symptoms are:

  • Headache
  • Nausea
  • Vomiting
  • Movement issues
  • Gait issues
  • Weakness
  • Loss of sensation

Diagnosing an Ependymoma

These are the standard tools used for diagnosing an ependymoma:

  • CT Imaging

    A CT scan is used in order to locate the tumor and determine its size. Bleeding in the surrounding areas, thickening of tissues and fluid filled sacs can also be identified using a CT image.

  • MRI Imaging

    An MRI image is needed to clearly visualize nerve and soft tissue involvement. MRI can also be used to locate a tumor that was missed out by the CT.

Treatment of Ependymomas

Following is the preferred order of treatment for ependymoma:

Surgical Treatment

Excision of tumor: For an ependymoma, the treatment of choice is a surgery. The surgeon removes the tumor, along with a portion of surrounding normal tissue, is carefully removed without damaging the surrounding nerves.

Tumor Debulking: Large tumors, particularly the ones that invade the surrounding tissue, are partially removed. This relieves the compression caused by the tumor on neighboring structures.

Radiation Treatment

In case of large tumors and the tumors that have spread into surrounding tissue, radiation therapy is started after debulking the tumor. This helps to destroy the remaining tumor cells as much as possible.

Chemotherapy

Chemotherapy stands for special class of drugs that are specially designed to destroy cancer cells. Chemotherapy is not very effective for most of the ependyomas.

Medical Treatment

Pharmachology is not very helpful in treatment endymomas. However, for a patient who has ependymomas, the doctor may prescribe drugs to reduce the fluid accumulation and to relieve the pain.

 

Treatment Window

Like with any cancer, detecting it early and treating it aggressively is the key to extending the longevity of patients with this disease.

Extradural Hematoma

The brain is a delicate organ. It is protected by a thick outer covering, known as dura mater. A bleed in between the dura mater and the skull is known as an External Hematoma.

Introduction

Some head injuries result in fracture of the skull bone. This causes separation of the dura mater from the skull it is attached to. The stress results in disruptions of the blood vessels that come in between the dura mater and the skull bone. Thus resulting in an extradural hematoma or a bleed.

Complication of an Extradural Hematoma

 

Symptoms of Extradural Hematoma

Here are some of the symptoms of an external hematoma:

  • Conscious throughout
  • Unconscious throughout
  • Initially conscious but unconscious few hours later
  • Initially unconscious but later in a dreamy state
  • Weakness in one half of the body
  • Headache
  • Nausea
  • Vomiting

Diagnosing Extradural Hematoma

Here are the standard tools used for diagnosing an external hematoma:

  • X-Ray

    An X-Ray image of the skull shows evidence of a fracture

  • CT Scan

    40% of the time a fracture can be missed on X Ray. As much as possible, an urgent CT is important. In a CT Scan, a fracture is seen much clearer and the bleed is seen as a white patch in the shape of a lens.

  • MRI Imaging

    MRI images can be taken but they are in no way superior to CT in identification of an extradural bleed.

  • Infrared Spectroscopy

    This is a newer diagnostic modality that uses infrared radiation to identify the damaged tissue in the brain within a short span of time.

Treatment of Extradural Hematoma

Minor cases of hematoma are always managed medically. Severe cases need surgical intervention.

Medical Treatment

Small Extradural Hematomas with minimal symptoms can be managed medically with fluid management and nerve protective medications.

Surgical Treatment: Burr Hole

In this surgical treatment of choice for extradural hematoma, a small hole is drilled through the skull and a tube is inserted. Blood is drained out through this tube after which the hole is sutured back.

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Treatment Window

If the size of an extradural hematoma increases rapidly, or if the condition of the patient worsens clinically, then an immediate surgery is recommended to manage the condition.

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