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Subdural empyema

Dr Ian Bickle ◉ and A.Prof Frank Gaillard ◉ ◈ et al.

Subdural empyema is uncommon but nonetheless can account for a significant number of intracranial infections.

On this page:

Article:

Epidemiology
Clinical presentation
Pathology
Radiographic features
Treatment and prognosis
Related articles
References

Images:

Cases and figures

Epidemiology

Subdural empyemas account for approximately 20-33% of all intracranial infections.

Clinical presentation

Clinical presentation depends to some degree on the etiology. When empyemas result from sinusitis or mastoiditis they are often associated with seizures, focal neurological deficits and rapid deterioration of consciousness, progressing from obtundation to coma ¹. Empyemas that occur secondary to prior trauma or surgery are usually more clinically indolent.

Pathology

In the most common scenario, patients develop subdural empyemas as a result of frontal sinusitis. There are two putative mechanisms of spread ³:

direct extension
indirect: secondary to thrombophlebitis

Direct spread, resulting from erosion of the posterior wall of the frontal sinus (the corollary of Pott puffy tumor) is relatively uncommon. Thrombophlebitis of communicating veins is thought to be the most common cause of spread ³.

Etiology

frontal sinusitis: vast majority
mastoiditis/otitis media
surgical intervention
meningitis
trauma
seeding of existing subdural hematoma

Radiographic features

CT is usually the first investigation performed, and often is the only one required, as patients usually expediently proceed to the surgical theater for evacuation.

CT

Subdural empyemas typically resemble subdural hematomas in their shape and the relationship to sutures and dural reflections. They are typically crescentic in shape (compared to epidural empyemas which are typically lentiform), although collection pockets may appear biconvex (see case 1). A surrounding membrane that enhances intensely and uniformly following contrast administration is typical.

MRI

Appearance on MRI is similar to that on CT, although contrast enhancement is more readily detected. Furthermore, the content of the collection will typically demonstrate restricted diffusion (see case 1).

MRI is also more sensitive to the complications of subdural empyemas, e.g. cerebritis, cerebral abscess, and venous thrombosis.

Treatment and prognosis

Mortality associated with subdural empyemas now approaches 10%, compared with approximately 15-40% in the pre-CT era ¹.

Successful treatment is predicated on prompt diagnosis, followed by surgical evacuation of the collection and administration of appropriate antibiotics.

Complications

Complications are relatively common and may be the cause of presentation. They include:

cortical vein thrombosis with or without venous infarction
cerebritis or cerebral abscess formation

Quiz questions

References

Infections of the central nervous system

CNS infections
- classification by etiology
  - viral
  - bacterial
    - CNS listeriosis (Listeria monocytogenes)
      - listeria rhombencephalitis
    - CNS nocardiosis (Nocardia spp)
    - CNS tuberculosis (Mycobacterium tuberculosis)
      - extra-axial
        
        tuberculous leptomeningitis
        
        tuberculous pachymeningitis
      - intra-axial
        
        intracranial tuberculous granuloma (tuberculoma)
        
        focal tuberculous cerebritis
        
        intracranial tuberculous abscess
        
        tuberculous rhombencephalitis
        
        tuberculous encephalopathy
    - Lyme disease (Borrelia burgdorferi)
    - neurosyphilis (Treponema pallidum)
      - tabes dorsalis
    - Rocky Mountain spotted fever (Rickettsia rickettsii)
  - fungal
    - CNS aspergillosis (Aspergillus spp)
    - CNS coccidioidomycosis (Coccidioides immitis)
    - CNS cryptococcosis (Cryptococcus neoformans)
    - CNS mucormycosis (order Mucorales)
    - neurocandidiasis (Candida spp)
  - parasitic
    - cerebral amoebiasis
      - primary amoebic meningoencephalitis (Naegleria fowleri)
      - granulomatous amoebic encephalitis (Acanthamoeba spp, Balamuthia mandrillaris and Sappinia pedata)
    - cerebral malaria (Plasmodium falciparum)
    - cerebral sparganosis (Spirometra mansonoides)
    - neurocysticercosis (Taenia solium)
    - neurohydatidosis (Echinococcus spp)
      - cerebral hydatid disease
      - spinal hydatid disease
    - neurotoxoplasmosis (Toxoplasma gondii)
      - toxoplasmosis vs lymphoma
  - prion
    - Creutzfeldt-Jakob disease
    - kuru
  - others or those with possible infectious etiologies
    - acute necrotizing encephalopathy of childhood
    - encephalitis lethargica
    - hemorrhagic shock and encephalopathy syndrome
    - Mollaret meningitis (idiopathic recurrent meningitis)
    - Rasmussen encephalitis
- classification by location
  - extra-axial
  - intra-axial

Article information

rID: 13827

System: Central Nervous System

Tag: infection, emergencymedicine

Synonyms or Alternate Spellings:

Sub-dural empyema (SDE)
Subdural empyemas

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Cases and figures

Case 1: T1 C+Case 1: T1 C+

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Case 1: DWICase 1: DWI

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Case 2: T2Case 2: T2

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Case 2: T1 C+Case 2: T1 C+

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Case 3: with concurrent porecephalic cyst posteriorlyCase 3: with concurrent porecephalic cyst posteriorly

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Case 4Case 4

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Case 5Case 5

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Case 6Case 6

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Case 8Case 8

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Case 9Case 9

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