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Images in Neurology |

The Diagnostic Pitfall of Infratentorial Subdural Empyema

Kirsten S. Adriani, MD; Diederik van de Beek, MD, PhD; Dirk Troost, MD, PhD; Matthijs C. Brouwer, MD, PhD
Arch Neurol. 2012;69(8):1076-1077. doi:10.1001/archneurol.2012.151.
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A 58-year-old woman presented at the emergency department at midnight with a minor head trauma. On presentation, she had a normal temperature and neurological examination showed disorientation (Glasgow Coma Scale score E4M6V4) but was otherwise normal. Computed tomography of the head was initially misinterpreted and reported to be normal (Figure 1). The patient was admitted for observation. Five hours later, she suddenly became comatose (Glasgow Coma Scale score E1M1V1). Repeated cranial computed tomography showed a hypodense lesion causing compression of the brainstem and hyperdense sediments in the lateral ventricles. She underwent a posterior fossa craniotomy, and on opening of the dura, pus appeared. Infratentorial pus collections were drained and the necrotic right cerebellar hemisphere was resected. Postoperatively, her consciousness improved, and she was able to follow commands (Glasgow Coma Scale score E4M6Vtube).

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Figure 1. Axial computed tomography on hospital admission of midcerebellar region showing no clear abnormalities (A). Pronounced temporal horns of the lateral ventricles and asymmetric tissue near the tentorium (arrow) (B).

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Figure 2. Coronal computed tomography reconstruction showing a hypodense infratentorial collection (arrow) and hypodense lesion in the right cerebellar hemisphere (asterisk) (A). Sagittal computed tomography reconstruction showing subdural hypodense collection consistent with subdural empyema (arrowheads) (B). Postmortem macroscopic image of the brain, with remnants of the empyema covering the right cerebellar hemisphere (C). Macroscopic image of the skull base with pus on the meninges of the posterior fossa (asterisk) (D).

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