PMC8247720_01
(a) Head computed tomography (CT) shows right chronic subdural hematoma (CSDH) (black arrows). (b and c) Magnetic resonance imaging demonstrates uniform hyperintensity on diffusion-weighted imaging and hyperintensity with intrahematomal membrane structures on fluid-attenuated inversion recovery (white arrows). (d) One-month follow-up CT after the abatement of fever indicates a slight increase (black arrowheads) in the CSDH size.
SNI-12-288-g001.jpg
PMC8247720_01_SNI-12-288-g001.jpg
F1
The brain CT image demonstrated no change in the right CSDH [Figure 1a], and contrast-enhanced CT of the chest and abdomen revealed no abnormal findings. Head magnetic resonance imaging (MRI) showed that the subdural hematoma was uniformly hypointense on diffusion-weighted imaging (DWI) and hyperintense with multiple intrahematomal loculations on fluid-attenuated inversion recovery (FLAIR) [Figure 1b and c]. After 1 month, the serum CRP level remained between 5 and 16 mg/dL without fever, and the superior component of the CSDH gradually increased in volume [Figure 1d].
(a) Head computed tomography reveals a further increase in volume and a biconvex shape of the chronic subdural hematoma (black arrows). (b and c) Magnetic resonance imaging demonstrates an expanding subdural hematoma with no surrounding edema on fluid-attenuated inversion recovery and heterogeneous hyperintense signals corresponding to the expansive component of the subdural hematoma on diffusion-weighted imaging. (d) Postgadolinium T1-weighted image shows enhancement of the thickened hematoma capsule (white arrowheads).
SNI-12-288-g002.jpg
PMC8247720_01_SNI-12-288-g002.jpg
F2
After 5 months, the CSDH transformed into a biconvex shape on CT, and FLAIR and DWI demonstrated heterogeneous hyperintense signals corresponding to hematoma enlargement [Figure 2ac]. A gadolinium-enhanced T1-weighted image showed a thickened enhancement of the hematoma capsule [Figure 2d].
Intraoperative images. (a and b) After opening the thick outer membrane of the capsule, a large amount of yellowish purulent pus was observed followed by an organized hematoma (white arrowheads).
SNI-12-288-g003.jpg
PMC8247720_01_SNI-12-288-g003.jpg
F3
When the outer membrane was incised, pus was collected [Figure 3a], and a specimen was taken for the microbiological laboratories. The inferior component of the subdural hematoma consisted of an organized hematoma [Figure 3b].
Head diffusion-weighted magnetic resonance imaging confirms a gradual decrease in the hyperintense signals (indicating the abscess) and, finally, the complete disappearance of the infected subdural hematoma. (a) Two days after surgery, (b) 1 month later, (c) 3 months later, and (d) 6 months later.
SNI-12-288-g004.jpg
PMC8247720_01_SNI-12-288-g004.jpg
F4
One day postoperatively, MRI revealed near-complete disappearance of the DWI hyperintense lesion within the CSDH [Figure 4a] and no extracapsular perforation of the infection. Drainage for 10 days and antibiotic intravenous infusion therapy for 4 weeks resulted in normal serum CRP levels [Figure 4b and 5]. The patient was discharged without neurological sequelae and continued to receive oral minocycline (200 mg every 12 h), leading to complete resolution of the subdural empyema 6 months postsurgery [Figure 4c-d].
The clinical course of the patient. CEZ: Cefazolin, DIV: Drip infusion in vein, CTRX: ceftriaxone, MINO: Minocycline, CT: Computed tomography, PCR: Polymerase chain reaction, CRP: C-reactive protein.
SNI-12-288-g005.jpg
PMC8247720_01_SNI-12-288-g005.jpg
F5
Drainage for 10 days and antibiotic intravenous infusion therapy for 4 weeks resulted in normal serum CRP levels [Figure 4b and 5].