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Subdural Empyema Clinical Presentation

  • Author: Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM; Chief Editor: Niranjan N Singh, MD, DM  more...
Updated: Dec 08, 2015


A patient with subdural empyema could present with any of the following symptoms:

  • Fever - Temperature above 38°C (100.5°F)
  • Headache - Initially focal and later generalized
  • Recent history (< 2 wk) of sinusitis, otitis media, mastoiditis, meningitis, cranial surgery or trauma, sinus surgery, or pulmonary infection
  • Confusion, drowsiness, stupor, or coma
  • Hemiparesis or hemiplegia
  • Seizure - Focal or generalized
  • Nausea or vomiting
  • Blurred vision (amblyopia)
  • Speech difficulty (dysphasia)
  • History of intracerebral abscess (recent or in the past)


A patient with subdural empyema may show some of the following signs:

  • Mental status changes - Confusion, drowsiness, stupor, and coma
  • Meningismus or meningeal signs
  • Hemiparesis or hemisensory deficits
  • Aphasia or dysarthria
  • Seizure
  • Sinus tenderness, swelling, or inflammation
  • Papilledema and other features of increased intracranial pressure, such as nausea/vomiting, mental status changes, and gait disturbance
  • Homonymous hemianopsia
  • Palsies of cranial nerves III, V, or VI, especially if the abscess is near a petrous portion of the temporal bone, causing facial pain and lateral rectus muscle weakness
  • Fixed, dilated pupil on the ipsilateral side due to compression of cranial nerve III


The most common cause is extension from paranasal sinusitis, especially from the frontal and ethmoidal sinuses. It could also arise as a complication of otitis media, mastoiditis, septicemia, cranial trauma or surgery, or recent sinus surgery; by spread or extension from an intracerebral abscess; by hematogenous spread from pulmonary sources; or from septic thrombosis of cranial veins. Common causative organisms are anaerobes, aerobic streptococci, staphylococci, Haemophilus influenzae,Streptococcus pneumoniae, and other gram-negative bacilli.

  • Paranasal sinusitis -Staphylococcus aureus, alpha-hemolytic streptococci, anaerobic streptococci, Bacteroides species, Enterobacteriaceae
  • Otitis media, mastoiditis - Alpha-hemolytic streptococci, Pseudomonas aeruginosa, Bacteroides species, S aureus
  • Trauma, postsurgical infection -S aureus,Staphylococcus epidermidis, Enterobacteriaceae
  • Pulmonary spread -S pneumoniae,Klebsiella pneumoniae
  • Meningitis (infant or child) -S pneumoniae,H influenzae,Escherichia coli,Neisseria meningitidis
  • Neonates - Enterobacteriaceae, group B streptococci, Listeria monocytogenes
  • Others include hematogenous spread from skin postsurgery (eg, abdominal surgery). Spread from a focus of tuberculosis infection could also occur. A case of subdural empyema developing after infection with Plasmodium falciparum malaria.
Contributor Information and Disclosures

Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM Attending Interventional Physiatrist, Wellspan Health

Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM is a member of the following medical societies: American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation, Royal College of Surgeons of England, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.


Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

Edward L Hogan, MD Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina

Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, Society for Neuroscience, American Society for Biochemistry and Molecular Biology, American Academy of Neurology, American Neurological Association, Phi Beta Kappa, Sigma Xi, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

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MRI scan of a subdural empyema in the left parietal area.
CT scan of a subdural empyema in the left temporal/parietal area.
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