Subdural empyema medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; 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, first reported in literature approximately 100 years ago.[1] It consists of a localised collection of purulent material, usually unilateral, between the dura mater and thearachnoid mater. It 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] The intracranial type tends to behave like an expanding mass, causing clinical symptoms, such as fever, lethargy, headache and neurological deficits. These, result from the extrinsic compression of the brain, caused not only from the inflammatory mass, but also from the inflammation of the brain and meninges. Because thesubdural space has no septations, except in areas where arachnoid granulations attach to the dura mater, the subdural empyema tends to spread quickly, until it finds those boundaries. 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] The most common pathogens in the intracranial type are anaerobic and microaerophilic streptococci, however others like Escherichia coli and Bacteroides may be present simultaneously. Spinal subdural empyemas, on the other hand, are almost always caused bystreptococci or by staphylococcus aureus.[2] The classic clinical syndrome includes acute fever, that rapidly progresses into neurological deterioration, which if left untreated will eventually lead to a comaand death.[1] The diagnostic procedure of choice is the MRI with gadolinium enhancement. Since the clinical symptoms might be mild and unspecific initially, the rapid diagnosis and treatment are crucial. The sooner the proper treatment is initiated, the better the recovery will be. The treatment, for almost all causes, requires prompt surgical drainage and antibiotic therapy.[2] With treatment, resolution of the empyema occurs from the dural side, and, if it is complete, a thickened dura may be the only residual finding.
Medical Therapy
Complications
Follow-Up and Prognosis
Prognostic factors associated with Subdural Empyema
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Unfavorable prognostic factors ▸ Presenting with encephalopathy or coma ▸ Younger than 10 or elderly ▸ Late start of antibiotics ▸ Sterile cultures Favourable prognostic factors ▸ Craniotomy instead of burr holes as surgical procedure ▸ Isolation of Aerobic streptococci References
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