Subdural empyema pathophysiology: Difference between revisions
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The infection's main origin depends on the age of the individual. In younger children, the [[subdural empyema|empyema]] most commonly results from a complication of purulent [[meningitis]] while in older children and adults, it most commonly results from complication of [[sinusitis]] (more common), [[otitis media]] or [[mastoiditis]]. In case of [[sinusitis]] the [[frontal sinus]] is the most common culprit, followed by the [[ethmoid sinus|ethmoidal]], [[sphenoidal sinuses|sphenoidal]] and [[maxillary sinus|maxillary]] sinuses. The infection may then spread in two ways: <ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref><ref name="pmid12521560">{{cite journal| author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref><ref>{{Cite book | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages = }}</ref><ref name="pmid24171874">{{cite journal| author=Hendaus MA| title=Subdural empyema in children. | journal=Glob J Health Sci | year= 2013 | volume= 5 | issue= 6 | pages= 54-9 | pmid=24171874 | doi=10.5539/gjhs.v5n6p54 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24171874 }} </ref> | The infection's main origin depends on the age of the individual. In younger children, the [[subdural empyema|empyema]] most commonly results from a complication of purulent [[meningitis]] while in older children and adults, it most commonly results from complication of [[sinusitis]] (more common), [[otitis media]] or [[mastoiditis]]. In case of [[sinusitis]] the [[frontal sinus]] is the most common culprit, followed by the [[ethmoid sinus|ethmoidal]], [[sphenoidal sinuses|sphenoidal]] and [[maxillary sinus|maxillary]] sinuses. The infection may then spread in two ways: <ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref><ref name="pmid12521560">{{cite journal| author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref><ref>{{Cite book | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages = }}</ref><ref name="pmid24171874">{{cite journal| author=Hendaus MA| title=Subdural empyema in children. | journal=Glob J Health Sci | year= 2013 | volume= 5 | issue= 6 | pages= 54-9 | pmid=24171874 | doi=10.5539/gjhs.v5n6p54 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24171874 }} </ref> | ||
#hematogenous route via retrograde [[infection]], from [[thrombophlebitis]] of mucosal veins, which drain the [[sinuses]]. | #hematogenous route via retrograde [[infection]], from [[thrombophlebitis]] of mucosal veins, which drain the [[sinuses]]. | ||
#contiguous [[infection]] via [[bone]] erosion and [[Haversian canals]] in [[bone]], as a complication of [[osteomyelitis]]. | #contiguous [[infection]] via [[bone]] erosion and [[Haversian canals]] in [[bone]], as a complication of [[osteomyelitis]]. In case of [[infection]] of the [[mastoid]] or [[middle ear]] it spreads by eroding the ''tegmen tympani'', while if its an [[infection]] of the [[frontal air sinus]], the erosion occurs in its posterior wall. | ||
Other possible sources of infection may include: | Other possible sources of infection may include: | ||
*neurosurgical procedures | *neurosurgical procedures | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]
Overview
Subdural empyema, also referred to as subdural abscess, pachymeningitis interna and circumscript meningitis, is a life-threatening infection.[1] It consists of a localised collection of purulent material, usually unilateral, between the dura mater and the arachnoid mater and accounts for about 15-22% of the reported focal intracranial infections The empyema may develop intracranially (about 95%) or in the spinal canal (about 5%), and in both cases, it constitutes a medical and neurosurgical emergency.[2] Bacterial or occasionally fungal infection of the skull bones or air sinuses can spread to the subdural space producing a subdural empyema. The underlying arachnoid and subarachnoid spaces are usually unaffected, but a large subdural empyema may produce a mass effect. Further, a thrombophlebitis may develop in the bridging veins that cross the subdural space resulting in venous occlusion and infarction of the brain. In children, subdural empyema most often happens as a complication of meningitis while in adults it usually occurs as a complication of sinusitis, otitis media, mastoiditis trauma or as a complication of neurological procedures.[1]
If diagnosis and treatment are prompt, complete recovery is usual.
Pathophysiology
A localised collection of pus between the dura mater and the arachnoid mater. It's a rare infection that accounts for about 15-25% of focal CNS infections and may occur in the intracranial space or in the spinal canal, being that the intracranial type is fairly more common that the spinal subdural empyema. Since the etiologic agents, the course of the disease and the treatment of this two types of empyema are different, they should be approached in separate ways.[3][1][2]
Intracranial Subdural Empyema
Usually unilateral, it may involve the base of the brain, its convexity, the inter-hemispheric fissure along the falx cerebri or the posterior fossa. The anatomy of the meningeal membranes dictate to the course and characteristics of the disease. The dura mater and the arachnoid mater which define the initial limits of the empyema, are joined only at the base of the brain, along the falx cerebri and at the tentorium cerebelli, being elsewhere held against each other, by the pressure of the brain and cerebrospinal fluid. The virtual space between these two meningeal membranes makes the perfect way for the infection to oread along the cerebral hemisphere, inter-hemispheric fissure and posterior cranial fossa. The infection's main origin depends on the age of the individual. In younger children, the empyema most commonly results from a complication of purulent meningitis while in older children and adults, it most commonly results from complication of sinusitis (more common), otitis media or mastoiditis. In case of sinusitis the frontal sinus is the most common culprit, followed by the ethmoidal, sphenoidal and maxillary sinuses. The infection may then spread in two ways: [1][2][4][5]
- hematogenous route via retrograde infection, from thrombophlebitis of mucosal veins, which drain the sinuses.
- contiguous infection via bone erosion and Haversian canals in bone, as a complication of osteomyelitis. In case of infection of the mastoid or middle ear it spreads by eroding the tegmen tympani, while if its an infection of the frontal air sinus, the erosion occurs in its posterior wall.
Other possible sources of infection may include:
- neurosurgical procedures
- head trauma (In this setting subdural empyema may not develop immediately, taking up to months or years to develop)
- in rare occasions it may develop after bacteremic seeding of an existing subdural hematoma In this situation, a relatively indolent process may evolve into rapidly progressive one.[2]
However, there may be other sources for the infection, namely: distant sites, such as the lungs[1]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Agrawal, Amit; Timothy, Jake; Pandit, Lekha; Shetty, Lathika; Shetty, J.P. (2007). "A Review of Subdural Empyema and Its Management". Infectious Diseases in Clinical Practice. 15 (3): 149–153. doi:10.1097/01.idc.0000269905.67284.c7. ISSN 1056-9103.
- ↑ 2.0 2.1 2.2 2.3 Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Hendaus MA (2013). "Subdural empyema in children". Glob J Health Sci. 5 (6): 54–9. doi:10.5539/gjhs.v5n6p54. PMID 24171874.