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{{Subdural empyema}}
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==Overview==
==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.<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> It consists of a localised collection of [[purulent]] material, usually unilateral, between the [[dura mater]] and the [[arachnoid 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 emergency|medical]] and [[Surgical emergency|neurosurgical emergency]].<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> 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 the [[subdural 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.
[[Subdural empyema]] is a life-threatening [[infection]], consisting of a localized collection of [[purulent]] material, usually unilateral, between the [[dura mater]] and the [[arachnoid mater]]. Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal, with intracranial being the more common of the two groups, accounting for 95% of subdural empyema patients.<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> Subdural empyema accounts for approximately 15-25% of focal [[central nervous system]] [[infections]]. In 2014, the incidence of subdural empyema was estimated to be less than 1 case case per 100,000 individuals, with a male predominance.<ref name="PMC4052585">{{cite journal |vauthors=French H, Schaefer N |title=Intracranial Subdural Empyema: A 10-Year Case Series |journal=Oschner J|volume=12|issue=2 |year=2014|pmid=PMC4052585 |doi=10.1002/bip.360240911 |url=}}</ref>
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.<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> 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 by ''[[streptococci]]'' or by ''[[staphylococcus aureus]]''.<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>
The most common [[pathogens]] in intracranial subdural empyema are [[anaerobic]] and [[microaerophilic]] [[Streptococci]], compared to spinal subdural epmyema, which can be caused by either [[Streptococci]] or ''[[Staphylococcus aureus]]''.<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> If left untreated, subdural empyema frequently evolves into severe [[fever]], [[headache]], [[nausea]], [[vomiting]], [[seizures]], [[coma]], and subsequent mortality. Complications to subdural empyema include [[status epilepticus]], neurological deficits, and [[thrombosis]]. Prognosis is generally good with [[antimicrobial]] therapy. Physical examination of patients with subdural empyema is usually remarkable for [[fever]], [[facial pain]], and [[altered mental status]].<ref name="Hendaus2013">{{cite journal|last1=Hendaus|first1=Mohammed A.|title=Subdural Empyema in Children|journal=Global Journal of Health Science|volume=5|issue=6|year=2013|issn=1916-9744|doi=10.5539/gjhs.v5n6p54}}</ref><ref name="pmid23358438">{{cite journal| author=Bruner DI, Littlejohn L, Pritchard A| title=Subdural empyema presenting with seizure, confusion, and focal weakness. | journal=West J Emerg Med | year= 2012 | volume= 13 | issue= 6 | pages= 509-11 | pmid=23358438 | doi=10.5811/westjem.2012.5.11727 | pmc=PMC3555596 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23358438  }} </ref><ref name=Mandell>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref> [[MRI]] is the primary imaging study of epidural abscess, with [[CT scan]] as a secondary alternative. Treatment of subdural empyema requires a combined medical and surgical approach. In order to evacuate the pus, [[burr hole]] placement or [[craniotomy]] may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is [[craniotomy]].
The classic clinical syndrome includes acute [[fever]], that rapidly progresses into neurological deterioration, which if left untreated will eventually lead to a [[coma]] and death.<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> 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.<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> With treatment, resolution of the [[empyema]] occurs from the dural side, and, if it is complete, a thickened [[dura mater|dura]] may be the only residual finding.
==Historical Perspective==
In 1869, subdural empyema was first operated on by François Gigot de la Peyronie.<ref name="pmid6144382">{{cite journal| author=Khan M, Griebel R| title=Subdural empyema: a retrospective study of 15 patients. | journal=Can J Surg | year= 1984 | volume= 27 | issue= 3 | pages= 283-5, 288 | pmid=6144382 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6144382 }} </ref> The first detailed description of the disease was by Cyril Brian Courville in 1939.
 
==Classification==
Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal.<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>


==Pathophysiology==
==Pathophysiology==
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.   If diagnosis and treatment are prompt, complete recovery is usual.
Subdural empyema is a localized collection of [[pus]] between the [[dura mater]] and [[arachnoid mater]], occurring in either the [[intracranial space]] or the [[spinal canal]].<ref name =MEDICI>{{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="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> Subdural empyema generally follows the same progression for both intracranial and spinal subtypes, spreading via [[blood]] or from nearby infection. [[Bacterial]] [[infections]] of the [[skull]] 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.
 
==Causes==
Common causes of subdural empyema include [[Streptococci]], [[Staphylococci]], and other [[Gram-negative]] [[bacilli]].<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> In children, the majority of cases of subdural empyema occur due to [[meningitis]], while in adults the most common causes are [[sinusitis]], [[otitis media]], [[mastoiditis]], and [[trauma]].<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="pmid16777239">{{Cite journal|author=Quraishi H, Zevallos JP |title=Subdural empyema as a complication of sinusitis in the pediatric population |journal=Int. J. Pediatr. Otorhinolaryngol. |volume=70 |issue=9 |pages=1581–6 |year=2006 |month=September |pmid=16777239 |doi=10.1016/j.ijporl.2006.04.007 |url=http://linkinghub.elsevier.com/retrieve/pii/S0165-5876(06)00135-2}}</ref>
 
==Differentiating Subdural Empyema from Other Diseases==
Subdural empyema must be differentiated from other diseases that cause [[fever]], [[headache]], focal neurological signs, [[seizures]], and altered mental status, such as [[subdural hematoma]], [[brain abscess]], and [[bacterial meningitis]]. These conditions may be distinguished from subdural empyema by their clinical findings, brain imaging findings, and laboratory studies.


==Epidemiology and Demographics==
==Epidemiology and Demographics==
Subdural empyema, also referred to as subdural abscess, pachymeningitis interna and circumscript meningitis, is a life-threatening [[infection]].<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> It consists of a localised collection of [[pus|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 emergency|medical]] and [[surgical emergency|neurosurgical emergency]].<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>
Subdural empyema accounts for approximately 15-25% of focal [[central nervous system]] [[infections]]. In 2014, the incidence of subdural empyema was estimated to be less than 1 case per 100,000 individuals.<ref name="PMC4052585">{{cite journal |vauthors=French H, Schaefer N |title=Intracranial Subdural Empyema: A 10-Year Case Series |journal=Oschner J|volume=12|issue=2 |year=2014|pmid=PMC4052585 |doi=10.1002/bip.360240911 |url=}}</ref> Prior to [[antibiotics]], the case fatality rate of subdural empyema was estimated to be near 100%. However, with antibiotics, the current rate is estimated between 10-20%.<ref name="pmid10069590">{{cite journal |vauthors=Nathoo N, Nadvi SS, van Dellen JR, Gouws E |title=Intracranial subdural empyemas in the era of computed tomography: a review of 699 cases |journal=Neurosurgery |volume=44 |issue=3 |pages=529–35; discussion 535–6 |year=1999 |pmid=10069590 |doi= |url=}}</ref> The disease usually occurs in children and young adults (70% cases occurring in the second and third decades of life), being more frequent in men than women, possibly due to sex-related differences in sinus anatomy.
[[Bacterial]] or occasionally [[fungal]] [[infection]] of the [[skull]] bones or air [[sinuses]] can spread to the [[subdural space]] producing a subdural empyema.
 
==Risk Factors==
Common risk factors in the development of subdural empyema are [[meningitis]], [[sinusitis]], [[otitis]], [[mastoiditis]], [[immunodeficiency]], head [[trauma]], and [[lumbar puncture]].


==Causes==
==Natural History, Complications, and Prognosis==
Subdural empyema, also referred to as subdural abscess, pachymeningitis interna and circumscript meningitis, is a life-threatening [[infection]].<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> It consists of a localised collection of [[pus|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 emergency|medical]] and [[surgical emergency|neurosurgical emergency]].<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>
If left untreated, subdural empyema frequently evolves into severe [[fever]], [[headache]], [[nausea]], [[vomiting]], [[seizures]], [[coma]], and subsequent [[mortality]]. Complications to subdural empyema include [[status epilepticus]], neurological deficits, and [[thrombosis]]. Prognosis is generally good with [[antimicrobial]] therapy.
Depending on the site of origin of the [[infection]], as well as location of the empyema in the [[subdural space]], there will be different causative agents. The rate of success of bacterial cultures from the surgically removed pus is 54-81%. Common agents of subdural empyema include: [[anaerobes]], [[aerobic]] [[streptococci]], [[staphylococci]], ''[[Haemophilus influenzae]]'', ''[[Streptococcus pneumoniae]]'' and other [[gram-negative]] [[bacilli]]. <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>
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.<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="pmid16777239">{{Cite journal|author=Quraishi H, Zevallos JP |title=Subdural empyema as a complication of sinusitis in the pediatric population |journal=Int. J. Pediatr. Otorhinolaryngol. |volume=70 |issue=9 |pages=1581–6 |year=2006 |month=September |pmid=16777239 |doi=10.1016/j.ijporl.2006.04.007 |url=http://linkinghub.elsevier.com/retrieve/pii/S0165-5876(06)00135-2}}</ref>


==Diagnosis==
==Diagnosis==
===Symptoms===
===History and Symptoms===
Symptoms include those referable to the source of the infection.  
If possible, a detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include prior [[neurosurgery]], [[sinusitis]], or [[mastoiditis]]. Common symptoms of subdural empyema include [[headache]], [[altered mental status]], [[vomiting]], and [[seizures]].
 
===Physical Examination===
Physical examination of patients with subdural empyema is usually remarkable for [[fever]], [[facial pain]], and [[altered mental status]].<ref name="Hendaus2013">{{cite journal|last1=Hendaus|first1=Mohammed A.|title=Subdural Empyema in Children|journal=Global Journal of Health Science|volume=5|issue=6|year=2013|issn=1916-9744|doi=10.5539/gjhs.v5n6p54}}</ref><ref name="pmid23358438">{{cite journal| author=Bruner DI, Littlejohn L, Pritchard A| title=Subdural empyema presenting with seizure, confusion, and focal weakness. | journal=West J Emerg Med | year= 2012 | volume= 13 | issue= 6 | pages= 509-11 | pmid=23358438 | doi=10.5811/westjem.2012.5.11727 | pmc=PMC3555596 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23358438  }} </ref><ref name=Mandell>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref>
 
===Laboratory Findings===
Laboratory findings associated with subdural empyema are generally unspecific. Often, elevated inflammatory markers are present, including:<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="Hendaus2013">{{cite journal|last1=Hendaus|first1=Mohammed A.|title=Subdural Empyema in Children|journal=Global Journal of Health Science|volume=5|issue=6|year=2013|issn=1916-9744|doi=10.5539/gjhs.v5n6p54}}</ref>
*[[Leukocytes]]
*[[Erythrocyte sedimentation rate]]
*[[C-reactive protein]]


In the case of '''infants''', common symptoms will include:
===Lumbar Puncture===
*altered mental status
Lumbar puncture is not diagnostic of subdural empyema. Lumbar puncture is an invasive procedure which is contraindicated in case of suspicion of subdural empyema and [[increased intracranial pressure]], due to risk of [[brain herniation]], and mortality.<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>
*[[fever]]
*[[neck stiffness]]
*[[headache]], [[nausea]]/[[vomiting]], ocular palsies
*seizures


In the case of most '''adult''' patients, common symptoms are
===X ray===
*[[fever]]
Generally, [[x ray]] is not helpful in the diagnosis of subdural empyema.
*[[sinusitis]]
*[[headache]]
*[[neck stiffness]]
If untreated, my develop:
*focal neurologic signs
*[[lethargy]]
*[[coma]]


===Laboratory Findings===
===CT===
Patients with subdural empyema usually have:
Head [[CT scan]] may be helpful in the diagnosis of subdural empyema. CT scan is secondary to [[MRI]] for subdural empyema imaging. Findings on CT scan suggestive of subdural empyema include a crescentic shape, although collection pockets may appear bi-convex. A surrounding membrane that enhances intensely and uniformly following contrast administration is typically identified.<ref name= SDEct> Subdural empyema. Radiopaedia.org (2015). http://radiopaedia.org/articles/subdural-empyema Accessed on December 4, 2015.</ref>
*elevated [[white blood cell count]]
*elevated erythrocyte sedimentation rate
*elevated C-reactive protein
Children with hyperglycaemia or diabetes have an increased risk of developing sinogenic intracranial empyema.


The [[CSF]] profile is similar to that seen in [[brain abscesses]], because both are parameningeal infectious processes:
===MRI===
*increased [[white blood cell count]]
MRI in the optimal imaging study in the diagnosis of subdural empyema. Findings on MRI suggestive of subdural empyema are similar to those on [[CT scan]], and include a crescent or bi-convex shaped collection. A surrounding membrane that enhances intensely and uniformly following [[gadolinium]] enhancement is typically identified and may also demonstrate restricted diffusion.<ref name= SDEct> Subdural empyema. Radiopaedia.org (2015). http://radiopaedia.org/articles/subdural-empyema Accessed on December 4, 2015.</ref>
*increased [[protein]] level
*decreased [[glucose]] levels
*occasionally [[CSF]] results may be normal and sterile


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
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 (via [[burr hole]] procedure or [[craniotomy]]) and [[antibiotic]] therapy, which should be broad-spectrum initially, and adjusted to the organism , once results from the drained infected material are know. <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>
Subdural empyema is a medical emergency and requires prompt treatment. Treatment of subdural empyema requires a combined medical and surgical approach. Empiric antimicrobial therapy depends on the location of the infection (intracranial vs. spinal) and whether it was community-acquired or hospital-acquired. The clinical symptoms may be mild and unspecific initially.  
With treatment, including surgical drainage, resolution of the empyema occurs from the dural side, and, if it is complete, a thickened dura may be the only residual finding.
 
===Surgery===
Subdural empyema is a [[neurosurgery|neurosurgical]] condition, which requires emergency surgical drainage and subsequent medical therapy. In order to evacuate the pus, [[burr hole]] placement or [[craniotomy]] may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is [[craniotomy]]. A wide craniotomy allows a wide exposure of the area, adequate exploration, and better evacuation of the infected material and decompression of the underlying cerebral hemisphere, thereby improving the outcome.<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>
 
===Prevention===
Effective measures for the primary prevention of subdural empyema include rapid treatment of inflammatory diseases of the head and prevention of [[trauma]]. Secondary prevention strategies following subdural empyema include treatment and management of existing infection.  


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Infectious disease]]
 
 


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Latest revision as of 18:53, 18 September 2017

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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]; Anthony Gallo, B.S. [3]

Overview

Subdural empyema is a life-threatening infection, consisting of a localized collection of purulent material, usually unilateral, between the dura mater and the arachnoid mater. Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal, with intracranial being the more common of the two groups, accounting for 95% of subdural empyema patients.[1][2] Subdural empyema accounts for approximately 15-25% of focal central nervous system infections. In 2014, the incidence of subdural empyema was estimated to be less than 1 case case per 100,000 individuals, with a male predominance.[3] The most common pathogens in intracranial subdural empyema are anaerobic and microaerophilic Streptococci, compared to spinal subdural epmyema, which can be caused by either Streptococci or Staphylococcus aureus.[2] If left untreated, subdural empyema frequently evolves into severe fever, headache, nausea, vomiting, seizures, coma, and subsequent mortality. Complications to subdural empyema include status epilepticus, neurological deficits, and thrombosis. Prognosis is generally good with antimicrobial therapy. Physical examination of patients with subdural empyema is usually remarkable for fever, facial pain, and altered mental status.[4][5][6] MRI is the primary imaging study of epidural abscess, with CT scan as a secondary alternative. Treatment of subdural empyema requires a combined medical and surgical approach. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy.

Historical Perspective

In 1869, subdural empyema was first operated on by François Gigot de la Peyronie.[7] The first detailed description of the disease was by Cyril Brian Courville in 1939.

Classification

Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal.[1][2]

Pathophysiology

Subdural empyema is a localized collection of pus between the dura mater and arachnoid mater, occurring in either the intracranial space or the spinal canal.[8][1][2] Subdural empyema generally follows the same progression for both intracranial and spinal subtypes, spreading via blood or from nearby infection. Bacterial infections of the skull 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.

Causes

Common causes of subdural empyema include Streptococci, Staphylococci, and other Gram-negative bacilli.[1] In children, the majority of cases of subdural empyema occur due to meningitis, while in adults the most common causes are sinusitis, otitis media, mastoiditis, and trauma.[1][9]

Differentiating Subdural Empyema from Other Diseases

Subdural empyema must be differentiated from other diseases that cause fever, headache, focal neurological signs, seizures, and altered mental status, such as subdural hematoma, brain abscess, and bacterial meningitis. These conditions may be distinguished from subdural empyema by their clinical findings, brain imaging findings, and laboratory studies.

Epidemiology and Demographics

Subdural empyema accounts for approximately 15-25% of focal central nervous system infections. In 2014, the incidence of subdural empyema was estimated to be less than 1 case per 100,000 individuals.[3] Prior to antibiotics, the case fatality rate of subdural empyema was estimated to be near 100%. However, with antibiotics, the current rate is estimated between 10-20%.[10] The disease usually occurs in children and young adults (70% cases occurring in the second and third decades of life), being more frequent in men than women, possibly due to sex-related differences in sinus anatomy.

Risk Factors

Common risk factors in the development of subdural empyema are meningitis, sinusitis, otitis, mastoiditis, immunodeficiency, head trauma, and lumbar puncture.

Natural History, Complications, and Prognosis

If left untreated, subdural empyema frequently evolves into severe fever, headache, nausea, vomiting, seizures, coma, and subsequent mortality. Complications to subdural empyema include status epilepticus, neurological deficits, and thrombosis. Prognosis is generally good with antimicrobial therapy.

Diagnosis

History and Symptoms

If possible, a detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include prior neurosurgery, sinusitis, or mastoiditis. Common symptoms of subdural empyema include headache, altered mental status, vomiting, and seizures.

Physical Examination

Physical examination of patients with subdural empyema is usually remarkable for fever, facial pain, and altered mental status.[4][5][6]

Laboratory Findings

Laboratory findings associated with subdural empyema are generally unspecific. Often, elevated inflammatory markers are present, including:[1][4]

Lumbar Puncture

Lumbar puncture is not diagnostic of subdural empyema. Lumbar puncture is an invasive procedure which is contraindicated in case of suspicion of subdural empyema and increased intracranial pressure, due to risk of brain herniation, and mortality.[2]

X ray

Generally, x ray is not helpful in the diagnosis of subdural empyema.

CT

Head CT scan may be helpful in the diagnosis of subdural empyema. CT scan is secondary to MRI for subdural empyema imaging. Findings on CT scan suggestive of subdural empyema include a crescentic shape, although collection pockets may appear bi-convex. A surrounding membrane that enhances intensely and uniformly following contrast administration is typically identified.[11]

MRI

MRI in the optimal imaging study in the diagnosis of subdural empyema. Findings on MRI suggestive of subdural empyema are similar to those on CT scan, and include a crescent or bi-convex shaped collection. A surrounding membrane that enhances intensely and uniformly following gadolinium enhancement is typically identified and may also demonstrate restricted diffusion.[11]

Treatment

Medical Therapy

Subdural empyema is a medical emergency and requires prompt treatment. Treatment of subdural empyema requires a combined medical and surgical approach. Empiric antimicrobial therapy depends on the location of the infection (intracranial vs. spinal) and whether it was community-acquired or hospital-acquired. The clinical symptoms may be mild and unspecific initially.

Surgery

Subdural empyema is a neurosurgical condition, which requires emergency surgical drainage and subsequent medical therapy. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy. A wide craniotomy allows a wide exposure of the area, adequate exploration, and better evacuation of the infected material and decompression of the underlying cerebral hemisphere, thereby improving the outcome.[1][2]

Prevention

Effective measures for the primary prevention of subdural empyema include rapid treatment of inflammatory diseases of the head and prevention of trauma. Secondary prevention strategies following subdural empyema include treatment and management of existing infection.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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. 2.0 2.1 2.2 2.3 2.4 2.5 Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
  3. 3.0 3.1 French H, Schaefer N (2014). "Intracranial Subdural Empyema: A 10-Year Case Series". Oschner J. 12 (2). doi:10.1002/bip.360240911. PMID PMC4052585 Check |pmid= value (help).
  4. 4.0 4.1 4.2 Hendaus, Mohammed A. (2013). "Subdural Empyema in Children". Global Journal of Health Science. 5 (6). doi:10.5539/gjhs.v5n6p54. ISSN 1916-9744.
  5. 5.0 5.1 Bruner DI, Littlejohn L, Pritchard A (2012). "Subdural empyema presenting with seizure, confusion, and focal weakness". West J Emerg Med. 13 (6): 509–11. doi:10.5811/westjem.2012.5.11727. PMC 3555596. PMID 23358438.
  6. 6.0 6.1 Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
  7. Khan M, Griebel R (1984). "Subdural empyema: a retrospective study of 15 patients". Can J Surg. 27 (3): 283–5, 288. PMID 6144382.
  8. Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
  9. Quraishi H, Zevallos JP (2006). "Subdural empyema as a complication of sinusitis in the pediatric population". Int. J. Pediatr. Otorhinolaryngol. 70 (9): 1581–6. doi:10.1016/j.ijporl.2006.04.007. PMID 16777239. Unknown parameter |month= ignored (help)
  10. Nathoo N, Nadvi SS, van Dellen JR, Gouws E (1999). "Intracranial subdural empyemas in the era of computed tomography: a review of 699 cases". Neurosurgery. 44 (3): 529–35, discussion 535–6. PMID 10069590.
  11. 11.0 11.1 Subdural empyema. Radiopaedia.org (2015). http://radiopaedia.org/articles/subdural-empyema Accessed on December 4, 2015.


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