A case report of secondary complex hydrocephalus following surgical treatment of bilateral intraventricular empyema

Background Bilateral intraventricular empyema is a rare and severe intracranial infection that may lead to ventricular adhesions and secondary complex hydrocephalus, posing substantial therapeutic challenges. Case presentation A 52-year-old man with recent pneumonia and a 5-year history of type 2 diabetes mellitus presented with altered consciousness, fever, cough, headache, and fatigue. Lumbar puncture revealed an opening pressure of 240 mmH₂O . Cerebrospinal fluid analysis showed a white blood cell count of 1,840/mm 3 (61% neutrophils) and a protein concentration of 3.68 g/L. Imaging findings were consistent with bilateral intraventricular empyema, and cultures identified Streptococcus intermedius . Left occipital horn puncture with external ventricular drainage and neuroendoscopic evacuation of the right intraventricular empyema were performed, followed by targeted antimicrobial therapy. Results The intraventricular purulent material progressively decreased, and the ventricular drainage catheters were removed on postoperative days 8 and 15. On postoperative day 20, secondary complex hydrocephalus developed, requiring Ommaya reservoir placement. Fourteen days later, the patient developed recurrent coma with bilateral fixed, dilated pupils (5 mm), accompanied by enlargement of the isolated right temporal horn and fourth ventricle. Combined lumboperitoneal and ventriculoperitoneal shunting was subsequently performed. The patient's neurological condition progressively improved, and follow-up CT demonstrated improvement in ventricular dilatation. Conclusion This case highlights the challenges of managing intraventricular empyema complicated by secondary complex hydrocephalus. Neuroendoscopic evacuation may be considered in selected patients, while subsequent CSF diversion should be individualized according to changes in ventricular morphology.