Cranio-Spinal Subdural Empyema due to S. Intermedius: a Case Report Angelo Pompucci, MD, Pasquale De Bonis, MD, Giovanni Sabatino, MD, Giovanni Federico, MD, Massimo Moschini, MD, Carmelo Anile, MD, Annunziato Mangiola, MD From the Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy (AP, PDB, GS, CA, AM); Institute of Infectious Diseases, Catholic University School of Medicine, Rome, Italy (GF); Institute of Radiology, Catholic University School of Medicine, Rome, Italy (MM). Keywords: Abscess, brain subdural empyema, cranial subdural empyema, spinal subdural empyema, Streptococcus intermedius, subdural collection. Acceptance: Received September 30, 2006, and in revised form September 30, 2006. Accepted for publication October 19, 2006. Correspondence: Address correspon- dence to Pasquale De Bonis, MD, In- stitute of Neurosurgery, Catholic Uni- versity School of Medicine, l.go A. Gemelli, 8 00168 Rome Italy. E-mail: debonisvox@gmail.com. J Neuroimaging 2007;17:358-360. DOI: 10.1111/j.1552-6569.2006.00084.x ABSTRACT BACKGROUND AND PURPOSE Subdural empyema represents a loculated infection between the dura and the arachnoid. It has been described either intracranially or in the spinal canal, the latter localization being quite rare. While treatment guidelines for a single (either brain or spinal) localization of a subdural empyema are more or less established, its management when a massive involvement of CNS is evident represents a challenge. METHODS The authors describe a unique case of a 65-year-old woman having a massive involvement of the entire CNS with multiple localizations, both intracranial and spinal. Early diagnosis was obtained through brain CT scans followed by cranio-spinal contrast enhanced MRI scans. Patient was treated with external ventricular drainage and suboccipital craniectomy, while on antibiotic therapy. RESULTS Patient’s neurological condition gradually improved. By the end of the eighth hospital week, she was discharged without any neurological deficit. CONCLUSIONS Spinal subdural empyema and brain subdural empyema are not always, as in our case, two different entities. Prompt diagnosis and treatment constitute the major variables affecting outcome. Introduction The prognosis for patients with infectious processes that affect the CNS has substantially improved over the past 30 years, re- sulting from technological advances in diagnostic and treatment modalities. The common use of CT and MRI has revolutionized the diagnosis and the management of these pathologies. 1,2 Subdural empyema (SE) represents a loculated infection be- tween the outermost layer of meninges. The empyema may develop intracranially or in the spinal canal. Spinal subdural empyema is by far the less common localization, with rela- tively few cases reported in the literature and no large case series. Early diagnosis and treatment are critical to prevent pro- gression of neurologic deficit or death. We present an unusual case of an immunocompetent patient with both brain and spinal subdural empyema due to Streptococ- cus intermedius infection, who totally recovered after a combined surgical–medical treatment. Case Report A 65-year-old woman with a 3-week history of lumbar pain and sciatica presented to the emergency room because of the rapid onset of lethargy and confusion. Neurological examination re- vealed a withdrawal flexion to pain and neck stiffness. Lab- oratory findings showed a peripheral white blood cells count of 32,000 /mm 3 . Cultures of urine and blood were negative. Chest radiographs were normal. Brain CT scan revealed supra- tentorial hydrocephalus. A right frontal ventriculostomy was performed and an external ventricular drain was inserted. Cere- brospinal fluid (CSF) analysis and Gram staining were normal. The patient’s neurological condition further deteriorated in a few days, and her consciousness level deteriorated markedly. Brain and spinal MRI revealed multiple subdural huge collec- tions along the entire spinal cord as well as in the right frontal lobe and in both cerebellar hemispheres (Figs. 1A–C). Needle aspiration from one of the lumbar localizations revealed puru- lent material. Gram positive cocci were found and the patient was initially treated with Vancomycin and Rifampin. S. inter- medius was then isolated in the pus culture. It proved to be sensitive to Ampicillin; the antibiotic regimen was changed ac- cordingly. Clinical conditions remained stable for some days but then worsened, with evidence of a decerebrate postur- ing. Urgent contrast-enhanced CT scans showed an increased volume of the posterior fossa empyemas determining brain- stem compression (Fig. 1A). A suboccipital craniectomy was performed, and the empyema was drained (Fig. 1E). The pa- tient’s neurologic conditions gradually improved. By the end of the eighth hospital week, antibiotics were discontinued. Se- rial CT-MRI scans showed the resolution of hydrocephalus and the almost complete disappearance of the SE (Fig. 1F). The patient is well and without any neurological deficit after 1 year. 358 Copyright ◦ C 2007 by the American Society of Neuroimaging