Intracranial subdural empyema …

John E Greenlee MD

Infectious Disorders

Updated 02.08.2024
Released 04.04.1995
Expires For CME 02.08.2027

Intracranial subdural empyema

Author: John E Greenlee MD

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Intracranial subdural empyema

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Introduction

Overview

Intracranial subdural empyema represents infection arising in the cleavage plane between the cranial dura mater and the subjacent layer of the meninges, the arachnoid. Although the condition is traditionally associated with sinusitis or otitis, it may also occur as a complication of other cranial or dental infections, neurosurgical procedures, or cranial trauma. Intracranial subdural empyema represents one of the most urgently dangerous of all intracranial processes because it can spread rapidly to cover an entire cerebral hemisphere or much of the posterior fossa, producing a rapidly expanding, potentially fatal mass lesion. In this article, the author reviews the pathogenesis, clinical features, diagnosis, and treatment of this disorder.

Key points

	• Intracranial subdural empyema represents loculated infection in the potential space between the outer layer of the meninges, the dura, and the arachnoid. This potential space encompasses a large intracranial area in which infection can rapidly spread to cover, and compress, an entire hemisphere or much of the posterior fossa.
	• The condition is most commonly a complication of sinusitis or otitis, particularly in males in later childhood, adolescence, or early adulthood. Less frequently, intracranial subdural empyema may also occur as a complication of dental infections, neurosurgical procedures, or trauma. The condition may be preceded by intracranial epidural abscess.
	• Subdural empyema is a neurologic and neurosurgical emergency, which should be suspected in any febrile patient with rapidly developing signs indicating involvement of an entire cerebral hemisphere.
	• MRI with gadolinium enhancement is the diagnostic procedure of choice. Contrast-enhanced CT scan may be used if MRI is not available but is less sensitive.
	• Treatment of intracranial subdural empyema almost always involves surgical drainage with adjunctive antibiotic therapy.
	• Occasionally, subdural empyemas may be identified by MRI at a time when they are too small to allow surgical drainage. In such cases, the empyema is treated with antibiotics alone, with close follow-up by MRI or CT to make certain that the empyema is not enlarging, which would require neurosurgical intervention.

Historical note and terminology

The fact that ear infections could progress to delirium and death was known to ancient writers including Hippocrates (105), but the association of this process with intracranial extension of infection was not understood. Although a case suggestive of subdural empyema was described by Richter in 1773 (22), recognition of subdural empyema as a distinct clinical and pathological entity did not occur until the mid-19th century (22; 54). Major case series in the past century included those of Kubik and Adams, Courville, and Schiller and colleagues (21; 22; 54; 87). Early terms for the condition included "pachymeningitis interna" (to distinguish the entity from epidural abscess, termed "pachymeningitis externa") and "purulent pachymeningitis." Association of intracranial subdural empyema with sinus and ear infections came through case series published in the late 19th and early 20th centuries (21; 22; 54).

Subdural empyema was initially purely a clinical diagnosis, and its rapid progression and malignant course were such that Le Beau termed intracranial subdural empyema "the most imperative of all neurosurgical emergencies" (55). Before the advent of MRI, diagnosis of subdural empyema was made by burr holes, angiography, or, beginning in the mid-1970s, CT. Treatment was invariably surgical, with antibiotics being assigned an adjunctive but not curative role. The introduction of MRI, however, has provided a rapid, noninvasive method for diagnosing and following subdural empyemas and can identify empyemas too small to require surgery (103; 91; 53; 79). With the widespread use of CT and then MRI, mortality from subdural empyema has fallen, and it has become possible (in occasional, carefully selected cases) to treat a subdural empyema with antibiotic therapy alone (67; 60; 78; 32).

Clinical manifestations

Presentation and course

	• Intracranial subdural empyema is significantly more common in males than in females and is predominantly a condition of children and young adults.
	• Onset of symptoms is frequently abrupt. Initial symptoms include fever, headache or localized head pain, and congestion.
	• A minority of patients with intracranial subdural empyema may present with seizures.
	• Enlargement of the empyema, which may occur very rapidly, may produce neurologic symptoms indicating involvement of an entire cerebral hemisphere or extensive involvement of posterior fossa structures. The enlarging empyema may cause brain herniation.

Intracranial subdural empyema is significantly more common in males than in females and is predominantly a condition of children and young adults; 70% of cases occur in the second and third decades of life (47; 89; 76; 35; 81). In a series including cases occurring after craniotomy, the male-to-female ratio was 56:44, and the mean age was older (32). In many series, there has been a bimodal distribution of infection: cases in infancy associated with meningitis or mastoiditis, and cases in older children, adolescents, and young adults associated with sinusitis (37). The onset of symptoms in subdural empyema is often abrupt (48; 47; 76; 09; 32). If the diagnosis of subdural empyema is not made early in the course of infection, progression of neurologic injury occurs over hours to days, producing signs that indicate involvement of an entire cerebral hemisphere or widespread involvement of posterior fossa structures (22; 54; 20; 48; 72; 89; 35; 32). Rapidity of progression was emphasized by a case in which an empyema was observed by MRI to triple in size within a period of 12 hours (110). In cases following neurosurgical procedures, however, more gradual onset of symptoms over a period of up to 3 weeks may be seen (20; 83; 32; 81). Forty percent of patients will present with nausea and vomiting (81). Early symptoms include fever (present in over 70% to 80% of patients), localized cranial pain, focal or generalized headache, and symptoms of nasal or sinus congestion (20; 48; 32). Roughly a quarter of patients will present with seizures (48; 47; 76; 09; 32). Lin and colleagues have reported a patient in whom development of subdural empyema and meningitis was preceded by symptoms consistent with trigeminal neuralgia (61). Nuchal rigidity is often present and may suggest meningitis (48; 09). Enlargement of the empyema is accompanied by signs of increased intracranial pressure and alteration in mental status. Focal neurologic deficits, particularly hemiplegia, are present in the majority of patients, and subdural empyemas overlying the dominant hemisphere may produce aphasia (20; 48). Focal symptoms, however, are often overshadowed by more ominous findings produced by mass effect of the empyema. Subdural empyema is extremely irritating to underlying brain and is accompanied by focal or generalized seizures in approximately 50% of cases (48). Enlargement of the empyema may be so rapid that coma and death may occur before papilledema becomes clinically evident. Venous extension of infection inward may produce meningitis, brain abscess, or septic intracranial venous thrombosis (54; 48; 09). Parafalcine subdural empyemas may present without clear localizing symptoms or signs other than headache, signs of meningeal irritation, or increased intracranial pressure (98). Rare patients may develop a subtentorial subdural empyema, with danger of hydrocephalus and upward as well as transtentorial herniation (97; 92; 71). These patients, who are at extreme risk for rapid decompensation, may be without cerebellar or brainstem signs, although sixth nerve palsies may be present (97; 71). The clinical course of subdural empyema in children older than 6 years of age and in adolescents is similar to that seen in adults (35; 52; 74; 65). Subdural empyema in infants and small children is usually a complication of bacterial meningitis (80; 99). Diagnosis in these young patients is often more difficult because early symptoms may be masked by those of meningitis, and the subdural empyema may come to be suspected only as the patient fails to improve despite successful treatment of meningitis (90; 62; 65). In infants, a bulging fontanelle may be present. The empyema may be sufficiently turbid; however, that transillumination may be negative.

Prognosis and complications

Untreated subdural empyema is rapidly fatal. With therapy, overall mortality in subdural empyema in older children and adults has fallen from 20% to 40% in the late 1970s, to 7% to 25% at present (48; 89; 82; 101; 12; 27; 76; 58). Germiller and colleagues, in a review of nine cases of intracranial subdural empyema in children and adolescents, reported no deaths (35), as did French and colleagues in a series of 36 patients presenting from 2001 to 2011 (32), and Otto and colleagues in a series of 54 patients between 1 and 21 years of age (81). Morbidity rates in reported studies have varied from 14% to 58% (40; 82; 101; 12; 27; 32); up to 30% of survivors may be left with severe neurologic deficits. Likelihood of death and severity of neurologic injury are functions of delay in diagnosis and of patient neurologic status at the presentation. A minority of patients may require repeat surgical intervention (32). In a study, intracranial subdural empyemas related to sinogenic infection were found to have significantly more severe clinical presentation, a higher morbidity, and need for a longer duration of antibiotic therapy than that those associated with otogenic infection (84).

Clinical vignette

A 47-year-old male was in excellent health until 1 week prior to admission, when he developed an upper respiratory infection with accompanying severe nasal congestion. Over the next several days the patient repeatedly instrumented his nasal mucosa in an effort to improve his ability to breathe. On the morning of admission, his wife found him unresponsive, with irregular respirations, and brought him to the hospital. On examination, the patient was comatose, without response to voice, loud noise, or pain. The patient initially had Cheyne-Stokes respirations. Respirations became rapid and irregular during the examination. Pulse was 75 per minute and regular. Blood pressure was 150/90. Temperature was 39.5°C. General physical examination was unremarkable except for nuchal rigidity; optic discs were flat. Cranial nerve examination revealed a right third nerve palsy involving the pupil and a left facial weakness. Motor examination revealed a flaccid left hemiparesis. Reflexes were depressed on the left. Babinski sign was present bilaterally. Emergent CT scanning showed bilateral frontal and maxillary sinusitis. A large hypodense space-occupying lesion was present over the left hemisphere, extending along the falx cerebri. The patient was begun on nafcillin, metronidazole, and cefotaxime. Emergent craniotomy resulted in drainage of over 75 mL of purulent material. Cultures grew out microaerophilic streptococci, sensitive to penicillin. The patient's antibiotics were changed to intravenous penicillin G. The patient awakened and made a gradual recovery but was left with a mild right hemiparesis and mild intellectual impairment.

Biological basis

Etiology and pathogenesis

	• The major agents associated with intracranial subdural empyema in the setting of sinusitis or otitis include agents of the Streptococcus milleri/Streptococcus anginosus group.
	• Streptococcus pneumoniae is the most common isolate from cases of intracranial subdural empyema associated with bacterial meningitis.
	• Staphylococcus aureus is the most common organism in cases associated with cranial trauma or surgical procedures and can also be seen in a minority of nonsurgical patients.
	• A number of cases of intracranial subdural empyema have been reported in both adults and children in temporal association with SARS-CoV2 (COVID-19) infection, with two reports observing that there has been an overall increase in numbers of cases of intracranial subdural empyema during the SARS-CoV2 epidemic. The pathogenic mechanisms involved in this apparent increase in intracranial bacterial infection have not been defined.

The causative agents of subdural empyema are similar to those associated with intracranial epidural abscess and brain abscess. Aerobic, microaerophilic, and anaerobic streptococci, including Streptococcus milleri and Streptococcus anginosus, are common in epidural abscesses associated with sinusitis or otitis (48; 47; 109; 89; 04; 27; 44; 76; 52; 19; 32; 81). Mirza and colleagues reported isolation of Escherichia coli from a subdural empyema associated with mastoiditis and cholesteatoma (70). Streptococcus pneumoniae has been identified as the most common organism in cases of intracranial subdural empyema complicating meningitis (46). Multiple additional organisms, including Bacteroides species and enteric bacteria such as Escherichia coli, Proteus species, or Pseudomonas species may also be present in this setting (109; 90; 04; 15; 76). Nontyphoidal Salmonella species have been associated with intracranial subdural empyema in the setting of advanced AIDS or, occasionally, in children (02; 26). Anaerobic organisms may be detected in up to 100% of cases in which meticulous care is taken in obtaining cultures (109). Staphylococcus aureus is the most common organism in cases associated with cranial trauma or surgical procedures and can also be seen in a minority of nonsurgical patients. Subdural empyema following neurosurgical procedures may also be caused by coagulase-negative strains of Staphylococcus; Propionobacterium acnes; Mycoplasma hominis; Eikenella corrodens; anaerobes, including S milleri; or Gram-negative organisms, including Campylobacter fetus (107; 90; 04; 69; 32). Infections due to P acnes and M hominis are particularly likely to occur in immunosuppressed patients or to be associated with implanted surgical devices. In such cases, presentation of the empyema may be significantly delayed (36). Subdural empyema associated with internal jugular vein thrombosis and septic pulmonary vein thrombosis (Lemierre syndrome) has been associated with Fusobacterium septicemia (94). In a minority of patients, multiple organisms may be present (107; 90; 04; 69; 32). As noted above, subdural empyema in infants and small children is almost always a complication of meningitis, and isolates from subdural fluid are usually identical to those causing the meningitis (29; 90; 57; 95; 32). In older children, as in adults, subdural empyema is most commonly a complication of sinusitis or otitis (57; 99). Tuberculous subdural empyema has been reported in children but is extremely rare (05).

Subdural empyema represents infection within the potential space that lies between the dura and arachnoid (08; 09). This space surrounds the brain and is interrupted only where the arachnoid and dura are joined along the falx cerebri, the tentorium cerebelli, and the base of the brain. Infection within the subdural space can, thus, spread rapidly (at times within hours) over an entire cerebral hemisphere or most of the posterior fossa to behave as a large, rapidly expanding mass lesion (08; 09). Historically, subdural empyema has most commonly occurred as a complication of sinusitis or otitis and develops following septic thrombophlebitis of the emissary veins that connect the venous drainage of facial structures, sinuses, middle ear, and mastoid with the deep cerebral venous system (54; 48; 102; 33; 09). In this setting, subdural empyema is frequently preceded or accompanied by epidural abscess (48). Empyemas along the falx (parafalcine subdural empyemas) or the tentorium most commonly arise as complications of otitis media (86; 100). In a series of 10 patients, Salunke and colleagues found parafalcine subdural empyemas as most commonly representing a complication of otitis media, with a minority of cases appearing to have been hematogenous in origin (86). Subdural empyema may also develop following cranial trauma or neurosurgical procedures (107; 90; 04; 75; 73), and in a series by French and colleagues, this was the most common setting in which subdural empyema was found, followed by sinusitis and otitis (32). In this series and that by Kim and colleagues, the most common setting was following drainage of a subdural hematoma (32; 51). A small number of cases have occurred following dental procedures (16). At times, subdural empyema may occur months or years after cranial injury (93). In infants, subdural empyema most commonly occurs as a complication of bacterial meningitis (57; 32). In children, subdural empyema may occur as a complication of otitis or mastoiditis, with a small number of cases associated with bacterial meningitis or sinusitis (06; 57). Rarely, subdural empyema will develop after bacteremic seeding of a preexisting subdural hematoma, transforming an indolent pathologic process into a fulminantly progressive one (20; 14; 59; 50; 23). Extension of infection inward from the subdural empyema may result in meningitis, cortical vein or venous sinus thrombophlebitis, or brain abscess. The empyema frequently produces intense cortical encephalitis within underlying brain (54; 89).

A number of cases of intracranial subdural empyema have been reported in both adults and children in association with SARS-CoV-2 (COVID-19) virus (17; 10; 63; 108; 03; 39). Two of these studies suggest an increased incidence of intracranial subdural empyema in association with COVID-19 (03; 39). The relationship, if any, between the development of empyemas and SARS-CoV2 infection with its ability to target endothelial cells and its possible accompanying hypercoagulable state is not known.

Diagnostic workup

	• Intracranial subdural empyema should suspected in any patient with sinusitis or otitis who develops fever accompanied by focal cranial pain or diffuse headache, or both, especially if focal neurologic signs are present.
	• Intracranial subdural empyema should also be considered in patients suffering clinical deterioration following craniotomy, especially if accompanied by development of focal signs. In this setting, progression of neurologic signs may be gradual rather than abrupt.
	• MRI with gadolinium contrast is the diagnostic procedure of choice. Contrast-enhanced CT may be used if MRI is not available. Angiography should be strongly considered on an emergency basis in cases in which MRI is not available, and subdural empyema is suspected despite negative CT.
	• Because intracranial subdural empyema is often accompanied by increased intracranial pressure, lumbar puncture should not be performed as a diagnostic technique.

The possibility of intracranial subdural empyema should be kept in mind in any patient with sinusitis or otitis who develops fever accompanied by focal cranial pain, or diffuse headache, or both. The presence of sinusitis or otitis should heighten suspicion that a subdural empyema might be present, although the sinusitis or otitis that led to the empyema may be clinically silent.

Right frontal sinusitis in subdural empyema (CT)

Arrow indicates frontal sinusitis. (Provided by Dr. Sudhir Purohit.)

Fever and leukocytosis are often present but may be attributed to the sinusitis or otitis. Frontal subperiosteal swelling, indicative subperiosteal abscess (Pott’s puffy tumor) is most often associated with intracranial epidural abscess but may occasionally be seen when infection has spread into the subdural space (11). Experience in children suggests that elevation in erythrocyte sedimentation rate or C-reactive protein may help in distinguishing epidural abscess or subdural empyema from uncomplicated sinusitis (01). CSF procalcitonin, although used for rapid diagnosis of bacterial meningitis, appears to be insensitive in the diagnosis of subdural empyema (43). The diagnostic procedure of choice, however, is MRI with gadolinium enhancement (103; 104; 53; 68; 85; 41; 77).

Subdural empyema (MRI) (1)

T1-weighted axial image. Blue arrow: midline shift; Yellow arrow: subdural collection; Red arrow: compressed ventricle. (Provided by Dr. Sudhir Kothari.)
Subdural empyema (MRI) (2)

T2-weighted axial image. Blue arrow: gyral edema; Red arrow: subdural collection. (Provided by Dr. Sudhir Kothari.)
Subdural empyema (MRI) (3)

T2-weighted image. Arrow indicates subdural collection. (Provided by Dr. Sudhir Kothari.)
Left hemispheric subdural empyema (MRI)

Gadolinium-enhanced MRI of a patient with left hemispheric subdural empyema. The empyema extends from the interhemispheric fissure over the convexity. There is extensive, significant left-to-right shift and compression of the left...
Subdural empyema (CT) (1)

The CT demonstrates the presence of an empyema extending from the frontal pole over much of the hemisphere. Left hemispheric cerebral edema is present with left-to-right shift and compression of the lateral ventricle. (Contributed...

This procedure, used with a high level of suspicion, may diagnose subdural empyema at a time when symptoms are confined to headache and fever (25). Work by Tsuchiya and colleagues and by Wong and colleagues suggests that diffusion-weighted imaging, together with comparison of images with apparent diffusion coefficient studies may be of value in differentiating subdural from epidural intracranial infections, and in differentiating subdural empyemas from subdural effusions (96; 106; 13). Patient sedation, with careful monitoring of vital signs, may be essential to achieve an adequate study. CT will also reveal the presence of an empyema in many cases.

Intracranial subdural empyema (CT)
Subdural empyema (CT) (2)

CT scan of patient presenting with headache and alteration of consciousness, followed by seizures in the chronic otitis setting. A multiloculated empyema overlies much of the left hemisphere. (Contributed by Dr. Sherman Stein.)

It should be kept in mind, however, that although CT is superior to MRI in providing information about actual injury to adjacent bone (103), it may fail to detect empyemas easily visible by MRI (42; 53; 68; 09). For this reason, angiography should be strongly considered on an emergency basis in cases in which MRI is not available, and subdural empyema is suspected despite negative CT. Radiological imaging should be studied with care for evidence of sinusitis or otitis, osteomyelitis, or brain abscess. Spinal fluid in older children and in adults is usually sterile, with nonspecific changes in cell count, glucose concentration, and protein level. Superficial review of imaging studies may be misleading: a small subdural or parafalcine ribbon of abscess, given its extent over much of the subdural space may contain a large volume of pus and produce mass effect. Intracranial subdural empyema is almost invariably accompanied by significant elevation of intracranial pressure, and lumbar puncture may precipitate brain herniation and death (48; 41).

Management

	• Intracranial subdural empyema constitutes a medical and neurosurgical emergency.
	• Immediate surgical drainage of the empyema with accompanying antibiotic coverage remains the mainstay of treatment.
	• Infrequently, intracranial subdural empyemas may be identified when they are too small to allow surgical drainage. In this case, antibiotic treatment should be initiated, and the empyema should be followed with serial imaging to detect enlargement of the empyema in the face of adequate antibiotics. This represents an absolute indication for surgery.

Immediate surgical drainage of the empyema and antibiotic coverage remain the mainstays of treatment. Neurosurgical approaches to subdural empyema have included drainage by craniotomy and drainage through multiple burr holes. Although the merits of both approaches have been discussed in articles spanning more than 40 years, the efficacy and morbidity of the two approaches have never been compared in a carefully controlled study (89; 30; 82; 101; 12; 41). In the series reported by French and colleagues, however, three of the four patients treated with burr holes alone required subsequent craniotomy (32). MRI-guided stereotactic surgery has been successfully used in selected cases (18; 64), as has use of flexible endoscopy (31). One elderly patient was successfully treated by drainage through burr holes followed by prolonged intracranial irrigation (28). Surgery may also be required for treatment of the associated sinusitis or otitis. Material obtained at surgery should be submitted for both aerobic and anaerobic culture. Reaccumulation of pus may require repeat surgery (52). In occasional, carefully selected cases, the diagnostic sensitivity of MRI allows diagnosis of subdural empyema at a time when the empyema is too small to permit surgical drainage. In such cases, therapy is undertaken with antibiotics alone, and the empyema is scrupulously followed with serial MRI scans to document resolution of infection and exclude enlargement of the empyema despite antibiotic therapy. Where surgical drainage is deferred, it is imperative that the treating neurologist and neurosurgeon monitor the patient together so that neurosurgical intervention can be initiated on an emergency basis at any time.

Controlled studies of antibiotic treatment of subdural empyema do not exist as of yet. The similarity in the bacterial culture of subdural empyema and that of brain abscess suggests the following approach to treatment (09; 45; 38). Because many abscesses contain a mixed culture of organisms, two or more agents may be required.

Table 1. Antibiotics for Empiric Therapy of Intracranial Subdural Empyema

Suspected organism	Recommended antibiotic
Streptococci and other Gram-positive organisms excluding S aureus	Ceftriaxone, or cefotaxime. Vancomycin should be used in place of penicillin in areas where the incidence of penicillin resistance is known to be high.
Staphylococcus aureus	Oxacillin (less apt to produce thrombophlebitis) or nafcillin; vancomycin if the patient is allergic to penicillins or if nafcillin resistance is suspected.
Gram-negative organisms excluding P aeruginosa	Ceftriaxone or cefotaxime
Pseudomonas aeruginosa	Ceftazidime
Bacteroides species	Metronidazole

For initial therapy, where no information exists as to the source of infection, the combined use of vancomycin and ceftriaxone, plus metronidazole should be considered (09). Ceftazidime should be used in place of ceftriaxone if P aeruginosa is strongly suspected (105). Linezolid has been used in individual cases to treat central nervous system infections with methicillin-resistant Staphylococcus aureus (MRSA) and other multidrug-resistant organisms and has been used, both with and without rifampin, in selected cases of subdural empyema not responding to more conventional agents (49; 66; 34; 56). The antibiotic regimen used in a given patient may need to be revised as data become available from cultures obtained at surgery. Length of therapy is determined by patient course and follow-up MRI or CT. In general, antibiotics should be continued for at least 4 weeks if surgery is not undertaken, or 6 to 8 weeks if osteomyelitis is present. The mean duration of antibiotic therapy in the series by Cole and colleagues was 14.4 weeks (19). Careful follow-up of the infection by MRI or, if MRI is not available, by CT is essential if the empyema is treated with antibiotics only.

Media

References

01: Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in children. Pediatrics 2005;116(3):e461-7. PMID 16140693
02: Aliaga L, Mediavilla JD, Lopez de la Osa A, Lopez Gomez M, de Cueto M, Miranda C. Nontyphoidal salmonella intracranial infections in HIV-infected patients. Clin Infect Dis 1997;25:1118-20. PMID 9402368
03: Angelo SJ, Anderson MG, Sutter PA, et al. Changes in the epidemiology of pediatric sinogenic and otogenic intracranial infections during the COVID-19 pandemic: a single-institution study. J Neurosurg Pediatr 2023;32(2):231-41. PMID 37243559
04: Ariza J, Casanova A, Fernandez Viladrich F, et al. Etiological agent and primary source of infection in 42 cases of focal intracranial suppuration. J Clin Microbiol 1986;24:899-902. PMID 2877009
05: Banerjee AD, Pandey P, Ambekar S, Chandramouli BA. Pediatric intracranial subdural empyema caused by Mycobacterium tuberculosis-a case report and review of literature. Childs Nerv Syst 2010;26(8):1117-20. PMID 20437243
06: Banerjee AD, Pandey P, Devi BI, Sampath S, Chandramouli BA. Pediatric supratentorial subdural empyemas: a retrospective analysis of 65 cases. Pediatr Neurosurg 2009;45(1):11-8. PMID 19221458
07: Blayney AW, Frootko NJ, Mitchell RG. Complications of sinusitis caused by Streptococcus milleri. J Laryngol Otol 1984;98:895-9. PMID 6148372
08: Bleck TF, Greenlee JE. Approach to the patient with central nervous system infection. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 5th ed. New York: Churchill Livingstone, 2000a:950-9.
09: Bleck TF, Greenlee JE. Subdural empyema. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 5th ed. New York: Churchill Livingstone, 2000b:1028-31.
10: Blitz SE, McMahon JT, Chalif JI, et al. Intracranial complications of hypercoagulability and superinfection in the setting of COVID-19: illustrative cases. J Neurosurg Case Lessons 2022;3(21):CASE22127. PMID 35734230
11: Blumfield E, Misra M. Pott's puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol 2011;18:203-10. PMID 21380513
12: Bok AP, Peter JC. Subdural empyema: burr holes or craniotomy. A retrospective computerized tomography-era analysis of treatment in 90 cases. J Neurosurg 1993;78:574-8. PMID 8095519
13: Bonfield CM, Sharma J, Dobson S. Pediatric intracranial abscesses. J Infect 2015;71 Suppl 1:S42-6. PMID 25917804
14: Braun CW, Axelrod J. Hematogenous infection of subdural hematoma. Arch Neurol 1980;37:467-8. PMID 6992753
15: Brook I. Aerobic and anaerobic bacteriology of intracranial abscesses. Pediatr Neurol 1992;8:210-4. PMID 1622518
16: Cariati P, Cabello-Serrano A, Monsalve-Iglesias F, Roman-Ramos M, Garcia-Medina B. Meningitis and subdural empyema as complication of pterygomandibular space abscess upon tooth extraction. J Clin Exp Dent 2016;8:e469-72. PMID 27703619
17: Charlton M, Nair R, Gupta N. Subdural empyema in adult with recent SARS-CoV-2 positivity case report. Radiol Case Rep 2021;16(12):3659-61. PMID 34630795
18: Chou CK, Chung WY, Pan HC, et al. MRI-guided stereotactic aspiration for the treatment of deep-seated tentorial empyema: a case report. Chung Hua I Hsueh Tsa Chih (Taipei) 1997;60:164-7. PMID 9419954
19: Cole TS, Clark ME, Jenkins AJ, Clark JE. Pediatric focal intracranial suppuration: a UK single-center experience. Childs Nerv Syst 2012;28(12):2109-14. PMID 22864509
20: Coonrod JD, Dans PE. Subdural empyema. Am J Med 1972;53:85-91. PMID 5037292
21: Courville CB. Fatal complications of otitis media: with particular reference to the intracranial lesions in a series of ten thousand autopsies. Arch Otolaryngol 1934;19:451-501.
22: Courville CB. Subdural empyema secondary to purulent frontal sinusitis. Arch Otolaryngol 1939;39:211-39.
23: Dabdoub CB, Adorno JO, Urbano J, Silveira EN, Orlandi BM. Review of the management of infected subdural hematoma. World Neurosurg 2016;87:663.e1-8. PMID 26585725
24: Dale BA, Mackenzie J. The complications of sphenoid sinusitis. J Laryngol Otol 1983;97:661-70. PMID 6875369
25: de Falco R, Scarano E, Cigliano A, et al. Surgical treatment of subdural empyema: a critical review. J Neurosurg Sci 1996;40:53-8. PMID 8913961
26: De Malet A, Ingerto S, Gañán I. Meningitis caused by salmonella newport in a five-year-old child. Case Rep Infect Dis 2016;2016:2145805. PMID 28058121
27: Dill SR, Cobbs CG, McDonald CK. Subdural empyema: analysis of 32 cases and review. Clin Infect Dis 1995;20:372-86. PMID 7742444
28: Eom KS, Kim TY. Continuous subdural irrigation and drainage for intracranial subdural empyema in a 92-year-old woman. Minim Invasive Neurosurg. 2011;54:87-9. PMID 21656444
29: Farmer TW, Wise GR. Subdural empyema in infants, children and adults. Neurology 1973;23:254-60. PMID 4735178
30: Feuerman T, Wackym PA, Gade GF, Dubrow T. Craniotomy improves outcome in subdural empyema. Surg Neurol 1989;32:105-10. PMID 2568693
31: Fiorindi A, Marton E, Gioffrè G, et al. New perspectives in the endoscopic treatment of brain purulent collections: targets, techniques, results in a case series, and overview of the literature. Acta Neurochir (Wien) 2020;162(11):2867-74. PMID 32358657
32: French H, Schaefer N, Keijzers G, Barison D, Olson S. Intracranial subdural empyema: a 10-year case series. Ochsner J 2014;14(2):188-94. PMID 24940128
33: Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope 1998;108(11 Pt 1):1635-42. PMID 9818818
34: Gallagher RM, Pizer B, Ellison JA, Riordan FA. Glycopeptide insensitive Staphylococcus aureus subdural empyema treated with linezolid and rifampicin. J Infect 2008;57:410-3. PMID 18703232
35: Germiller JA, Monin DL, Sparano AM, Tom LW. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg 2006;132(9):969-76. PMID 16982973
36: Ghalayini SR, Likhith AM, Golash A. Propionibacterium acnes causing delayed subdural empyema - a case report and review of literature. J Clin Neurosci 2004;11(6):677-9. PMID 15261253
37: Gilchrist JJ, Hoy T, Bijker EM, et al. Intracranial empyema in children: a single-center retrospective case Series. Pediatr Infect Dis J 2023;42:e417-20. PMID 37647356
38: Greenlee JE. Subdural empyema. Curr Treat Options Neurol 2003;5(1):13-22. PMID 12521560
39: Hall BJ, Duddy JC, Apostolopoulou K, et al. Intracranial empyemas in the COVID-19 era: a new phenomenon? A paediatric case series and review of the literature. Pediatr Neurosurg 2023;58(4):215-22. PMID 37393893
40: Harris LF, Haws FP, Triplett JN Jr, Maccubbin DA. Subdural empyema and epidural abscess: recent experience in a community hospital. South Med J 1987;80(10):1254-8. PMID 2889269
41: Hartman BJ, Helfgott DC, Weingarten K. Subdural empyema and suppurative intracranial phlebitis. In: Scheld WM, editor. Philadelphia: Lippincott Williams & Wilkins, 2004:523-36.
42: Hodges J, Anslow P, Gillett G. Subdural empyema--continuing diagnostic problems in the CT scan era. Q J Med 1986;59:387-93. PMID 2875483
43: Hoshina T, Takimoto T, Nanishi E, Nishio H, Kusuhara K, Hara T. The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection. J Infect Chemother 2015;21:620-2. PMID 25971424
44: Hutchin ME, Shores CG, Bauer MS, Yarbrough WG. Sinogenic subdural empyema and Streptococcus anginosus. Arch Otolaryngol Head and Neck Surg 1999;125:1262-6. PMID 10555700
45: Infection in Neurosurgery Working Party of the British Society for Antimicrobial Chemotherapy. The rational use of antibiotics in the treatment of brain abscess. Br J Neurosurg 2000;14:525-30. PMID 11272029
46: Jim KK, Brouwer MC, van der Ende A, van de Beek D. Subdural empyema in bacterial meningitis. Neurology 2012;79(21):2133-9. PMID 23136260
47: Kaufman DM, Litman N, Miller MH. Sinusitis-induced subdural empyema. Neurology 1983;33:123-32. PMID 6681653
48: Kaufman DM, Miller MH, Steigbigel NH. Subdural empyema: analysis of 17 recent cases and review of the literature. Medicine 1975;54:485-98. PMID 1186492
49: Kessler AT, Kourtis AP. Treatment of meningitis caused by methicillin-resistant Staphylococcus aureus with linezolid. Infection 2007;35:271-4. PMID 17646913
50: Kim JH, Lee CH, Hwang SH, Kang DH. Superimposed propionibacterium acnes subdural empyema in a patient with chronic subdural hematoma. J Korean Neurosurg Soc 2009;45(1):53-6. PMID 19242574
51: Kim YS, Joo SP, Song DJ, Kin SH, Kim TS. Delayed intracranial subdural empyema following burr hole drainage: case series and literature review. Medicine 2018;97:e0664. PMID 29718890
52: Kombogiorgas D, Seth R, Athwal R, Modha J, Singh J. Suppurative intracranial complications of sinusitis in adolescence. Single institute experience and review of literature. Br J Neurosurg 2007;21:603-9. PMID 18071989
53: Komori H, Takagishi T, Otaki E, et al. The efficacy of MR imaging in subdural empyema. Brain Dev 1992;14:123-5. PMID 1352435
54: Kubik CS, Adams RD. Subdural empyema. Brain 1943;66:18-42.
55: Le Beau J, Creissard P, Harispe L, Redondo A. Surgical treatment of brain abscess and subdural empyema. J Neurosurg 1973;38:198-203. PMID 4694219
56: Lefebvre L, Metellus P, Dufour H, Bruder N. Linezolid for treatment of subdural empyema due to Streptococcus: case reports. Surg Neurol 2009;71:89-91. PMID 18262639
57: Legrand M, Roujeau T, Meyer P, Carli P, Orliaguet G, Blanot S. Paediatric intracranial empyema: differences according to age. Eur J Pediatr 2009;168(10):1235-41. PMID 19137324
58: Leong SC, Waugh LK, Sinha A, De S. Clinical outcomes of sinogenic intracranial suppuration: the Alder Hey experience. Ann Otol Rhinol Laryngol 2011;120:320-5. PMID 21675588
59: Levy I, Sood S. Staphylococcus aureus dissemination to a preexisting subdural hematoma. Pediatr Infect Dis J 1996;15:1139-40. PMID 8970233
60: Leys D, Christiaens JL, Derambure P, et al. Management of focal intracranial infections: is medical treatment better than surgery. J Neurol Neurosurg Psychiatry 1990;53:472-5. PMID 1974282
61: Lin YW, Lin SK, Weng IH. Fatal paranasal sinusitis presenting as trigeminal neuralgia. Headache 2006;46(1):174-8. PMID 16412169
62: Liu ZH, Chen NY, Tu PH, Lee ST, Wu CT. The treatment and outcome of postmeningitic subdural empyema in infants. J Neurosurg Pediatr 2010;6:38-42. PMID 20593986
63: Ljubimov VA, Babadjouni R, Ha J, et al. Adolescent subdural empyema in setting of COVID-19 infection: illustrative case. J Neurosurg Case Lessons 2022;3(4):CASE21506. PMID 36130569
64: Longatti P, Perin A, Ettorre F, Fiorindi A, Baratto V. Endoscopic treatment of brain abscesses. Childs Nerv Syst 2006;22:1447-50. PMID 16733758
65: Lundy P, Kaufman C, Garcia D, Partington MD, Grabb PA. Intracranial subdural empyemas and epidural abscesses in children. J Neurosurg Pediatr 2019;24(1):14-21. PMID 31553545
66: Malacarne P, Viaggi B, Di Paolo A, Danesi R, Del Tacca M. Linezolid cerebrospinal fluid concentration in central nervous system infection. J Chemother 2007;19:90-3. PMID 17309857
67: Mauser HW, Ravijst AP, Elderson A, Van Gijn J, Tulleken CA. Nonsurgical treatment of subdural empyema. J Neurosurg 1985;63:128-30. PMID 2861262
68: Maytal J, Patel M, Apeatuh S, Schneider S, Eviatar L. Subdural empyema in 12-year-old girl: the value of magnetic resonance imaging. Neuroimaging 1996;6:258-60. PMID 8903084
69: Mendelson MH, Nicholas P, Malowany M, Lewin S. Subdural empyema caused by Campylobacter fetus spp. J Infect Dis 1986;153:1183-5. PMID 2871115
70: Mirza O, Varadarajan V, Youshani AS, Willatt DJ. Escherichia coli positive infratentorial subdural empyema secondary to mastoiditis and underlying cholesteatoma. BMJ Case Rep 2014;2014. PMID 24777089
71: Mohindra S, Kursa GK, Reddy R. Bilateral symmetrical infratentorial subdural empyema: delay proves detrimental. J Pediatr Neurosci 2015;10:285-6. PMID 26557179
72: Morgan DW, Williams B. Posterior fossa subdural empyema. Brain 1985;108:983-92. PMID 2866809
73: Munusamy T, Dinesh SK. Delayed occurrence of Escherichia coli subdural empyema following head injury in an elderly patient: a case report and literature review. J Neurol Surg Rep 2015;76(1):e79-82. PMID 26251817
74: Muzumdar D, Biyani N, Deopujari C. Subdural empyema in children. Childs Nerv Syst 2018;34:1881-7. PMID 30014307
75: Nathoo N, Nadvi SS, Van Dellen JR. Traumatic cranial empyemas: a review of 55 patients. Br J Neurosurg 2000;14:326-30. PMID 11045197
76: Nathoo N, Nadvi SS, van Dellen JR, Gouws E. Intracranial subdural empyemas in the era of computed tomography: a review of 699 cases. Neurosurg 1999;44:529-35. PMID 10069590
77: Nickerson JP, Richner B, Santy K, et al. Neuroimaging of pediatric intracranial infection--part 1: techniques and bacterial infections. J Neuroimaging 2012;22:e42-51. PMID 22304299
78: Obana WG, Rosenblum ML. Nonoperative treatment of neurosurgical infections. Neurosurg Clin N Am 1992;3:359-73. PMID 1353004
79: Ogilvy CS, Chapman PH, McGrail K. Subdural empyema complicating bacterial meningitis in a child: enhancement of membranes with gadolinium on magnetic resonance imaging in a patient without enhancement on computed tomography. Surg Neurol 1992;37:138-41. PMID 1347665
80: Oliveira CR, Morriss MC, Mistrot JG, Cantey JB, Doern CD, Sánchez PJ. Brain magnetic resonance imaging of infants with bacterial meningitis. J Pediatr 2014;165:134-9. PMID 24726712
81: Otto WR, Paden WZ, Connors M, et al. Suppurative intracranial complications of pediatric sinusitis: a single-center experience. J Pediatric Infect Dis Soc 2021;10(3):309-16. PMID 32955086
82: Pathak A, Sharma BS, Mathuriya SN, Khosla VK, Khandelwal N, Kak VK. Controversies in the management of subdural empyema: a study of 41 cases with review of literature. Acta Neurochir Wien 1990;102:25-32. PMID 1968310
83: Post E, Modesti LM. "Subacute" postoperative subdural empyema. J Neurosurg 1981;55:761-5. PMID 7310498
84: Raineau M, Crowe AM, Beccaria K, et al. Pediatric intracranial empyema complicating otogenic and sinogenic infection. Int J Pediatr Otorhinolaryngol 2024;177:111860. PMID 38224655
85: Rich PM, Deasy NP, Jarosz JM. Intracranial dural empyema. Br J Radiol 2000;73:1329-36. PMID 11205681
86: Salunke PS, Malik V, Kovai P, Mukherjee KK. Falcotentorial subdural empyema: analysis of 10 cases. Acta Neurochir (Wien) 2011;153(1):164-9. PMID 20505960
87: Schiller F, Cairns H, Russell DS. The treatment of purulent pachymeningitis and subdural suppuration with special reference to penicillin. J Neurol Neurosurg Psychiatry 1948;11:143-82. PMID 18878023
88: Seven H, Coskun BU, Calis AB, Sayin I, Turgut S. Intracranial abscesses associated with chronic suppurative otitis media. Eur Arch Otorhinolaryngol 2005;262(10):847-51. PMID 15959795
89: Silverberg AL, DiNubile MJ. Subdural empyema and cranial epidural abscess. Med Clin North Am 1985;69:361-74. PMID 2859404
90: Smith HP, Hendrick EB. Subdural empyema and epidural abscess in children. J Neurosurg 1983;58:392-7. PMID 6827325
91: Sze G, Zimmerman RD. The magnetic resonance imaging of infections and inflammatory diseases: imaging in neuroradiology, part I. Radiol Clin North Am 1988;26:839-59. PMID 3289077
92: Taha MM, Hassanain S. Subtentorial subdural empyema: report of two cases and review of the literatures. Turk Neurosurg 2011;21:669-73. PMID 22194137
93: Takoro K, Yamataki A, Nakajima F. Subdural empyema occurring 20 years after trauma: case report. Neurosurgery 1987;21:724-6. PMID 2892146
94: Teng HW, Chen CY, Chen HC, Chung WT, Lee WS. Fusobacterium septicemia complicated by cerebral subdural and epidural empyemas: a rare case of Lemierre syndrome. J Emerg Med 2012;43(4):671-3. PMID 20566261
95: Tsou T, Lee PI, Lu CY, et al. Microbiology and epidemiology of brain abscess and subdural empyema in a medical center: a 10-year experience. J Microbiol Immunol Infect 2009;42(5):405-12. PMID 20182670
96: Tsuchiya K, Osawa A, Katase S, Fujikawa A, Hachiya J, Aoki S. Diffusion-weighted MRI of subdural and epidural empyemas. Neuroradiology 2003;45(4):220-3. PMID 12687304
97: van de Beek D, Campeau NG, Wijdicks EF. The clinical challenge of recognizing infratentorial empyema. Neurology 2007;69:477-81. PMID 17664407
98: van der Stel T, Treuniet FE, Hoffmann C, Koppen H. Parafalcine empyema, a tricky infectious cause of headache: a case report. Am J Emerg Med 2015;33(7):992.e1-2. PMID 25618767
99: van der Velden FJS, Battersby A, Pareja-Cebrian L, Ross N, Ball SL, Emonts M. Paediatric focal intracranial suppurative infection: a UK single-centre retrospective cohort study. BMC Pediatr 2019;19(1):130. PMID 31023283
100: Viswanatha B. Interhemispheric subdural abscess: a rare complication of atticoantral ear disease. Ear Nose Throat J 2012;91(8):E26-8. PMID 22930091
101: Wackym PA, Canalis RF, Feuerman T. Subdural empyema of otorhinological origin. J Laryngol Otol 1990;104:118-22. PMID 1969916
102: Weber AL, Mikulis DK. Inflammatory disorders of the paraorbital sinuses and their complications. Radiol Clin N Am 1987;25:615-30. PMID 3575691
103: Weingarten K, Zimmerman RD, Becker RD, et al. Subdural and epidural empyemas: MR imaging. AJNR 1987;10:81-7. PMID 2563623
104: Weingarten K, Zimmerman RD, Becker RD, Heier LA, Haimes AB, Deck MD. Subdural and epidural empyemas: MR imaging. AJR Am J Roentgenol 1989;152:615-21. PMID 2563623
105: Wispelwey B, Dacey RG, Scheld WM. Brain abscess. In: Scheld WM, Whitley RJ, Durack D, editors. Infections of the central nervous system. 2nd ed. New York: Raven, 1997:463-93.
106: Wong AM, Zimmerman RH, Simon EM, Pollock AN, Bilaniuk RT. Diffusion-weighted MR imaging of subdural empyemas in children. AJNR Am J Neuroradiol 2004;25(6):1016-21. PMID 15205140
107: Wright RL. Septic complications of neurological procedures. Springfield: Charles C Thomas, 1970.
108: Yazar U, Aydın ZGG, Özkaya AK, Kırımlı K, Güvercin AR. Subdural empyema in immunocompetent pediatric patients with recent SARS-CoV-2 positivity: case report. Childs Nerv Syst 2022. PMID 36534133
109: Yoshikawa TT, Chow AW, Guze LB. Role of anaerobic bacteria in subdural empyema: report of four cases and review of 327 cases from the English literature. Am J Med 1975;58:99-104. PMID 234678
110: Yuksel MO, Gurbuz MS, Karaarslan N, Caliskan T. Rapidly progressing interhemispheric subdural empyema showing a three-fold increase in size within 12 hours: Case report. Surg Neurol Int 2016;7(Suppl 37):S872-5. PMID 27999711

Patient Profile

Age range of presentation: 1 month to 65+ years
Sex preponderance: male>female, >2:1
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

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Intracranial subdural empyema

Associated Disorders

Aseptic meningitis
Bacterial meningitis
Cerebral edema
Head trauma
Meningitis
- Otitis
- Sepsis
- Sinusitis

Differential Diagnosis

severe sinusitis
otitis
empyema
epidural abscess
brain abscess
- meningitis

Intracranial subdural empyema …

Intracranial subdural empyema

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Table 1. Antibiotics for Empiric Therapy of Intracranial Subdural Empyema

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Patient Profile

ICD & OMIM codes

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Questions or Comment?

Also in This Category

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	• Intracranial subdural empyema accounts for 15% to 25% of space-occupying intracranial infections and is predominantly a disorder seen in males.
	• Intracranial subdural empyemas in infancy most commonly occur as a complication of meningitis.
	• In older patients, subdural empyema usually occurs as a complication of sinusitis or otitis.

Intracranial subdural empyema

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Table 1. Antibiotics for Empiric Therapy of Intracranial Subdural Empyema

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Neuropathies associated with cytomegalovirus infection

Genital herpes: neurologic complications

Zika virus: neurologic complications

Gram-negative bacillary meningitis

Pneumococcal meningitis

HTLV-1 associated myelopathy

Infective endocarditis

Japanese encephalitis

This is an article preview.
Start a Free Account
to access the full version.