eMedicine Specialties > Neurology > Neurological Infections

Subdural Empyema: Follow-up

Author: Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed), Former Clinical Instructor, Mount Sinai Medical School; Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain and Sports Medicine Associates
Coauthor(s): Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Contributor Information and Disclosures

Updated: Mar 11, 2009

Follow-up

Further Inpatient Care

  • Recurrence of subdural empyema requires immediate surgical evacuation. If a burr hole was the initial surgical procedure, a craniotomy flap should be considered.
  • Complications such as seizures and subdural effusion may require more aggressive treatment modalities.
  • Assess and treat residual neurological deficits. Inpatient rehabilitation (either subacute or acute) may be necessary.

Further Outpatient Care

  • Outpatient follow-up by the treating medical, surgical, and infectious disease teams is required.
  • A decision needs to be made concerning whether to continue antiseizure prophylaxis. An EEG may be needed to rule out an epileptic focus.
  • Outpatient rehabilitation for physical therapy, occupational therapy, and speech therapy may be needed.

Inpatient & Outpatient Medications

  • Intravenous antibiotics for a total period of 3-6 weeks can be administered on either an inpatient or outpatient basis.
  • Antiepileptic medication may be indicated.

Transfer

  • Transfer to appropriate facilities for medical, surgical, and rehabilitative interventions.
  • Complete, adequate transfer notes with results of all tests and discussion among the physicians are helpful to the receiving institution.

Complications

  • Seizures
  • Cavernous sinus thrombosis from septic thrombosis of adjacent cerebral veins
  • Increased intracranial pressure
  • Hydrocephalus from compressed cerebrum resulting in interference with CSF flow
  • Cerebral edema from compressed cerebrum leading to interference with cerebral blood flow
  • Cerebral infarction
  • Cranial osteomyelitis, primarily in adjacent cranial bones
  • Residual neurological deficits (eg, hemiparesis, aphasia)

Prognosis

  • The mortality rate gradually is decreasing secondary to more timely diagnosis and intervention (eg, antibiotics, surgical drainage).
  • Unfavorable prognostic factors
    • Encephalopathy or coma at the time of presentation
    • Elderly or younger than 10 years
    • Delay in starting antibiotics
    • Sterile cultures
  • Favorable prognostic factors
    • Craniotomy as surgical modality (rather than burr holes)
    • Early treatment (surgery and antibiotics)
    • Young age (10-20 y is optimal)
    • Patient alert, awake, and oriented at the time of presentation
    • Paranasal sinus as source of initial infection
    • Isolation of aerobic streptococci in the culture

Patient Education

  • Education should emphasize compliance with medication. Urge patients to follow the advice and instructions of rehabilitation programs. The following should be emphasized:
    • The need to complete the full course of antibiotics
    • Regular intake of antiseizure medication, if prescribed
    • A helmet to protect the area of craniotomy
    • Home exercise program
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center, Infections Center, and Public Health Center. Also, see eMedicine's patient education articles Brain Infection and Antibiotics.

Miscellaneous

Medicolegal Pitfalls

  • Symptoms of subdural empyema may be mild and can mimic sinusitis.
  • Rapid recognition and treatment are of critical importance.
  • Brain MRI is the imaging study of choice; CT scan could be equivocal or negative in subdural empyema.
  • Neurosurgical intervention and high-dose intravenous antibiotics are the backbone of treatment.
 


More on Subdural Empyema

Overview: Subdural Empyema
Differential Diagnoses & Workup: Subdural Empyema
Treatment & Medication: Subdural Empyema
Follow-up: Subdural Empyema
Multimedia: Subdural Empyema
References
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References

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  2. Chen CY, Huang CC, Chang YC. Subdural empyema in 10 infants: US characteristics and clinical correlates. Radiology. Jun 1998;207(3):609-17. [Medline].

  3. Brennan MR. Subdural empyema. Am Fam Physician. Jan 1995;51(1):157-62. [Medline].

  4. Greenlee JE. Subdural empyema. In: Mandell GL, ed. Principles and Practice of Infectious Diseases. Vol 1. 4th ed. New York: Churchill;1994:900-903.

  5. Feuerman T, Wackym PA, Gade GF. Craniotomy improves outcome in subdural empyema. Surg Neurol. Aug 1989;32(2):105-10. [Medline].

  6. Sanford JP. Guide to antimicrobial therapy. Bethseda MD: Uniformed Services University Health Sciences. 1993;3.

  7. Delgado Tapia JA, Galera Lopez J, Santiago Martin J, et al. Subdural empyema due to Mycoplasma hominis after a cesarean section under spinal anesthesia. Rev Esp Anestesiol Reanim. 2005;52(4):239-242. [Medline].

  8. Dwarakanath S, Suri A, Mahapatra AK. Spontaneous subdural empyema in falciparum malaria: a case study. J Vector Borne Dis. Sep-Dec 2004;41(3-4):80-2. [Medline].

  9. Foerster BR, Thurnher MM, Malani PN, Petrou M, Carets-Zumelzu F, Sundgren PC. Intracranial infections: clinical and imaging characteristics. Acta Radiologica. October 2007;48(8):875-93. [Medline].

  10. Hall WA, Truwit CL. The surgical management of infections involving the cerebrum. Neurosurgery. February 2008;62 Supplement 2:519-30. [Medline].

  11. Krauss WE, McCormick PC. Infections of the dural spaces. Neurosurg Clin N Am. Apr 1992;3(2):421-33. [Medline].

  12. Mauser HW, Van Houwelingen HC, Tulleken CA. Factors affecting the outcome in subdural empyema. J Neurol Neurosurg Psychiatry. Sep 1987;50(9):1136-41. [Medline].

  13. Migirov L, Eyal A, Kronenberg J. Intracranial complications following mastoidectomy. Pediatr Neurosurg. Sep-Oct 2004;40(5):226-9. [Medline].

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Further Reading

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Keywords

subdural empyema, circumscript meningitis, cortical abscess, pachymeningitis interna, phlegmonous meningitis, purulent pachymeningitis, subdural abscess, SE, focal intracranial infections

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Contributor Information and Disclosures

Author

Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed), Former Clinical Instructor, Mount Sinai Medical School; Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain and Sports Medicine Associates
Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed) is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

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, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Michael K Racke, MD, Professor of Neurology and Molecular Virology, Immunology, and Medical Genetics, Chairman of Neurology, Chief of Neurology Service, Ohio State University Medical Center
Michael K Racke, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for the Advancement of Science, American Association of Immunologists, and American Neurological Association
Disclosure: Teva Neuroscience Consulting fee Consulting; Peptimmune Inc. Consulting fee Consulting; Bristol Myers Squibb Consulting fee Consulting; EMD Serono Honoraria Speaking and teaching

 
 
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