无可见骨折的颅内积气先于硬膜下积脓：一例急诊科延迟诊断

文献信息

中文摘要

背景： 硬膜下积脓是一种罕见、快速进展的颅内感染，可继发于鼻窦炎、颅面外伤或邻近面部感染。早期表现可能轻微，在急诊科延迟识别可导致神经系统恶化。
病例报告： 一名16岁男性在额部轻微钝性外伤后约2小时就诊，当时其前额撞到汽车引擎盖。由于他呕吐两次，进行了头颅计算机断层扫描（CT），显示无可见骨折、无急性颅内病变、无鼻旁窦混浊。他被离院。第1天，他再次就诊，表现为额部头皮及双侧眶周肿胀和红斑。复查CT显示无可见骨折的颅内积气，以及新出现的轻度额窦、筛窦和上颌窦混浊。第2天，他因眶隔前蜂窝织炎入院，并开始静脉抗生素治疗。第6天，他出现呕吐，随后发生全面性强直-阵挛发作；其格拉斯哥昏迷量表评分持续为5分，需要气管插管。磁共振成像显示右侧额部轴外积液，怀疑为积脓，伴有硬脑膜和软脑膜强化及弥散受限。第8天行钻孔引流，引流出脓液，确诊为硬膜下积脓。他完成了抗微生物治疗，在1个月随访时神经系统完好，无癫痫复发。为什么急诊医生应了解这一点？：再次就诊时无可见骨折的颅内积气应被视为警示信号。它应促使审查颅底和鼻窦影像，早期请耳鼻喉科、感染科和神经外科会诊，考虑收住院，并降低重复神经影像学检查的门槛。

英文摘要

BACKGROUND: Subdural empyema is a rare, rapidly progressive intracranial infection that may follow sinusitis, craniofacial trauma, or contiguous facial infection. Early findings may be subtle, and delayed recognition in the emergency department can result in neurologic deterioration.
CASE REPORT: A 16-year-old male presented approximately 2 hours after minor blunt frontal trauma after striking his forehead against a car hood. Because he vomited twice, cranial computed tomography (CT) was performed and showed no visible fracture, acute intracranial pathology, or paranasal sinus opacification. He was discharged. On Day 1, he re-presented with frontal scalp and bilateral periorbital swelling and erythema. Repeat CT demonstrated pneumocephalus without visible fracture and new mild frontal, ethmoid, and maxillary sinus opacification. On Day 2, he was admitted with preseptal cellulitis and started on intravenous antibiotics. On Day 6, he developed vomiting followed by a generalized tonic-clonic seizure; his Glasgow Coma Scale score remained 5, requiring endotracheal intubation. Magnetic resonance imaging demonstrated a right frontal extra-axial collection suspicious for empyema with dural and leptomeningeal enhancement and restricted diffusion. Burr-hole drainage on Day 8 revealed pus, confirming subdural empyema. He completed antimicrobial therapy and remained neurologically intact without seizure recurrence at 1-month follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pneumocephalus without visible fracture on return presentation should be treated as a warning sign. It should prompt skull-base and sinus imaging review, early otorhinolaryngology, infectious diseases, and neurosurgical consultation, consideration of admission, and a low threshold for repeat neuroimaging.