Intracranial Empyemas in the COVID-19 Era: A New Phenomenon? A Paediatric Case Series and Review of the Literature

Abstract

Introduction: We present the largest series of paediatric intracranial empyemas occurring after COVID-19 infection to date, and discuss the potential implications of the pandemic on this neurosurgical pathology.

Methods: Patients admitted to our centre between January 2016 and December 2021 with a confirmed radiological diagnosis of intracranial empyema were retrospectively reviewed, excluding non-otorhinological source cases. Patients were grouped according to onset before or after onset of the COVID-19 pandemic and COVID-19 status. A literature review of all post-COVID-19 intracranial empyemas was performed. SPSS v27 was used for statistical analysis.

Results: Sixteen patients were diagnosed with intracranial empyema: n = 5 prior to 2020 and n = 11 after, resulting in an average annual incidence of 0.3% prior to onset of the pandemic and 1.2% thereafter. Of those diagnosed since the pandemic, 4 (25%) were confirmed to have COVID-19 on recent PCR test. Time from COVID-19 infection until empyema diagnosis ranged from 15 days to 8 weeks. Mean age for post-COVID-19 cases was 8.5 years (range: 7-10 years) compared to 11 years in non-COVID cases (range: 3-14 years). Streptococcus intermedius was grown in all cases of post-COVID-19 empyema, and 3 of 4 (75%) post-COVID-19 cases developed cerebral sinus thromboses, compared to 3 of 12 (25%) non-COVID-19 cases. All cases were discharged home with no residual deficit.

Conclusion: Our post-COVID-19 intracranial empyema series demonstrates a greater proportion of cerebral sinus thromboses than non-COVID-19 cases, potentially reflecting the thrombogenic effects of COVID-19. Incidence of intracranial empyema at our centre has increased since the start of the pandemic, causes of which require further investigation and multicentre collaboration.

Keywords: COVID-19; Empyema; Intracranial empyemas; Paediatric neurosurgery; Subdural empyemas.

Fig. 1.

Patient 1: axial preoperative T2 (a) and sagittal FLAIR MRI sequences (b), demonstrating midline frontal extradural empyema. Patient 2: axial preoperative T2 MRI sequence, demonstrating right frontal subdural empyema (c) and underlying restricted diffusion on DWI (d). Patient 3: axial preoperative T2 sequence MRI, demonstrating frontal extradural collection, frontal sinusitis, and midline subgaleal extension (e); confirmed on coronal FLAIR (f). Patient 4: axial preoperative T2 sequence MRI highlighting right-sided frontal subdural empyema (g), with evidence of right-sided orbital abscess on preoperative coronal FLAIR (h).